Volume 183 · Issue 10 · Supplement

I am pleased to introduce this supplement on research in primary health care. In 2001, the Australian Government introduced the Primary Health Care Research Education and Development Program. One element of this is the Australian Primary Health Care Research Institute, which commenced in 2003 and is based at the Australian National University. The Institute aims to draw together research capacity focusing on policy questions relevant to Australia’s primary health care system with a view to establishing what works best and disseminating it to researchers, practitioners, policy makers and the community. Areas under consideration include: developments in federal/state relationships; different funding arrangements for new or existing services/models; and innovation in organisation and linkages within the primary health care sector. This supplement reports the outcomes of the first round of the Institute’s research. In particular, it addresses the important question of the long-term sustainability of primary health care. The supplement is a valuable contribution to a better understanding of primary health care in Australia. It highlights some of the important political, institutional, economic and workforce factors that need to be considered in the development of primary health care policy to deliver sustainable system improvements.

Tony Abbott MHR

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. Spoke initiativesThe 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. ApproachThrough 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

Beverly M Sibthorpe NZRN, BA(Hons), PhD · Nicholas J Glasgow MD, FRACGP · Robert W Wells BA

“SNAP” is a model for the general practice management of four common behavioural risk factors: smoking, nutrition, alcohol and physical activity. The SNAP program was developed for the Australian Government in 2002. In 2003 and 2004, a feasibility study was conducted in one urban and one rural division of general practice (DGP) in NSW, in partnership with their local area health services. Information technology support and referral directories were developed, based on an initial needs assessment, SNAP guidelines, a clinical summary chart, patient education materials, and general practitioner and staff training. GPs reported that the SNAP approach fitted general practice consultations well. After its implementation, they were more confident in using motivational interviewing and SNAP interventions and referred more frequently. The impact and sustainability of the SNAP program were limited by a lack of effective practice teamwork, poor linkages with referral services, and the lack of a business model to support SNAP in the practices. DGPs could play an important role in providing practice visits and resources to improve communication, education and collaboration to support SNAP programs.

Mark F Harris DRACOG, FRACGP, MD · Coletta Hobbs BSc(Psych)(Hons), PhD · Gawaine Powell Davies BA, MHP · Sarah Simpson BA(Hons), BAppSci(Health Ed), MPH · Diana Bernard BSocStud, Grad Dip Early Childhood Studies, MPH · Anthony Stubbs BA(Health Ed)

The Care and Prevention Programme (CPP) began in 1998. It is based on the philosophy of primary health care, and has improved health among homosexually active men, including about a third of HIV-positive South Australians. The CPP was assessed using financial analysis and qualitative methods. Participants wanted to access care where they could feel comfortable and safe to talk about issues of sexuality and lifestyle. The CPP model is “economically” sustainable, but not “financially” sustainable within the Medicare Benefits Schedule. It is vulnerable to changes in political environment. The financing model for the CPP has been adapted by including state funding. General practitioners have adapted by lowering their personal incomes (but not quality of care). These adaptations have achieved fragile financial viability. Facilitators of sustainability for the CPP included: It is part of the community that it serves; The creation of deeply integrated networks of diversity-competent service providers; and “Virtuous non-adaptability” of service providers in refusing to compromise care standards despite financial pressure to do so. Threats to sustainability included: Difficulty maintaining a diversity-competent workforce skilled in HIV medicine; Marginal financial viability; and Political vulnerability.

Gary D Rogers MB BS, MGPPsych, FACPsychMed · Christopher A Barton PhD, MMedSci, BSc · Ann C Lawless BA, GradDipEd · Joy M Oddy · Rebecca Hepworth MB BS · Justin J Beilby MD, MPH, FRACGP, DRCOG, DA · Brita A Pekarsky BEc(Hons), GradDipHealthEcon

