Sustainability of reforms is the key to progress
According to Starfield,1 the birth of contemporary interest in primary health care can be traced back to the 30th annual meeting of the World Health Assembly in 1977. This meeting set in motion a series of activities including, in the subsequent year, the Declaration of Alma-Ata.2 Drawing on the principles enunciated in this Declaration and a more recent review,3 the Australian Primary Health Care Research Institute (APHCRI) has defined primary health care as:
. . . socially appropriate, universally accessible, scientifically sound first level care provided by a suitably trained workforce supported by integrated referral systems and in a way that gives priority to those most in need, maximises community and individual self-reliance and participation and involves collaboration with other sectors. It includes health promotion, illness prevention, care of the sick, advocacy and community development.
In the face of the pressures associated with ageing populations (and related rises in comorbid, chronic health conditions), increasingly expensive health care technologies, changing community expectations and increasing inequalities in health outcomes, many countries are undergoing significant health system reform.4,5 Strategies to control costs and improve health outcomes have frequently strengthened the role of primary health care,4 a reorientation well demonstrated by the national health policies of the United Kingdom and New Zealand. Australia has also seen a plethora of large and small-scale initiatives aimed at strengthening primary health care, although these are not enshrined in a national health policy. Large scale efforts include the national Coordinated Care Trials of funds pooling and care planning, the Indigenous health Primary Health Care Access Program and, more recently, the Australian Primary Care Collaboratives Program. At a more local level, Divisions of General Practice6 and Area Health Services have implemented a wide range of programs and activities to strengthen general practice and primary health care. However, all too often, we know little about the sustainability of these reforms. Yet this question is the key to progress; the alternative is a health system landscape littered with short-term programs, projects and interventions which are developed and tested but do not survive.
Sustainability is an inherently dynamic construct that has to do with keeping going; enduring without failing or giving way; bearing up or withstanding (Shorter Oxford dictionary). Although questions about the sustainability of primary health care initiatives are of paramount concern in developing countries,7,8 there has been limited interest elsewhere. In their systematic review of diffusion of innovation in health systems, Greenhalgh and co-authors found so few studies addressing sustainability that they did not include it in their journal article based on the review.9 Despite this, it has been considered within Australia in relation to services in rural and remote settings,10-13 and in after-hours services in New South Wales14 and Queensland.15
The APHCRI was established in 2003 with core funding from the Australian Government Department of Health and Ageing. The Institute is expected to:
Provide national leadership in improving the quality and effectiveness of primary health care through the conduct of high quality priority-driven research and the support and promotion of best practice. It focuses on important sectoral questions relating to the organisation, financing, delivery and performance of primary health care, including its interaction with public health and the secondary and tertiary health care sectors.
The Institute’s priorities, determined by its Research Advisory Board are:
Innovation in state–Commonwealth relationships;
Innovation in funding arrangements for new or existing services/models; and
Innovation in organisation and linkages within the primary health care sector.
To get started, the APHCRI decided to address the question of sustainability of existing initiatives that represented innovation in one or more of these areas. For the purposes of this program of work, we are adopting Greenhalgh et al’s9 definition of innovation as a “novel set of behaviors, routines and ways of working that are directed at improving health outcomes, administrative efficiency, cost effectiveness, or user’s experience and that are implemented by planned and coordinated actions.” Five initiatives, diverse in nature and scope were selected, becoming the first “spokes” in the APHCRI’s “hub and spoke” model. They were:
The Care and Prevention Programme for people living with HIV;
A trial of smoking, nutrition, alcohol and physical activity interventions;
A regional integrated Aboriginal mental health program;
Two related initiatives investigating pathways of primary mental health care; and
The Sharing Health Care Initiative implemented in an Indigenous community-controlled health care setting.
The Care and Prevention Programme began in 1998 with time-limited Commonwealth funding from the Divisions and Project Grants Program (to the Adelaide Central and Eastern Division of General Practice), state support through Public Health Outcomes Funding Agreements, and pharmaceutical company support. In 2000, it became a focus of activity of the Department of General Practice at the University of Adelaide, and has since received funding from the HIV, Hepatitis C and Related Programs Unit of the South Australian Department of Human Services. It provides an integrated primary health care service for about a third of HIV-positive people in South Australia, drawn from Adelaide and surrounding regions.
Smoking, Nutrition, Alcohol and Physical Activity (SNAP) is a behavioural risk-reduction model developed for the Australian Government in 2002 and trialled in an urban (Sutherland) and rural (Hastings Macleay) Division in New South Wales in 2003–04. It focuses on people with existing or high risk of chronic disease and examines systematically how primary-care teams in general practice can provide more effective interventions for the prevention of chronic disease, and link with other services, especially health promotion units and non-government organisations that provide, for example, nutrition services, exercise programs and counselling for at-risk drinking.
