Evidence-based primary health care workforce reforms: priority areas for research

We all understand evidence-based practice, but what about evidence-based reform? The Australian Government emphasises the need to strengthen the primary health care (PHC) system1 and has undertaken to boost Australia’s health workforce by funding Health Workforce Australia (HWA)2 and committing policy investments in three areas in its National Health and Hospitals Network report:3

• Providing additional general practitioner, medical specialist and PHC training places.

• Improving PHC service delivery through GP Super Clinics.

• Improving planning and coordination of PHC services through Primary Health Care Organisations (PHCOs, also known as Medicare Locals).

Does the government have an evidence base for its primary health care workforce reforms? The need for evidence-informed policy making and implementation has been emphasised4 — rightly so, as the government needs to be transparent and accountable for its decisions and actions. Because policy implementation is complex and context-dependent, reflection is required on the evidence that informs policy implementation, and the likely success of such reforms. We acknowledge that multiple “policy vectors” (eg, practitioner and patient realities) also need to be considered. Although we focus on the Australian context here, similar issues and debates exist internationally.5,6 This editorial does not summarise evidence underpinning the PHC workforce,7,8 but draws on it to consider important strategic, evaluative and contextual research questions relating to the government’s three policy investment areas.

Providing additional GP, medical specialist and PHC training places. To ensure that the additional investments are targeted, research questions should include:

• Strategic questions. Where could training capacity be increased? What additional resources are required to maximise the effectiveness of these training places? How do additional training places address existing areas of workforce shortages?

• Evaluative questions. Do medical schools and training programs improve consumer access to services and meet the needs of communities over time?

• Contextual questions. Are these the most appropriate health professional groups to expand? Are there different models of care that might be more relevant to contemporary practice or, more importantly, practice in 2020?

Data from the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey, the Medical Schools Outcomes Database, Medicare, HWA surveys, and national registration may help to address these questions. For example, as part of the first wave of MABEL, a discrete-choice experiment was completed by 532 junior doctors in 2008 before they chose a specialty training program.9 In a policy simulation, researchers found that increasing GPs’ annual earnings by $50 000 and increasing opportunities for procedural or academic work could increase the number of junior doctors choosing general practice by between 8 and 16 percentage points (representing 212–376 junior doctors per year). These results can help policymakers to address the unbalanced supply of doctors across specialties.

Improving PHC service delivery through GP Super Clinics. Twenty-three new GP Super Clinics will be funded and 425 existing PHC facilities will be upgraded to improve team-based care. To efficiently plan the locations and roles of the new GP Super Clinics, research questions should include:

• Strategic questions. Are GP Super Clinics located in areas of workforce shortage and hence eligible for additional support? Do GP Super Clinic workforce skill mixes and skill sets match population health needs?

• Evaluative questions. What impacts are GP Super Clinics having over time on patient care and on workforce models of care and skill sets?

• Contextual questions. Given the importance of team-based care, what role can interprofessional learning have in GP Super Clinics?

Improving planning and coordination of PHC services through PHCOs. PHCOs will be established to improve the planning and coordination of PHC services at the local level.10 To efficiently plan the locations and roles of PHCOs, research questions should include:

• Strategic questions. How does the profile of the local PHC workforce need to be expanded, retrained or shifted in relation to population health profiles?

• Evaluative questions. Can PHCOs measure and predict access problems (eg, for refugees and Indigenous people) and hence inform the extent to which PHC services need to be tailored to these groups?

• Contextual questions. How can different models of care that focus on patients’ needs, and learning programs that inform patient choice, be developed to improve health literacy and reduce the demand on health services?

The above policies should also be considered from an equity perspective:

• What are the equity implications of each reform (especially GP Super Clinics and PHCOs) from a workforce point of view?

• Will these policies exacerbate imbalance in the workforce, which is already unequally distributed on the basis of socioeconomic need?

HWA and the National Primary Health Care Strategy provide the opportunity for these questions to be addressed. However, a national PHC workforce policy is needed to guide key policy reform investment, development, implementation and evaluation.

To respond to changing population and workforce needs and expectations, evidence must inform policy investment, implementation and evaluation. Until we have a better understanding of how evidence is being used, there will be limited knowledge about what makes policy implementation work, for whom and in what circumstances.