Questioning the sustainability of primary health care innovation

According to Starfield,1 the birth of contemporary interest in primary health care can be traced back to the 30th annual meeting of the World Health Assembly in 1977. This meeting set in motion a series of activities including, in the subsequent year, the Declaration of Alma-Ata.2 Drawing on the principles enunciated in this Declaration and a more recent review,3 the Australian Primary Health Care Research Institute (APHCRI) has defined primary health care as:

In the face of the pressures associated with ageing populations (and related rises in comorbid, chronic health conditions), increasingly expensive health care technologies, changing community expectations and increasing inequalities in health outcomes, many countries are undergoing significant health system reform.4,5 Strategies to control costs and improve health outcomes have frequently strengthened the role of primary health care,4 a reorientation well demonstrated by the national health policies of the United Kingdom and New Zealand. Australia has also seen a plethora of large and small-scale initiatives aimed at strengthening primary health care, although these are not enshrined in a national health policy. Large scale efforts include the national Coordinated Care Trials of funds pooling and care planning, the Indigenous health Primary Health Care Access Program and, more recently, the Australian Primary Care Collaboratives Program. At a more local level, Divisions of General Practice6 and Area Health Services have implemented a wide range of programs and activities to strengthen general practice and primary health care. However, all too often, we know little about the sustainability of these reforms. Yet this question is the key to progress; the alternative is a health system landscape littered with short-term programs, projects and interventions which are developed and tested but do not survive.

Sustainability is an inherently dynamic construct that has to do with keeping going; enduring without failing or giving way; bearing up or withstanding (Shorter Oxford dictionary). Although questions about the sustainability of primary health care initiatives are of paramount concern in developing countries,7,8 there has been limited interest elsewhere. In their systematic review of diffusion of innovation in health systems, Greenhalgh and co-authors found so few studies addressing sustainability that they did not include it in their journal article based on the review.9 Despite this, it has been considered within Australia in relation to services in rural and remote settings,10-13 and in after-hours services in New South Wales14 and Queensland.15

The APHCRI was established in 2003 with core funding from the Australian Government Department of Health and Ageing. The Institute is expected to:

• Innovation in state–Commonwealth relationships;

• Innovation in funding arrangements for new or existing services/models; and

• Innovation in organisation and linkages within the primary health care sector.

To get started, the APHCRI decided to address the question of sustainability of existing initiatives that represented innovation in one or more of these areas. For the purposes of this program of work, we are adopting Greenhalgh et al’s9 definition of innovation as a “novel set of behaviors, routines and ways of working that are directed at improving health outcomes, administrative efficiency, cost effectiveness, or user’s experience and that are implemented by planned and coordinated actions.” Five initiatives, diverse in nature and scope were selected, becoming the first “spokes” in the APHCRI’s “hub and spoke” model. They were:

• The Care and Prevention Programme for people living with HIV;

• A trial of smoking, nutrition, alcohol and physical activity interventions;

• A regional integrated Aboriginal mental health program;

• Two related initiatives investigating pathways of primary mental health care; and

• The Sharing Health Care Initiative implemented in an Indigenous community-controlled health care setting.

The mental health pathways initiative has explored two approaches to mental health care: the Primary Care Evidence Based Psychological Interventions (PEP) project and Panic Online. The PEP study, which is being undertaken in Victoria, is evaluating the effects of training general practitioners in focused psychological strategies for the management of mental health disorders in their patients. It is funded by the beyondblue Victorian Centre of Excellence in Depression and Related Disorders, a collaborative initiative by beyondblue: the national depression initiative and the Victorian Department of Human Services. Panic Online is an online therapy program developed and maintained at Monash University (http://www.med.monash.edu.au/mentalhealth/paniconline) by a team of investigators. It is designed to evaluate the use of online mental health resources by GPs who have been accredited to deliver focused psychological strategies in their treatment of patients with common mental disorders.

The Sharing Health Care Initiative is trialling a model of self-care in the management of chronic disease under the direction of the Katherine West Health Board in the Northern Territory. It involves employment of local Aboriginal Community Support Workers, supported self-management for individuals and their families, community-based health promotion initiatives, and training health professionals to teach chronic disease self-management.

Their reports follow. In keeping with the diverse nature of the initiatives, the spokes have taken different approaches to the question, with different emphases. However, within the six domains of sustainability some common themes emerge. These are addressed elsewhere in this Supplement (Sibthorpe et al).16