Rural nursing and health care reforms : building a social model

This article explores recent shifts in health-care policy and the implications for rural nursing in Australia. Health-care reforms have resulted in the implementation of a 'market forces' ideology, creating tensions between economic imperatives and the need for equity and greater access in rural service delivery. New models of health-service delivery have been developed that have significant implications for the way rural health care is defined, practised and received. The issues surrounding the context of rural nursing practice and service delivery are discussed.

Why primary health care offers a more comprehensive approach to tackling health inequities than primary care.

As governments attempt to focus more intently on how to deal with alarming measures of health disadvantage and inequities, a reformist gaze seems to have settled on the primary care sector. Simultaneously, in literature about this area, whether intended or not, primary health care and primary care are terms that are increasingly interchanged. This article argues that the slippage in language is counter-productive, first because it disguises the transformative potential of strategies and approaches that can make the fundamental changes necessary to improve health status, and second because the structures and practices of the primary care sector are not necessarily compatible with notions of comprehensive primary health care. There is much to be lost if primary health care and health promotion are disguised as primary care, and not understood for their capacity to make a difference to health inequities although of course in some circumstances, comprehensive primary health care is interdependent with services provided by primary care. In this article, characteristics of primary care and primary health care are juxtaposed to show that if the strengths and limitations of each model are understood, they can be mobilised in collaborative partnerships to deal more effectively with health inequities, than our system has so far been able to do.

The transition from pediatric to adult health care services for young adults with a disability : an ethical perspective

Young children with disabilities and their carers or parents tend to form a long-term dependent relationship with a paediatrician throughout childhood At some stage when the young person with a disability reaches early adulthood, the relationship is severed This paper draws upon recent research undertaken by the authors that describes the difficulties experienced by young people with disabilities as they go through the transition from paediatric care to adult mainstream health care services. The purpose of this article is to present the argument that the dependent, paternalistic relationship that tends to exist between young people with disabilities (and/or their carers) and paediatricians throughout childhood does not facilitate the successful negotiation of adult mainstream health care services, nor optimally promote the well-being of these young people with disabilities. It is proposed that the promotion of autonomy (or self-determination) via a well planned transition program will increase the likelihood that young adults with disabilities and/or their carers will be empowered to successfully negotiate the current mainstream health care system in Australia, and will enhance the well-being of young adults with disabilities.

Exploratory economic analyses of two primary care mental health projects : implications for sustainability

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.

Exploring distributive justice in health care

The allocation of resources to providers and the way in which the resources are then prioritised to specific service areas and patients remain the critical ethical decisions which determine the type of health system a community receives. Heath care providers will never be given enough resources to satisfy all the demands placed upon them by a community that is becoming increasingly informed and demanding. This paper discusses the matter of justice as it relates to the distribution of health resources. It translates the theoretical constructs of distribution into a practical situation that arose at The Geelong Hospital. It is important to emphasise that the aim of giving the example is not necessarily to provide the right answer but rather to assist in determining what ought to be the questions.

Checks and cheques : implementing a population health and recall system to improve coverage of patients with diabetes in a rural general practice

Identification of all diabetic patients in the population is essential if diabetic care is to be effective in achieving the targets of the St Vincent Declaration.¹ The challenge therefore is to establish population based monitoring and control systems by means of state of the art technology in order to achieve quality assurance in the provision of care for patients with diabetes. ^2,3 Disease management receives extensive international support as the most appropriate approach to organising and delivering healthcare for chronic conditions like diabetes.⁴ This approach is achieved through a combination of guidelines for practice, patient education, consultations and follow up using a planned team approach and a strong focus on continuous quality improvement using information technology. ^5,6 The current software (Medical Director) could not easily meet these requirements which led us to adopt a trial of Ferret. In designing this project we used change management⁷ and the plan, do, study, act cycle⁸ illustrated in Diagram 1.

Health care provider and consumer understandings of cultural safety and cultural competency in health care : an Australian study

There is increasing recognition in Australia that racial and ethnic minority groups experience significant disparities in health and health care compared with the average population and that the Australian health care system needs to be more responsive to the health and care needs of these groups. The paper presents the findings of a year long study that explored what providers and recipients of health care know and understand about the nature and implications of providing culturally safe and competent health care to minority racial and ethnic groups in Victoria, Australia. Analysis of the data obtained from interviewing 145 participants recruited from over 17 different organizational sites revealed a paucity of knowledge and understanding of this issue and the need for a new approach to redress the status quo.

A cost-based equity weight for use in the economic evaluation of primary health care interventions: case study of the Australian Indigenous population

Background : Efficiency and equity are both important policy objectives in resource allocation. The discipline of health economics has traditionally focused on maximising efficiency, however addressing inequities in health also requires consideration. Methods to incorporate equity within economic evaluation techniques range from qualitative judgements to quantitative outcomes-based equity weights. Yet, due to definitional uncertainties and other inherent limitations, no method has been universally adopted to date. This paper proposes an alternative cost-based equity weight for use in the economic evaluation of interventions delivered from primary health care services.

Methods : Equity is defined in terms of 'access' to health services, with the vertical equity objective to achieve 'equitable access for unequal need'. Using the Australian Indigenous population as an illustrative case study, the magnitude of the equity weight is constructed using the ratio of the costs of providing specific interventions via Indigenous primary health care services compared with the costs of the same interventions delivered via mainstream services. Applying this weight to the costs of subsequent interventions deflates the costs of provision via Indigenous health services, and thus makes comparisons with mainstream more equitable when applied during economic evaluation.

