The effectiveness of competency-based education in equipping primary health care workers to manage chronic disease in Australian general practice settings

Nicholas J Glasgow, Robert Wells, James Butler and Anna Gear
Med J Aust 2008; 188 (8): S92. || doi: 10.5694/j.1326-5377.2008.tb01755.x
Published online: 21 April 2008


Objective: To review the literature on the effectiveness of competency-based education (CBE) as a means of equipping the Australian general practice workforce to deliver optimal chronic disease outcomes to articulate policy options for the Australian context.

Methods: Systematic review of the literature (1991–2005) using a narrative approach followed by analysis of the findings using the actors/context/ processes/content framework of Buse et al.

Results: Few high-quality studies were identified. National policy options include incorporating clear statements about education and training, research and evaluation in any policy document targeting chronic disease; and provision of funding to enhance general practice teaching facilities and/or facilitate the development of supportive coordinating and administrative structures for training practices. Designers of CBE should consider five key questions: Are the educational objectives of the CBE clearly aligned with the chronic disease or workforce-related outcomes of interest? Is the design of the CBE sound? Have similar educational programs targeting the same outcomes been identified and every attempt made to maximise synergies between programs? Are the educational designers fully aware of and working within the existing complexity of the training environment? Are all involved in the program actively managing the process of change?

Conclusions: Policy options range from those relatively simple and achievable to more complex and difficult. The full report is available at

The increasing prevalence of chronic illness and comorbidity in Australia, combined with workforce shortages in general practice and primary health care settings,1,2 presents significant challenges for Australia’s health policymakers. Australian federal and state governments have made substantial commitments to tackling chronic disease through policies such as the 2005 National Chronic Disease Strategy, the 2006 Australian Better Health Initiative3 and the National Action Plan on Mental Health.4 But how can we move from these overarching national policies to the delivery of increasingly high-quality, safe, efficient chronic illness care in the face of workforce constraints? Education and training activities that more effectively equip the diminishing workforce to provide such high-quality care are essential components of any response.

Competency-based education (CBE) programs are educational programs focused on outcomes.5 In this article, we consider CBE synonymous with competency-based training programs. Outcomes-orientated programs are considered best educational practice.

We summarise here the findings of our recent systematic literature review6 of CBE and its role in equipping the general practice workforce to deliver optimal chronic disease care. Using the approach of Buse et al,7 we formulate some policy options and propose five questions for developers of CBE programs to consider.


In our systematic review of CBE, we focused on nursing and medical members of the primary health care workforce and the general practice context. Complementary treatments were not considered.


Our findings are summarised in Box 1. There was little direct evidence that CBE interventions in general practice settings are effective in influencing the specified chronic disease-related outcome measures.

Implications for policy and practice

Buse et al7 identify four factors — actors, context, processes and content — that are useful in health policy research. We discuss each of these factors as they relate to the development of CBE for chronic disease, and potential options for policy to facilitate this end. Although these factors are discussed separately, it is essential to bear in mind the dynamic interactions between them.


The delivery of chronic disease care, and workforce training for this task, involves many organisations with overlapping roles and responsibilities. For some organisations, health service delivery and/or education are at the core of their charters, while for others the connections are more peripheral. Yet all act in ways that shape or affect policy.

Australian Government involvement in chronic disease care is primarily through the Department of Education, Employment and Workplace Relations, the Department of Health and Ageing and the Office for Aboriginal and Torres Strait Islander Health. State and territory departments involved include those for education and health. Many educational organisations also play a role — some funded by government, some by members or through private fees, and some by combinations of these. They operate across a learning continuum, from undergraduate through vocational training to continuing professional development. They include universities, colleges (eg, the Royal Australian College of General Practitioners, the Australian College of Rural and Remote Medicine and the Royal College of Nursing, Australia), Australian General Practice Training’s regional training providers, postgraduate medical councils, and continuing professional development providers. Other organisations also have a direct interest in chronic disease care. These include the Australian Medical Association (AMA), chronic disease organisations (eg, the Australian Lung Foundation, Diabetes Australia), self-management groups, the pharmaceutical industry and private health insurers.

