Background
How does change affect rural health service sustainability?
Methods
Ethics
Results
How did Elmore develop a successful PHC service?
i. Community engagement
ii. Strong leadership and committed champions with a vision
iii. Strategic relationship building
iv. Health service linkages
How is the EPHS sustaining itself in the face of significant changes?
Core health service sustainability requirement | Threats to service sustainability | Impact of threats on sustainability | Elmore health service responses and outcomes |
---|---|---|---|
Addressing EXTERNAL threats to environmental enablers
| |||
Supportive policy environment
| Changes in IMG legislation/regulations | • Recruitment and appointment process for IMGs is more difficult | • Targeted recruitment of potential doctors by EPHS staff • Greater dependence on assistance of Rural Workforce Agency Victoria (RWAV) |
• Changes in funding arrangements (e.g. after-hours services) | • Affects total amount and mix of funding available to service | • Broaden income base through more education and training, research and incentive funding | |
• Changes in government funding schedule and service indicators | • Attempts by government to reduce the 'red-tape' requirements have complicated service performance monitoring and associated quality improvement | • Strengthen link with research evaluation team to identify and maintain sentinel indicators for measuring performance | |
Clearly-articulated Federal-State roles and responsibilities
| • Announcement of nation-wide orientation to PHC models and organisations (Medicare Locals) | • Implementation distracting service staff and workforce agencies from 'core business' | • Service is positioning itself with key agencies and authorities to maintain its role and visibility in new regional organisational arrangements |
Strong community involvement
| • Changing demography; impact of natural disasters (floods, bushfires) in the catchment area | • Population change due to ageing and in- and out-migration make it difficult to engage broad population in early intervention and results in need for different services | • Establishment of a single-point-of-entry to comprehensive PHC ensures access to the range of integrated services providing acute and chronic care, health promotion and disease prevention • Regular consultation with community about service changes |
Addressing INTERNAL threats to service sustainability requirements
| |||
Workforce supply and mix
| • Rapid expansion of EPHS catchment (i.e. into surrounding regions: 'hub-and-spoke' model of visiting services and establishment of permanent services in surrounding region) | • Risk of expansion beyond workforce capability and service capacity, high cost of ongoing recruitment | • Targeted recruitment ensures prospective staff are well-matched to service • Use of one doctor to provide locum relief across all sites |
• Ongoing dependence on IMGs | • Risk of short length of stay and need to re-recruit as IMGs relocate to metropolitan areas for cultural and family reasons | Staff retention maximised by: • Good matching of recruits to the service • Strong supervision and support for continuing professional development • Capitalising on the full range of workforce incentives • Critical mass of GPs means after-hours work is not too demanding and enables part-time work • Multidisciplinary teamwork reduces isolation and workload | |
• Growth of GP 'superclinic' in nearby large regional centre [23] | • May provide a more attractive alternative practice location for doctors | • Existing service maintains comprehensive whole-of-patient and community care activities that provide many professional opportunities and career satisfaction | |
• Older staff seek retirement or career change | • Need for pro-active succession planning to minimise impact of loss of experienced staff | • Links to Monash University and RWAV as a teaching practice for medical students and registrars • Proactive succession planning | |
i. Linkages
| • New leadership and change within partner organisations and government authorities | • Established relationships can be threatened by new arrangements that do not meet local needs and the complex public-private mix of services, ownership and investment arrangements | • Close collaboration with partners and ongoing involvement with established research team |
ii. Infrastructure
| • Infrastructure renewal required to accommodate organisational change and additional services | • Remodelling existing 'hospital' infrastructure can result in perceived 'loss' of services by some community residents | • Capitalising on infrastructure grants (e.g. new payment facilities, remodelling of infrastructure and 24/7 emergency care) |
iii. Funding
| • Dependence on fee-for-service funding and high level of bulk-billing • Changes to funding arrangements for after-hours service | • Diversification of financial sources required to ensure viability (i.e. total funding and blended-payment funding) | • Service capitalises on full range of financial incentives on offer (e.g. additional funding for after-hours service) |
Alternative services available in surrounding communities | • Patient attrition (e.g. following "usual doctor" to another practice, minimising the distance travelled by 'one-stop-shopping' in larger centres) affects income stream | • The comprehensive integrated range of services minimises patient leakage and maximises practice income | |
