A tale of two cities: academic service, research, teaching and community practice partnerships delivering for disadvantaged Australian communities

Cessnock Uni-Clinic provides the clinical environment to develop extended roles for women’s health nurses, practice/triage nurses, dietitians, mental health and drug and alcohol nurses, and other non-medical primary health care providers. The New South Wales Health Integrated Primary Health Care and Community Services Program (IPHCCSP; http://www.health.nsw.gov.au/pubs/2005/integrated_phcc_eoi.pdf) sees Cessnock as a lead site and integration is now proceeding well.

The Inala Chronic Disease Management Service identifies the opportunities available when local health services adopt integrated models of clinical care, information exchange, professional development and governance. Its clinicians will take a greater role in coordination of care, insulin management, onsite screening for diabetic retinopathy, and management of early chronic renal failure.

The Cessnock clinic offers diabetes care plans, asthma care plans, vaccination clinics, aged health assessments, case conferencing, chronic disease management plans, mental health assessments and counselling, and men’s health and women’s health clinics. Because of its success, the building has recently been tripled in size, allowing a much-needed increase in staff numbers and ability to deliver services.

Inala Primary Care has a strong focus on a broader health care team, care planning across biopsychosocial aspects of care, and patient self-efficacy. Staff are involved in advanced training by means of flexible modules from the University of Queensland Master of Medicine (General Practice) and nursing programs.

Inala Primary Care uses the Australian Government Department of Health and Ageing’s “Lifescripts” lifestyle intervention11 and a motivational counselling approach with its GPs and practice nurses. It also actively identifies those at risk of lifestyle-related illness for group, individual or family sessions with the Inala Chronic Disease Management Service team or the community health service.

Cessnock Uni-Clinic used a general practice model to tackle the problems of inequitable access to health care within a disadvantaged community. It approached the problem of small practice size by creating a multidisciplinary team of health professionals who apply their unique skills where they are truly appropriate. Integration of primary care services with other parts of the health system has been stimulated by the IPHCCSP, and relationships and joint programs are being developed with the community services of Hunter New England Area Health Service. Integration of some services, such as palliative and diabetes care, is already working well, and integration of others is being explored through a combination of virtual integration and collocation.

Programs such as the Inala Chronic Disease Management Service have established formal care delivery linkage for local general practices with both community health and public hospital services.

Cessnock Uni-Clinic has created a thriving general practice presence in a health service void. The Inala approach has allowed a chronically understaffed outer urban general practice to reach full staffing potential in 2007. The reorientation of triage and chronic disease management services around a model of partnered clinical management between doctors and nurses has encouraged and invigorated all clinicians to focus on an accessible, evidence-based care model. These successes reinforce the experience of programs such as More Allied Health Services (MAHS), which have demonstrated an ability to attract health care workers to difficult areas by offering role flexibility and innovative models of practice.12

Exemplars of innovative practice are possible only where local vision, leadership, and clinician and community commitment allow them to gestate and grow.13 The historical “disconnect” between general practice, acute care and community health services results in a fragmented, inefficient system that serves patients poorly. Redressing this arrangement requires political will and leadership, clear organisational roles and responsibilities, a commitment to services orientated around community need, and local integrated governance arrangements.13

The difficulties stemming from Australia’s system of health care funding and delivery being divided among federal and state governments are much reported.14,15 A number of settings have now been able to overcome these challenges16 and many more could follow suit with the cultural changes described above.

The Health Insurance Act 1973 (Cwlth) was groundbreaking in its day. However, it was written for a model of practice that is no longer appropriate 30 years later. Over the years, there have been many amendments, but its continuing literal interpretation remains a substantial impediment to the delivery of multiprofessional health care in 2007.

Effective evaluation of change in practice across community and hospital sectors, and the impact of such change on both consumers and the health care system, is sadly lacking in Australia. Queensland Health has recently moved to redress this, with one of the criteria for the multimillion-dollar state innovation grants being the requirement to have methods robust enough for publication.17 Academic departments should be strong partners in such projects.

Clinicians and communities are thirsty for better coordinated and more easily accessible care.14 Creating incentives — clinical, organisational, and business-related — that encourage efficient integrated approaches to patients and communities would be an excellent start. General practice sees nearly 90% of the Australian community each year;18 no other setting or service group can achieve this level of contact. Better use of general practice as the “hub” for other community and acute care “spokes” would allow more efficient use of scarce resources in both the public and private health sectors. The broadening team of health care workers in many practices now allows a much broader scope of preventive and comprehensive care in general practice than has been previously possible.

To make such changes happen in general practice, we need to examine the commonalities at both University practice sites. These were:

• a focus on important community health needs;

• matching service style to the available workforce, the broader health environment and an evidence basis for effective care;

• carefully managing the change process with practice personnel and local stakeholders;

• taking time to choose the right clinical model of care, communication infrastructure, professional training, and governance arrangements to make the innovation a sustained reality;

• measuring and reviewing progress and deliverables regularly; and

• being bold, well researched and relevant to the local communities.

While changing approaches to general practice are unfolding across Australia, the innovative models of practice described in this article demonstrate both the commitment of academic general practice departments to support such initiatives, and their special abilities to incubate the changes and measure their impact. Academic general practices are ideal vehicles for piloting and formally evaluating new models of primary care. They must be brave enough to push the barricades over, ever vigilant to work in partnership with local practices, and willing to share the benefits of good research in the crucial area of service delivery with the Australian and international communities.