The effectiveness of competency-based education in equipping primary health care workers to manage chronic disease in Australian general practice settings

The delivery of chronic disease care, and workforce training for this task, involves many organisations with overlapping roles and responsibilities. For some organisations, health service delivery and/or education are at the core of their charters, while for others the connections are more peripheral. Yet all act in ways that shape or affect policy.

Australian Government involvement in chronic disease care is primarily through the Department of Education, Employment and Workplace Relations, the Department of Health and Ageing and the Office for Aboriginal and Torres Strait Islander Health. State and territory departments involved include those for education and health. Many educational organisations also play a role — some funded by government, some by members or through private fees, and some by combinations of these. They operate across a learning continuum, from undergraduate through vocational training to continuing professional development. They include universities, colleges (eg, the Royal Australian College of General Practitioners, the Australian College of Rural and Remote Medicine and the Royal College of Nursing, Australia), Australian General Practice Training’s regional training providers, postgraduate medical councils, and continuing professional development providers. Other organisations also have a direct interest in chronic disease care. These include the Australian Medical Association (AMA), chronic disease organisations (eg, the Australian Lung Foundation, Diabetes Australia), self-management groups, the pharmaceutical industry and private health insurers.

At a national level, one policy option might be a simple but prominent statement included in a relevant strategy (eg, the National Primary Health Care Strategy proposed by the Rudd Government20) that makes clear that education and training, together with evaluation and research, are essential to realising optimal health outcomes for people with chronic disease. This would give all actors an educational “flag” around which to rally.

What can be said about the context in which the policy options will play out? The inherent complexity arising from the number of actors is compounded by the stress characterising the general practice setting. Educators are also clinicians, and increasing clinical demands are made on their time. Although CBE is often located in the workplace, the dominant small-business private model of Australian general practice has limited the ability to provide physical space for educational activities. All educational providers face budgetary difficulties paying educators to teach. General practitioners have competing demands outside any educational initiative. For example, a GP, confronted with new Medicare item numbers, continuing professional development requirements, accreditation, and business management complexity, may feel so pressured that he or she is unwilling to contribute to educational activities. The inherent complexity is further compounded by the needs of particular communities, including rural and remote communities, culturally and linguistically diverse groups, or Aboriginal or Torres Strait Islander peoples.

Policy options directed at lessening this stress include the provision of capital for training general practices to expand their capacity; remuneration packages for trainers that minimise financial penalties arising from the displacement of clinical activity; and supportive organisational structures to minimise any additional administrative impact of educational activities. With regard to the latter, the positive experience of the rural clinical schools program is informative.

Chronic disease and general practice/primary health care workforce shortages are high on Australian governments’ policy agendas. Significant investments have been made to address workforce shortages (eg, increased places for medical and nursing students at universities) and chronic disease (eg, the 2005 National Chronic Disease Strategy and the 2006 Australian Better Health Initiative).

Considerable changes have also been made to the Medicare Benefits Schedule, extending rebates beyond the medical profession following the Productivity Commission’s health workforce report.1 These initiatives are service-delivery oriented.

A key challenge is to garner explicit policy support, within these and other frameworks, for a forward-looking chronic disease education and training agenda across disciplines, and at all stages of the educational continuum. To ensure the evidence base continues to develop, educational initiatives should be complemented with major and sustained investments in applied research and evaluation activities targeting the delivery, organisation and funding of high-quality chronic disease services.

In mobilising support for these outcomes, care must be taken not to promote one chronic disease at the expense of another, or at the expense of education and research examining service delivery to people with coexistent chronic diseases.

As key sources of research funding, the National Health and Medical Research Council and the Australian Primary Health Care Research Institute would be actors. Implementation of particular CBE initiatives would be managed at a local level and would involve negotiations between relevant parties. The existing regional training provider network would be a logical place to start.

At a high level, policy content involves attempts to align funding streams in different parts of the system to drive particular activities. For example, contracts with educational providers may require interdisciplinary learning for parts of chronic disease courses. Regulatory changes may be needed to allow role extension (eg, prescribing by nurses) or new role creation (eg, physician assistant models).

At an organisational level, policy options are concerned with the content of specific CBE programs and their implementation. Based on our systematic review, candidate programs could include:

• analysis and planning;

• behaviour modification and patient education;

• clinical audits;

• clinical practice guidelines and clinical pathways;

• communication skills;

• critical appraisal;

• cross-cultural issues;

• disease registers;

• generalism;

• informatics and computer knowledge;

• leadership;

• patient self-management;

• prescribing;

• prevention, screening and early intervention;

• quality improvement; and

• teamwork.

Box 2 summarises the interplay between the actors (above the dotted line), context (general practice), process (service delivery, education and evaluation considered together), content (funding and regulatory roles of some of the actors as well as the role of standards) and how these connect with the steps in developing a CBE program. It also illustrates the interplay between educational outcomes (the vertical stack of boxes relating to competencies) and health, program and/or organisational outcomes that are part of the environment.

An overarching objective of policymakers, clinicians, and patients with diabetes might be to improve diabetic health outcomes. Sitting under this objective, the different groups might see diverse clusters of relevant intermediate objectives. Policymakers might focus on outcomes to do with access and delivery of care in the most efficient manner, and on population-level indicators. Clinicians might focus on clinical outcomes at individual patient level (eg, HbA1c concentration) or process measures (eg, date of last foot check). Patients might be concerned about costs associated with care. If CBE designers considered these different perspectives when developing new courses, and explicitly related the program’s educational objectives to them, it is more likely the program would be recognised as relevant by the many actors involved, thus increasing the likelihood of widespread support.

CBE programs should be developed in accord with educational best practice. Issues include the degree to which the program is aligned with standards, supported by an appropriate curriculum, assessed through validated and reliable formative and summative instruments and underpinned by continuous quality improvement cycles.

Universities, regional training providers, colleges, Divisions of General Practice, various non-government organisations and private companies are actively developing educational resources and activities relevant to chronic disease. The educational workforce is under pressure. It is sensible to actively pursue partnerships and collaborations to minimise possible duplication of effort. There will be times when such arrangements are impossible because of intellectual property considerations.

The multiple organisations in the training environment have legitimate interests as stakeholders, but will also face different pressures because of their diverse organisational goals. For example, a CBE program designed to equip practice nurses with competencies to prescribe selected medications in the context of ongoing chronic disease management is likely to raise AMA concerns about the roles and responsibilities of doctors and nurses. Optimal chronic disease management requires a fundamental change in health system orientation from acute, episodic and reactive care to proactive and continuing care. Any CBE program targeting chronic disease could be seen as part of a reform agenda and elicit vigorous responses.

Grol21 outlines key stages in the change process and strategies required in each for improving health service quality. These factors are relevant in implementing CBE programs, which are complex interventions aimed at behavioural change.

Many questions need to be asked. Have the program and the rationale been discussed and opinion leaders engaged? Is there interest and commitment? Do the parties have insight? Is there a positive attitude to the proposal? Have the programs been tested and do the results suggest both acceptability and benefit? Are the appropriate supports in place, such as extra staff and equipment? Can it become routine practice? Do incentives support its continuation?

Through consideration of the five questions discussed above, designers of CBE programs can take account of the interests and conflicting perspectives of the many stakeholders in the system. In doing so, it is unlikely that all perspectives will be included and reconciled within any one program, but their careful consideration will increase the likelihood of developing CBE programs that are widely accepted and supported.