A framework to support team-based models of primary care within the Australian health care system

Lucio Naccarella, Louise N Greenstock and Peter M Brooks
Med J Aust 2013; 199 (5): S22-S25. || doi: 10.5694/mja12.10069
Published online: 29 October 2013

This is a republished version of an article previously published in MJA Open

Health systems with strong primary care orientations are known to be associated with improved equity, better access for patients to an increased number of appropriate services at lower costs, and improved population health.1,2 However, these health systems also need to be able to respond to the increasing demands created by an ageing population and workforce, and increasing complexity in primary care presentations. This needs to occur in the setting of health systems that are becoming increasingly complicated and fragmented. Problems such as workforce shortages and maldistribution of workforce skill mix and roles within geographical and service settings lead to services not always matching the needs of patients.

Team-based models of care have emerged in response to such demands on health systems.3,4 The prevailing pattern of service delivery is evolving, from the solo general practitioner to team-based care (involving the GP, practice nurse and allied health professional) and to expanded primary care teams (involving health system facilitators, care coordinators, generalist rehabilitation assistants, physician assistants, nurse practitioners, pharmacists and paramedics). These expanded team-based models of primary care involve and support transformation in workforce roles and relationships within primary care. They are designed to:

Factors influencing team-based models of primary care

Multiple factors are required for successful team-based models of primary care, including interprofessional education and learning, organisational and management policies, and practice support systems.5-11

Practice support systems

We have chosen to describe two of the most current and relevant practice support systems within primary care that demonstrate the interrelatedness of health system innovations within care delivery, workforce systems, records management, and payment systems.

Electronic health records

Electronic health records (EHRs) are an example of a practice support system that is firmly on the agenda in many countries, and progress has been made in their introduction and use across primary and secondary care settings.18 EHRs have the capacity to enhance teamwork, but there is insufficient evidence to conclude that they are currently being used to achieve this. E-health systems underpinning EHRs are being poorly implemented and require substantial funding for successful integration and utilisation.18

Practice-level payment systems

Practice-level payment systems also can enhance teamwork but do not guarantee teamwork. The UK Quality and Outcomes Framework (QOF) is an example of a practice-level payment system that has led to an expanded workforce (eg, practice nursing) but has not facilitated teamwork, as payment systems have reinforced traditional hierarchies headed by GPs, and have disempowered nurses.20 The QOF has promoted task delegation rather than collaborative teamwork.20 Team-based performance management and payment systems have potential to enable, support and reward teams for collective performance within primary health care, though rewards to team members need to be viewed as equitable among team members.21,22 Evidence of the effect of specific funding parameters on team-based work is limited. For example, while capitation payment based on an enrolled population of patients has potential to enable teamwork, when it has been adopted there has been little evaluation of the contextual and mitigating factors influencing teamwork outcomes.12,14 Blended-payment systems are being used to reward teamwork, although their effect on teamwork and outcomes is unclear.14 Fee-for-service payment systems are a barrier to teamwork within primary care, as they reinforce professional autonomy and independence, and are not appropriate for patients with chronic and complex conditions, who often require continuous care (not episodic) by multiple primary care professionals working together.14

A framework to support team-based models of primary care

To ensure that practice is influenced by evidence about interprofessional education, organisational and management policies and practice support, we propose a framework to support team-based models of primary care within the Australian health care system.

Current Australian health reforms continue to emphasise the need to provide all Australians with access to cost-effective community-based primary care by supporting and strengthening a well trained, multi-disciplinary, team-based workforce.23 Thus an evidence-informed framework that assists policymakers, educators, researchers, managers and health professionals to support team-based models of primary care within the Australian health care system is essential.

Our proposed framework comprises five key domains: theory, implementation, infrastructure, sustainability and evaluation (Box). The framework was informed by a realist evaluation approach24 and seeks to understand what mechanisms work for whom, and within which contexts.