At a national level, one policy option might be a simple but prominent statement included in a relevant strategy (eg, the National Primary Health Care Strategy proposed by the Rudd Government20) that makes clear that education and training, together with evaluation and research, are essential to realising optimal health outcomes for people with chronic disease. This would give all actors an educational “flag” around which to rally.


What can be said about the context in which the policy options will play out? The inherent complexity arising from the number of actors is compounded by the stress characterising the general practice setting. Educators are also clinicians, and increasing clinical demands are made on their time. Although CBE is often located in the workplace, the dominant small-business private model of Australian general practice has limited the ability to provide physical space for educational activities. All educational providers face budgetary difficulties paying educators to teach. General practitioners have competing demands outside any educational initiative. For example, a GP, confronted with new Medicare item numbers, continuing professional development requirements, accreditation, and business management complexity, may feel so pressured that he or she is unwilling to contribute to educational activities. The inherent complexity is further compounded by the needs of particular communities, including rural and remote communities, culturally and linguistically diverse groups, or Aboriginal or Torres Strait Islander peoples.

Policy options directed at lessening this stress include the provision of capital for training general practices to expand their capacity; remuneration packages for trainers that minimise financial penalties arising from the displacement of clinical activity; and supportive organisational structures to minimise any additional administrative impact of educational activities. With regard to the latter, the positive experience of the rural clinical schools program is informative.


Chronic disease and general practice/primary health care workforce shortages are high on Australian governments’ policy agendas. Significant investments have been made to address workforce shortages (eg, increased places for medical and nursing students at universities) and chronic disease (eg, the 2005 National Chronic Disease Strategy and the 2006 Australian Better Health Initiative).

Considerable changes have also been made to the Medicare Benefits Schedule, extending rebates beyond the medical profession following the Productivity Commission’s health workforce report.1 These initiatives are service-delivery oriented.

A key challenge is to garner explicit policy support, within these and other frameworks, for a forward-looking chronic disease education and training agenda across disciplines, and at all stages of the educational continuum. To ensure the evidence base continues to develop, educational initiatives should be complemented with major and sustained investments in applied research and evaluation activities targeting the delivery, organisation and funding of high-quality chronic disease services.

In mobilising support for these outcomes, care must be taken not to promote one chronic disease at the expense of another, or at the expense of education and research examining service delivery to people with coexistent chronic diseases.

As key sources of research funding, the National Health and Medical Research Council and the Australian Primary Health Care Research Institute would be actors. Implementation of particular CBE initiatives would be managed at a local level and would involve negotiations between relevant parties. The existing regional training provider network would be a logical place to start.

Interactions between the four factors

Box 2 summarises the interplay between the actors (above the dotted line), context (general practice), process (service delivery, education and evaluation considered together), content (funding and regulatory roles of some of the actors as well as the role of standards) and how these connect with the steps in developing a CBE program. It also illustrates the interplay between educational outcomes (the vertical stack of boxes relating to competencies) and health, program and/or organisational outcomes that are part of the environment.

Five considerations when developing chronic disease CBE in the Australian general practice setting

In considering the results of the systematic review and the interplay between actors, context, process and content, we propose five questions CBE program developers for Australian general practice should consider to maximise the likelihood of programs improving sustained chronic disease management and workforce outcomes.


Although much has been written about CBE, direct evidence regarding its role in improving chronic disease management in general practice settings is limited. Evaluation of any new initiatives is therefore crucial. From a national policy perspective, incorporating clear statements about education and research in any policy document or strategy targeting chronic disease is one option. Other options include additional funding to enhance teaching facilities, purchase teacher time and/or facilitate the development of supportive organisational structures for training practices. All parties involved should consider the above five questions as part of the development of any new CBE program.

1 Key findings of our review


Improved access

Better integration and multidisciplinary care

Better management of chronic disease

Greater focus on prevention and early intervention

  • Direct evidence of CBE effectiveness in the general practice/PHC setting: no evidence found

  • Comments: according to Thompson et al,16 barriers to physicians providing such care include the following: (i) the health care system and its culture limit flexibility for physicians, and the intention to help alone is inadequate justification for change; (ii) time constraints and patient demand make a physician’s job one of responding to complaints rather than initiating action; (iii) feedback from preventive care is negative or neutral (eg, the physician does not receive feedback regarding the late-stage breast cancer averted by promoting mammography); and (iv) adequate resources are not available

Greater professional satisfaction and teamwork




Sustaining CBE

Barriers and facilitators



CBE = competency-based education. PHC = primary health care.