The Regional Integrated Aboriginal Mental Health Program in Port Augusta, SA, seeks to improve primary mental health care services to Aboriginal people through a partnership between Pika Wiya (the Aboriginal Community Controlled Health Service) and the mainstream Community Mental Health team. Program activities include the development of appropriate primary mental health care, joint casework and referral protocols; staff skills development; and the development of an integrated service-delivery model across and between Aboriginal and mainstream organisations.
The mental health pathways initiative has explored two approaches to mental health care: the Primary Care Evidence Based Psychological Interventions (PEP) project and Panic Online. The PEP study, which is being undertaken in Victoria, is evaluating the effects of training general practitioners in focused psychological strategies for the management of mental health disorders in their patients. It is funded by the beyondblue Victorian Centre of Excellence in Depression and Related Disorders, a collaborative initiative by beyondblue: the national depression initiative and the Victorian Department of Human Services. Panic Online is an online therapy program developed and maintained at Monash University (http://www.med.monash.edu.au/mentalhealth/paniconline) by a team of investigators. It is designed to evaluate the use of online mental health resources by GPs who have been accredited to deliver focused psychological strategies in their treatment of patients with common mental disorders.
The Sharing Health Care Initiative is trialling a model of self-care in the management of chronic disease under the direction of the Katherine West Health Board in the Northern Territory. It involves employment of local Aboriginal Community Support Workers, supported self-management for individuals and their families, community-based health promotion initiatives, and training health professionals to teach chronic disease self-management.
Through an iterative process that included face-to-face meetings in Canberra in October 2004 and February 2005, APHCRI hub and spoke staff collectively developed an overall approach and common set of questions to underpin the work, the dominant question being “How sustainable are these initiatives?” We agreed to approach this question by breaking sustainability into six domains: political, institutional, financial, economic, client and workforce. Each spoke was asked to identify key inhibitors and facilitators of sustainability for their respective initiatives, using the defined domains as reference points. They were to use a combination of existing and new data (the latter collected using the APHCRI funding) and approach the task in a way that made sense locally, while remaining within the defined parameters.
Their reports follow. In keeping with the diverse nature of the initiatives, the spokes have taken different approaches to the question, with different emphases. However, within the six domains of sustainability some common themes emerge. These are addressed elsewhere in this Supplement (Sibthorpe et al).16
- 1. Starfield B. Primary care: balancing health needs, services, and technology. Revised ed. New York: Oxford University Press, 1998.
- 2. Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978.
- 3. Bengoa R, Adams O, Kawar R. Primary health care: a framework for future strategic directions. Geneva: World Health Organization, 2003. Available at: http://www.who.int/chronic_conditions/primary_health_care/documentation/en/ (accessed Oct 2005).
- 4. Weller DP, Dunbar J. History, policy and context. In: General practice in Australia, 2004. Canberra: Commonwealth of Australia, 2005: 3-29.
- 5. O’Halloran D. Primary health care: changing systems and new models. Sydney: NSW General Practice Council, 2005.
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- 8. Sarriott E, Winch P, Ryan L, et al. Qualitative research to make practical sense of sustainability in primary health care projects implemented by non-governmental organizations. Int J Health Plann Manage 2004; 19: 3-22.
- 9. Greenhalgh T, Robert G, MacFarlane F, et al. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q 2004; 82: 581-629.
- 10. Taylor J, Blue I, Misan G. Approach to sustainable primary health care service delivery for rural and remote South Australia. Aust J Rural Health 2001; 9: 304-310.
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- 12. Gruen RL, Weeramanthri T, Bailie R. Outreach and improved access to specialist services for Indigenous people in remote Australia: the requirements for sustainability. J Epidemiol Community Health 2002; 56: 517-521.
- 13. The Darwin statement on sustainable general practice in Aboriginal primary health care in the Northern Territory. Darwin: General Practice and Primary Health Care NT, 2005.
- 14. Pekarsky B, Foster M, Hancock M. Maitland After Hours Primary Care Trial. Local economic and financial evaluation. Report for twelve months of trial. Newcastle: Hunter Urban Division of General Practice, 2004. Available at: http://www.hudgp.org.au/index.cfm?fuseaction=download&fusesubaction=template&libraryID=72 (accessed Oct 2005).
- 15. Wood L. Sustaining change — experiences of supporting after hours primary health care services in Queensland. In: Translating policy into practice. Queensland Divisions of General Practice Occasional Paper June 2002. Brisbane: QDGP, 2002: 17-20. Available at http://www.bndgp.com.au/documents/qdgp_translatingpolicy.pdf (accessed Oct 2005).
- 16. Sibthorpe BM, Glasgow NJ, Wells RW. Emergent themes in the sustainability of primary health care innovation. Med J Aust 2005; 183 (10 Suppl): S77-S80.
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