Results : Based on achieving 'equitable access', existing measures of health inequity are suitable for establishing 'need', however the magnitude of health inequity is not necessarily proportional to the magnitude of resources required to redress it. Rather, equitable access may be better measured using appropriate methods of health service delivery for the target group. 'Equity of access' also suggests a focus on the processes of providing equitable health care rather than on outcomes, and therefore supports application of equity weights to the cost side rather than the outcomes side of the economic equation.

Conclusion : Cost-based weights have the potential to provide a pragmatic method of equity weight construction which is both understandable to policy makers and sensitive to the needs of target groups. It could improve the evidence base for resource allocation decisions, and be generalised to other disadvantaged groups who share similar concepts of equity. Development of this decision-making tool represents a potentially important avenue for further health economics research.

What's needed to increase research capacity in rural primary health care

The aim of this study is to identify ways to build research capacity within primary health. A consultation was undertaken in late 2004 using a combination of a one-page survey and a guided meeting format, in a primary health setting in rural NSW. Most (81.3%) of the 134 individuals consulted were part of an Area Health Service, with 12.7% from non-government settings. Most (80.6%) were clinicians, with a third (31.5%) nurses, 8.3% in medicine, and the remainder from a range of allied health professions. Eleven organisations were represented. The main  outcome measures were identification of support needs, processes to enhance research engagement, and barriers and enablers to clinicians’ research  involvement. The results showed that popular delivery modes for research training and support were courses and “one-to- one” advice. Writing topics were generally more popular than others. Common barriers were time and technology issues. A key enabler was a discipline-specific focus. This is one of few rural Australian  consultations on research needs in primary health conducted with a diverse  range of clinicians at the clinician level. It will direct future research capacity  building efforts towards maximising face-to-face discipline specific options and  minimising technology use.

Geelong community's priorities and expectations of public health care

Abstract This thesis set out to achieve the following objectives: (1) To identify the priorities and expectations that the Geelong community has of its public health care system. (2) To determine if there is a common view on the attributes of a just health system. (3) To consider a method of utilising the data in the determination of health care priority setting in Barwon Health. (4) To determine a model of community participation which enables ongoing input into the decision making processes of Barwon Health. The methodology involved a combination of qualitative and quantitative research. The qualitative work involved the use of focus groups that were conducted with 64 members of the Geelong community. The issues raised informed the development of the interview schedule that was the basis of the quantitative study, which surveyed a representative sample of 400 members of the Geelong community. Prior to reporting on this work, the areas of distributive justice, scarcity and community participation in health care were considered. The research found that timely access to public hospitals, emergency care and aged care services were the major priorities; for many people, the cost was less relevant than a quality service. Shorter waiting times and increased staffing levels were strongly supported. Increased taxes were nominated as the best means of financing the health system they sought. Community based services were less relevant than hospital services but health education was supported. An egalitarian approach to resource distribution was favoured although the community was prepared to discriminate in favour of younger people and against older people. There was strong support for the community to be involved in decision making in the public health care system through surveys or focus groups but very little support was given to priorities being determined by politicians, administrators and to a lesser extent, medical professionals.

Rural primary health care workers and research : what is their present capacity?

Aims & rationale/Objectives : The main objectives of this project were to:
- conduct an audit of research skills and experience of primary health care staff in nine south western Victorian not-for-profit agencies
- identify capacity for research in five pre-identified areas
- investigate unpublished research endeavours/innovative projects taking place in the linked community organisations.
Methods : A 9-item survey was developed and will be distributed to all primary health care staff at the nine agencies via the internal email system of each organisation. The survey was developed after consultation with several agency directors, to obtain an organisational perspective on research capacity issues. Staff were also invited to take part in informal focus groups exploring key themes.
Principal findings : This study is in progress, and is expected to be completed at the end of March, 2007. Expected findings are the identification of primary health care staff's capacity for research, and discussion of relevant organisational assistance which would develop their research skills or enable continued participation in research.
Discussion : Phase 2 of the Australian PHC Research, Evaluation and Development Strategy aims to support the development and expansion of the primary health care research workforce. Findings from the current study will support this goal by assisting rural primary health care workers to identify the training and support they need to undertake quality research. The data could also be used to: a) assist the consortium to identify common research interests; b) to inform the consortium regarding the potential for collective research efforts; and c) to support funding submissions from the consortium or from individual agencies.
Implications : These findings will help to inform improved strategic planning in relation to building research capacity. The data could also be used by participating agencies to support applications for research grant funding.
Presentation type : Poster
Session theme : Building research capacity

Primary mental health care reform in Australia : the vision and the reality

Reports on primary mental health care reform in Australia 1991-2001 and the involvement of general practioners as the key providers. Investigates the degree to which the vision of policy makers and key stakeholders for a more integrated and effective system had been achieved. Findings suggested there is a considerable mismatch between the policy vision and the implementation reality and that the current system falls short of providing the support and systemic changes necessary for GPs to provide effective mental health care.

ICT alternative for primary care delivery in Indonesia : a proposal

This paper proposes a new research program and presents a current analysis of the potential of health information systems (HIS) to improve primary care delivery in rural Indonesia. A new HIS will be implemented to facilitate patient centred primary care and to support the interactions and collaborations between three types of participants including the patient, their doctors and pharmacist in Malang, Indonesia. A tetradic relationship between the new HIS and three participants (patient, doctors, and pharmacist) is examined through the lens of the actor network theory (ANT) with a view to form a new healthcare service delivery model for primary care providers in Indonesia. Based on this model, a network of primary care providers would share the patient medical records (PMR) and provide collaborative care programs to promote healthy life styles, prevent diseases, and to manage chronic disease care more effectively and efficiently.