Divisions of general practice in Australia: how do they measure up in the international context?

BACKGROUND: Since the late 1980s, there has been evidence of an international trend towards more organised primary care. This has taken a number of forms including the emergence of primary care organisations. Underpinning such developments is an inherent belief in evidence that suggests that well-developed primary care is associated with improved health outcomes and greater cost-effectiveness within health systems. In Australia, primary care organisations have emerged as divisions of general practice. These are professionally-led, regionally-based, and largely government-funded voluntary associations of general practitioners that seek to co-ordinate local primary care services, and improve the quality of care and health outcomes for local communities. DISCUSSION: In this paper, we examine and debate the development of divisions in the international context, using six roles of primary care organisations outlined in published research. The six roles that are used as the basis for the critique are the ability of primary care organisations to: improve health outcomes; manage demand and control costs; engage primary care physicians; enable greater integration of health services; develop more accessible services in community and primary care settings; and enable greater scrutiny and assurance of quality of primary care services. SUMMARY: We conclude that there has been an evolutionary approach to divisions' development and they now appear embedded as geographically-based planning and development organisations within the Australian primary health care system. The Australian Government has to date been cautious in its approach to intervention in divisions' direction and performance. However, options for the next phase include: making greater use of contracts between government and divisions; introducing and extending proposed national quality targets for divisions, linked with financial or other incentives for performance; government sub-contracting with state-based organisations to act as purchasers of care; pursuing a fund-holding approach within divisions; and developing divisions as a form of health maintenance organisation. The challenge for the Australian Government, should it wish to see divisions' role expand, is to find mechanisms to enable this without compromising the relatively strong GP engagement that increasingly distinguishes divisions of general practice within the international experience of primary care organisations

"All our people are dyin' ": diet and stress in an urban Aboriginal community

This is primarily a study of dietary practices and nutrient intakes in relation to health in an urban Aboriginal community in New South Wales. It examines the assumption that poor diet is one of the major, if not the major, contributing factors in poor Aboriginal health. The data indicate that in the community studied dietary patterns were consistent with those of the wider society. Intakes of nutrients were not always optimal compared with recommended dietary intakes (RDIs) for Australia, but compared to the rest of the Australian population, and different sub-sections within it, they were not as poor as expected. In particular, the high fat, high sugar, largely vitamin deficient diet frequently assumed to be ubiquitous in Aboriginal communities is not supported by this study. Consequently, it is argued that the importance of the role of diet in poor Aboriginal health may have been over-stated. In re-evaluating the current emphasis on diet and other 'lifestyle' factors it is suggested that the scope of the analysis needs to be considerably broadened to include other factors which may be more ambiguous in terms of their effects on health. What seems particularly important is the high level of stress evident in the community studied. This stress seems to be derived from a particular set of historical and contemporary social conditions which, it is argued, need to be more fully considered as part of the totality of environmental factors which impinge on the health of Aborigines in settled Australia

Furthering the quality agenda in Aboriginal community controlled health services: understanding the relationship between accreditation, continuous quality improvement and national key performance indicator reporting

A rapidly expanding interest in quality in the Aboriginal-community-controlled health sector has led to widespread uptake of accreditation using more than one set of standards, a proliferation of continuous quality improvement programs and the introduction of key performance indicators. As yet, there has been no overarching logic that shows how they relate to each other, with consequent confusion within and outside the sector. We map the three approaches to the Framework for Performance Assessment in Primary Health Care, demonstrating their key differences and complementarity. There needs to be greater attention in both policy and practice to the purposes and alignment of the three approaches if they are to embed a system-wide focus that supports quality improvement at the service level

National quality and performance system for Divisions of General Practice: early reflections on a system under development

Governments are increasingly introducing performance management systems to improve the quality and outcomes of health care. Two types of approaches have been described: assurance systems that use summative information for external accountability and internally driven systems that use formative information for continuous quality improvement. Australia recently introduced a National Quality and Performance System (NQPS) for Divisions of General Practice that has the dual purposes of increasing accountability and improving performance. In this article, we ask whether the framework can deliver on its objectives for achieving accountability and fostering performance improvement. We examine the system in terms of four factors identified in a recent systematic review of indicator systems known to improve their use. These are: involving stakeholders in development; having clear objectives; approach to data collection and analysis including using 'soft data' to aid interpretation; and feeding back information. RESULTS: We found that early consultative processes influenced system development. The system promotes the collection of performance information against defined program objectives. Data includes a mix of qualitative and quantitative indicators that are fitted to a conceptual framework that facilitates an approach to performance assessment that could underpin continuous quality improvement at the Division level. Feedback of information to support the development of quality improvement activities has not been fully developed. CONCLUSION: The system currently has elements that, with further development, could support a more continuous quality improvement or assurance based approach. Careful consideration needs to be given to the development of methods for analysis and review of performance indicators, performance assessment and engagement with consumers. The partnership arrangement that supported early development could be expected to serve as an important vehicle for further development