Context is a particularly complex concept in health care, and even within primary health care, due to the ever-changing and inconsistent nature of the context in which care is delivered. The ultimate goal of a realistic evaluation is that it opens up the “black box” and analyses how and why interventions work or don’t work in particular contexts or settings. This is important because it “closes the loop” on a new intervention, in this case changing the culture of primary health care delivery because we are able to explore the factors supporting this change in the relevant contexts.


There is wide recognition that interventions fail or succeed depending on the appropriateness or validity of the theory or assumption on which they are based. Multiple theoretical perspectives (eg, sociological, organisational, systems) exist about interprofessional working relationships that can inform support for team-based models of care. We discuss here the potential of an organisational (ie, relational coordination) and a system (ie, complex adaptive system) theoretical framework that may provide a way forward to use the evidence base to develop, implement and evaluate team-based models of primary care.

For over a decade, primary care has been described as a complex adaptive system (CAS).25 “Complex” implies diversity; “adaptive” suggests capacity to change and ability to learn from experience; “system” recognises that primary care is comprised of a set of multiple interconnected or interdependent agents acting with common purpose with dynamic environments. More recently within the public health setting, the term “fifth wave”26 has been used to rebalance and reorient our mindsets, our models and our learning processes in response to challenges facing public health. A CAS requires facilitative leadership, high-quality relationships, and feedback in reciprocal interactions to increase the capacity for collective, creative problem solving. A CAS can provide a framework for sharing common sets of concepts and principles, common language and a common approach that facilitates team-based approaches among primary care professionals.

Based on the argument that coordination is the management of task interdependence, and is therefore fundamentally relational,27 we need to understand the importance of relationships in coordinating team-based work. According to the theory of relational coordination, coordination that occurs through frequent, timely and problem-solving communication supported by shared goals, shared knowledge and mutual respect will better achieve the desired outcomes. The “relational coordination” lens can provide a theoretical framework for team-based models of primary care.


Policymakers, professionals and communities face challenges in sustaining worthwhile innovations, especially in primary care. Internationally and within Australia, multiple reviews of factors that promote or constrain sustainability of interventions within the system have been conducted. Endeavours to expand knowledge about sustainability have been labelled “sustainability science”,29 which is underpinned by the concept of “ecosystem”. This recognises that the organisation and interaction of the components of the system are as important as the system itself. Gruen and colleagues conducted a systematic review of conceptual frameworks and empirical studies about sustainability29 and developed a unifying model based on the “ecosystem” lens. The model proposes that sustainability of interventions within systems is influenced by the interaction and alignment between three key components: the health concerns of the population, the intervention elements, and the drivers (positive and negative) of the intervention. It can be used to determine the potential sustainability of interventions designed to support team-based models of primary care.


There is clearly a lack of evidence regarding the implementation and impact of team-based models of primary care to inform what works, for whom and in what circumstances. A review of incentives for primary health care team service provision10 recommended, on the basis of limited evaluative evidence, that a key priority was to develop teamwork-focused evaluative tools and indicator sets. The review also suggested that investment was required in reviewing existing (international and Australian) teamwork-related, evidence-based, evaluative inventories, tools and methods for use in the Australian setting, as well as in developing and piloting a set of process and summative teamwork-evaluation indicators (at patient, provider, organisational, and systems levels) for use in the Australian setting. Since then, a systematic review of instruments used to assess teamwork has been conducted28 that further emphasises recommendations supporting team-based service provision.10 Another review of instruments to measure teamwork30 found that very few existing measures demonstrated psychometric properties recommended for use, and that there was inconsistency in conceptualisations of teamwork. A key recommendation was that more research be undertaken to aid in developing and refining measures of teamwork for reliable use by researchers and practitioners or managers. Overall, there is a need for an integrated evaluation strategy focusing on interprofessional, organisational, and practice support strategies for team-based models of primary care.

Provenance: Commissioned; externally peer reviewed.

  • Lucio Naccarella1
  • Louise N Greenstock2
  • Peter M Brooks3

  • Australian Health Workforce Institute, University of Melbourne, Melbourne, VIC.


Competing interests:

No relevant disclosures.

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