  • Nicholas J Glasgow1
  • Robert Wells2
  • James Butler3
  • Anna Gear1

  • 1 Australian Primary Health Care Research Institute, Australian National University, Canberra, ACT.
  • 2 Menzies Centre for Health Policy, Australian National University, Canberra, ACT.
  • 3 Australian Centre for Economic Research, Australian National University, Canberra, ACT.



Our review was funded by an Australian Primary Health Care Research Institute hub research grant.

Competing interests:

None identified.

  • 1. Productivity Commission. Australia’s health workforce. Productivity Commission research report. Canberra: Commonwealth of Australia, 2005. (accessed Feb 2008).
  • 2. Australian Medical Workforce Advisory Committee. The general practice workforce in Australia: supply and requirements to 2013. Sydney: AMWAC, 2005.
  • 3. Council of Australian Governments (COAG). Better health for all Australians. (Report of COAG meeting 10 Feb 2006.) (accessed Feb 2008).
  • 4. Council of Australian Governments (COAG). Mental health. (Report of COAG meeting 14 Jul 2006.) (accessed Feb 2008).
  • 5. Carraccio C, Wolfsthal S, Englander R, et al. Shifting paradigms: from Flexner to competencies. Acad Med 2002; 77: 361-367.
  • 6. Glasgow N, Wells R, Butler J, et al. Using competency-based education to equip the primary health care workforce to manage chronic disease. Canberra: Australian Primary Health Care Research Institute, 2006. (accessed Feb 2008).
  • 7. Buse K, Mays N, Walt G. Making health policy. Maidenhead, UK: Open University Press, 2005.
  • 8. Basnet I, Clapham S, Shakya G, et al. Evolution of the postabortion care program in Nepal: the contribution of a national Safe Motherhood Project. Int J Gynaecol Obstet 2004; 86: 98-108.
  • 9. Llewellyn-Jones R, Baikie K, Smithers H, et al. Multifaceted shared care intervention for late life depression in residential care: randomised controlled trial. BMJ 1999; 319: 676-682.
  • 10. Woods R, Longmire W, Galloway M, et al. Development of a competency based training programme to support multidisciplinary working in a combined biochemistry/haematology laboratory. J Clin Pathol 2000; 53: 401-404.
  • 11. Zwarenstein M, Reeves S, Barr H, et al. Interprofessional education: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2001; (1): CD002213.
  • 12. Cooper H, Carlisle C, Gibbs T, et al. Developing an evidence base for interdisciplinary learning: a systematic review. J Adv Nurs 2001; 35: 228-237.
  • 13. Hampson S, Skinner T, Hart J, et al. Effects of educational and psychosocial interventions for adolescents with diabetes mellitus: a systematic review. Health Technol Assess 2001; 5 (10): 1-79.
  • 14. Renders C, Valk G, Griffin S, et al. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database Syst Rev 2001; (1): CD001481.
  • 15. Bellamy N, Goldstein L, Tekanoff R. Continuing medical education-driven skills acquisition and impact on improved patient outcomes in family practice settings. J Contin Educ Health Prof 2000; 20: 52-61.
  • 16. Thompson R, Taplin S, McAfee T, et al. Primary and secondary prevention services in clinical practice: twenty years’ experience in development, implementation, and evaluation. JAMA 1995; 273: 1130-1135.
  • 17. Dockery A, Kelly R, Norris K, et al. Costs and benefits of new apprenticeships. Aust Bull Labour 2001; 27: 192-203.
  • 18. Blake J. Competency-based training: the way ahead for Australia? Train Dev Aust 2004; 31: 6-9.
  • 19. Walker D, McDermott J, Fox-Rushby J, et al. An economic analysis of midwifery training programmes in South Kalimantan, Indonesia. Bull World Health Organ 2002; 80: 47-55.
  • 20. Australian Labor Party. National Primary Health Care Strategy. Media statement, 17 Nov 2007. (accessed Jan 2008).
  • 21. Grol R. Changing physicians’ competence and performance: finding the balance between the individual and the organization. J Contin Educ Health Prof 2002; 22: 244-251.


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