Impact of the introduction of national performance indicators on Divisions of General Practice planning processes

The research reported in this paper is a project of the Australian Primary Health Care Research Institute, which is supported by a grant from the Australian Government Department of Health and Ageing under the Primary Health Care Research, Evaluation and Development Strategy

Implementation of continuous quality improvement in Aboriginal and Torres Strait Islander primary health care in Australia: a scoping systematic review

BACKGROUND: Continuous Quality Improvement (CQI) programs have been taken up widely by Indigenous primary health care (PHC) services in Australia and there has been national policy commitment to support this. However, international evidence shows that implementing CQI is challenging, impacts are variable and little is known about the factors that impede or enhance effectiveness. A scoping review was undertaken to explore uptake and implementation in Indigenous PHC, including barriers and enablers to embedding CQI in routine practice. We provide guidance on how research and evaluation might be intensified to support implementation. METHODS: Searches were conducted in MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews. Key websites and publications were handsearched. Studies conducted in Indigenous PHC which demonstrated some combination of CQI characteristics and assessed some aspect of implementation were included. A two stage analysis was undertaken. Stage 1 identified the breadth and focus of literature. Stage 2 investigated barriers and enablers. The Framework for Performance Assessment in PHC (2008) was used to frame the analysis. Data were extracted on the study type, approach, timeframes, CQI strategies, barriers and enablers. RESULTS: Sixty articles were included in Stage 1 and 21 in Stage 2. Barriers to implementing CQI processes relate primarily to professional and organisational processes and operate at multiple levels (individual, team, service, health system) whereas barriers to improved care relate more directly to knowledge of best practice and team processes that facilitate appropriate care. Few studies described implementation timeframes, number of CQI cycles or improvement strategies implemented and only two applied a change theory. CONCLUSION: Investigating barriers and enablers that modify implementation and impacts of CQI poses conceptual and methodological challenges. More complete description of CQI processes, implementation strategies, and barriers and enablers could enhance capacity for comparisons across settings and contribute to better understanding of key success factors

Issues for designing and evaluating a 'heroin trial': three discussion papers

Report on a workshop on trial evaluation / G. Bammer and D.N. McDonald -- An evaluation of possible designs for a heroin trial / R.G. Jarrett and P.J. Solomon -- Service provision considerations for the evaluation of a heroin trial. A discussion paper / D.N. McDonald, G. Bammer, D.G. Legge and B.M. Sibthorpe

A cost effectiveness study of integrated care in health services delivery: a diabetes program in Australia

BACKGROUND: Type 2 diabetes is rapidly growing as a proportion of the disease burden in Australia as elsewhere. This study addresses the cost effectiveness of an integrated approach to assisting general practitioners (GPs) with diabetes management. This approach uses a centralized database of clinical data of an Australian Division of General Practice (a network of GPs) to co-ordinate care according to national guidelines. METHODS: Long term outcomes for patients in the program were derived using clinical parameters after 5 years of program participation, and the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model, to project outcomes for 40 years from the time of diagnosis and from 5 years postdiagnosis. Cost information was obtained from a range of sources. While program costs are directly available, and costs of complications can be estimated from the UKPDS model, other costs are estimated by comparing costs in the Division with average costs across the state or the nation. The outcome and cost measures are used derive incremental cost-effectiveness ratios. RESULTS: The clinical data show that the program is effective in the short term, with improvement or no statistical difference in most clinical measures over 5 years. Average HbA1c levels increased by less than expected over the 5 year period. While the program is estimated to generate treatment cost savings, overall net costs are positive. However, the program led to projected improvements in expected life years and Quality Adjusted Life Expectancy (QALE), with incremental cost effectiveness ratios of $A8,106 per life-year saved and$A9,730 per year of QALE gained. CONCLUSIONS: The combination of an established model of diabetes progression and generally available data has provided an opportunity to establish robust methods of testing the cost effectiveness of a program for which a formal control group was not available. Based on this methodology, integrated health care delivery provided by a network of GPs improved health outcomes of type 2 diabetics with acceptable cost effectiveness, which suggests that similar outcomes may be obtained elsewhere