The Sharing Health Care Initiative (SHCI) demonstration project, which aimed to improve management of chronic diseases, was implemented in four small remote communities in the Katherine region which are serviced by the Katherine West Health Board, a remote Aboriginal-community-controlled health organisation in the Northern Territory. We reviewed the project proposal, final report, evaluation reports and transitional funding proposal, and supplemented these with in-depth interviews with key individuals. We determined factors critical to the sustainability of the SHCI project in relation to context, community engagement, systems flexibility and adaptability, the availability and effect of information systems, and the human nature of health care and policy. The project had a significant impact on community awareness of chronic disease and an improvement in clinic processes. We found that a number of interrelated factors promoted sustainability, including: An implementation strategy sufficiently flexible to take account of local conditions; A high level of community engagement; Appropriate timeframes, timing and congruence between national policy and local readiness to implement a chronic disease project; Effective communication between participating organisations; Project champions (key individuals) in participating organisations; Effective use of monitoring and evaluation data; and Adequate and ongoing funding. The absence of a number of these factors, such as poor communication, inhibited sustainability. Other factors could both promote and inhibit. For example, the impact of key individuals was important, but could be idiosyncratic and have negative effects.

John Wakerman MTH, FAFPHM, FACRRM · Elizabeth M Chalmers MPH, FAFPHM, FACRRM · Christine L Clarence BPE, MICD, DipTeaching · John S Humphreys BA, Dip Ed, PhD · Andrew I Bell MB BS, FAFPHM, FACRRM · Ann Larson BA, MA, PhD · David Lyle MB BS, FAFPHM, PhD · Dennis R Pashen MPHTM, FRACGP, FACCRM

The Regional Aboriginal Integrated Social and Emotional (RAISE) Wellbeing program commenced in February 2003 as an Aboriginal mental health service partnership between one Aboriginal Health Service and three mainstream services: a community mental health team, a hospital mental health liaison, and an “outback” community counselling service. A case study method was used to describe the drivers (incentives for program development), linkage processes (structures and activities through which the partnership operated), and sustainability of the program. Program drivers were longstanding problems with Aboriginal peoples’ access to mental health care, policy direction favouring shared service responsibility, and a relatively small amount of new funding for mental health that allowed the program to commence. Linkage processes were the important personal relationships between key individuals. Developing the program as a part of routine practice within and across the partner organisations is now needed through formal agreements, common care-management tools, and training. The program’s sustainability will depend on this development occurring, as well as better collection and use of data to communicate the value of the program and support calls for adequate recurrent funds. The development of care-management tools, training and data systems will require a longer period of start-up funding as well as some external expertise.

Jeffrey D Fuller PhD, MSc(PrimHlthCare), RN · Lee Martinez BN, GradDipHlthCounselling, GradDipHlthSecMgmt · Kuda Muyambi MSc(Development Administration), Partnership Development Project Officer · ; Kathy Verran BSW(Hons), Regional Aboriginal Social and Emotional Wellbeing Manager · Bronwyn Ryan · Ruth Klee BA, MSW

We evaluated an Internet-based psychological intervention supported by either general practitioners or psychologists (Panic Online), and a Primary-care Evidence-based Psychological-interventions (PEP) strategy which involves training GPs to deliver specific psychological interventions. Economic modelling suggests that Panic Online is cost-effective when supported by either GPs or psychologists. Threshold analysis of the psychological training of GPs suggests that a modest effect size for clinical benefit would be sufficient to provide an acceptable cost-effectiveness ratio. The sustainability of these approaches depends on a range of factors, including funding, workforce availability, and acceptability to consumers and health care providers.

Cathrine Mihalopoulos BBSc(Hons), GDECSt, PGDHlthEc · Sophy Ting-Fang Shih BSc, MPH, DrPH · Litza Kiropoulos BEd-Sc, BSc(Hons), MClinPsych, PhD · Grant Blashki MD, FRACGP · Graham Meadows MD, MRCP, FRANZCP · Jane Gunn FRACGP, DRANZCOG, PhD

A synthesis of the findings of the five studies of sustainability of primary health care innovation across six domains (political, institutional, financial, economic, client and workforce) yielded three main themes. These were: the importance of social relationships, networks and champions; the effect of political, financial and societal forces; and the motivation and capacity of agents within the system. The need for routine assessment of the sustainability of primary health care innovations is discussed. Given the dearth of literature on the sustainability of primary health care innovation, there is potential to develop a program of research directed towards a future synthesis of evidence.

Beverly M Sibthorpe NZRN, BA(Hons), PhD · Nicholas J Glasgow MD, FRACGP · Robert W Wells BA