iv. Governance leadership and management
| • Leadership changes (e.g. principal GP expands practice to other towns; new Chief Executive Officer recruited to key partner organisation [BCHS]) | • When organisational leaders reduce or withdraw their services, the community may experience a sense of "loss" and perceive the quality of the services to have declined • Potentially weakened relationships between key partners | • The need for pro-active leadership succession planning within the health service is recognised • Mentoring new staff for clinical leadership roles • Practice manager shares expertise with and devolves responsibility to other administrative staff • Use new developments (e.g. building works) as an opportunity to revitalise relationship with key partners and extend opportunity for joint service provision |
Implications for policy, practice and research
Lessons for policy-makers, service providers and consumers
-
Importance of monitoring service performance to ensure appropriate, high quality care: Validated, evidence-based performance indicators are required to measure sentinel aspects of service provision. However, compliance with best practice can only be assessed if there is a system to enable monitoring of activities over time against performance benchmarks. Quality improvements not only benefit patient care, service efficiency and professional satisfaction, but can also increase the funding coming into the health service.
-
Remaining alert to environmental enablers: The nature, scale and speed of changes at both macro and micro levels requires continuous assessment of their direct and indirect impacts upon the performance and sustainability of the local service.
-
Community participation: Just as community participation was vital in the evolution and acceptance of a comprehensive PHC service, so ongoing community involvement is required to sustain a service geared towards community needs and in managing the impact of change. It is essential that information is shared beyond the service about what changes are occurring, why, and their likely effects in order to avoid a perception of loss of services or decline in the quality of care as the service evolves and adapts to new external requirements.
-
Succession planning: Community leadership succession planning is essential to maintain dialogue between the community and the health service. For example, some of the early community leaders no longer play such a central role in advocating for the health needs of the community and in informing the community about what is happening in the service - new leaders are now required. Organisational succession planning is vital. Staff recruitment and development processes should ensure leadership skills (e.g. vision, good communication, initiative) exist within the staff group.
-
Evaluation funding: Longitudinal evaluations require (i) appropriate funding to make them happen, and (ii) an anchor person within the service. While monitoring service performance should be integral to health service activity, the reality is that significant time, skills and expertise are required to establish an appropriate methodology, data collection and analysis framework for a specific service. Data collection and feedback for rigorous health service evaluation is a process rather than a one-off activity. Few services have the additional capacity or skills to undertake such monitoring. The timeliness and consistency of data collection activities can be improved by identifying and training a suitable person within the service to undertake the evaluation tasks (while acknowledging the need for succession planning for these tasks). External funding for evaluation should therefore make appropriate recompense for service time and include provision for capacity building.
Lessons for researchers undertaking collaborative health service evaluation
-
Demonstrable benefits to both parties: Evaluations risk being intrusive and onerous unless they are developed collaboratively and there is an explicit feedback loop. Benefits may include simultaneously the capacity to bring about quality improvement for the health service, and the generation of new knowledge for academics.
-
Capacity building, communication and commitment: Health service evaluation should be embedded as an integral aspect of a service [24]: long-term health service evaluations are at risk if they are overly dependent on a single person and not well-founded among all health service staff. Excellent ongoing communication between the evaluation team, the staff and the consumers of the health service is therefore vital. Regular meetings, newsletters, feedback presentations, and reference groups all contribute to a lasting relationship that provides security to the study.
-
Knowledge translation: Rigorous evaluation can constitute good research. Not only can it generate new knowledge, but often more importantly these insights bring applied benefits to the health care available to communities; contribute to better and more viable health care services; and assist policy-makers to respond with appropriate and effective program support and interventions.