|ORIGINAL RESEARCH PAPER
|Year : 2007 | Volume
| Issue : 2 | Page : 60
Project to Policy: TUFH Principles in Action in Australia
I Cameron1, V Matic2, R Mathews3
1 NSW Rural Doctors Network, Newcastle, NSW, Australia
2 Walgett, NSW, Australia
3 NSW Health department, North Sydney, NSW, Australia
|Date of Submission||28-Jun-2007|
|Date of Web Publication||26-Aug-2007|
3/133 King St Newcastle 2300 NSW
Source of Support: None, Conflict of Interest: None
Context: In 1999, Towards Unity For Health developed principles for patient-based health systems which included partnerships, raising the level of partnerships, integration of individual, population and public health, information management and measurement of outcomes.
Objective: To address the health workforce crisis in an area of remote north western New South Wales (NSW) in Australia.
Method: The NSW Rural Doctors Network applied the TUFH principles in overcoming much of the crisis and developing an ongoing local health system which has answered many of the local needs.
Conclusion: The project provided experience for policy change and development at both State and National levels.
Keywords: Rural, Health, General Practice, Integrated Primary Care, TUFH
|How to cite this article:|
Cameron I, Matic V, Mathews R. Project to Policy: TUFH Principles in Action in Australia. Educ Health 2007;20:60
The region of NSW described covers 22,000 square kilometres and includes the small towns of Walgett, Lightning Ridge, and Collarenabri. Its population is 8,307 with 21% of the population being Aboriginal people (Australian Bureau of Health Statistics, 2001). The area has some of the worst health outcomes statistics in Australia. While it is always an arid region, from 1999 the whole area has been in extreme drought with consequent severe economic and social distress. It is an area that has always struggled to maintain a health workforce.
In rural areas in NSW, General Practitioners (GPs) provide services both to public hospitals (remunerated by the NSW State Health Department) and in the community (largely remunerated by the Australian Government through its national health insurance Medicare scheme). GPs traditionally operate as small business cottage industries. By 2001, the area was down to three doctors, two of whom were not providing services to hospitals, one of whom became ill and unable to practice soon after. It was plain that GP services were not sustainable and without GPs other health services could not provide the needed level of service.
The NSW Rural Doctors Network (RDN) is a Non-Government Organisation that is funded by the NSW and Australian Governments to increase the attraction, recruitment and retention of GPs in rural areas (NSW Rural Doctors Network 2006). It does this through short, medium and long-term strategies which include attracting rural youth into health careers, supporting positive rural experience for people training in health careers and acting as a network of support for existing GPs and their families. It works closely with Governments, communities, academic institutions, health service organisations and practitioners. While RDN’s overt focus is on increasing workforce, it has always taken a broader approach than individual recruitment and retention, more along the system encompassing lines of Human Resources for Health as operated by the World Health Organization.
The formation of the Walgett Shire Health Forum was the first step in moving towards a resolution of the crisis. The Forum came about in response to a health workforce crisis. Instead of the more usual consultative process by a lead agency, it brought the stakeholders together, at the same time, in open meeting. A classic TUFH pentagon of partnership (fig. 1), it has involved policy makers, health service organisations, practitioners, community and academics (Boelen, 2000). RDN formed and chaired the Forum, but other stakeholders had structural roles. The Shire Council provided meeting space and the Division of General Practice acted as secretariat.
At the same time RDN formed a not-for-profit company to manage infrastructure for GP services, including employment of staff, renting surgery space from Local Government, and ensuring housing for doctors. Known as Rural and Remote Medical Services (RARMS), it became an integral part of the pentagon. The formation of the Forum was the first step in raising the existing rural ad hoc integration to a higher level. This happened when various contractual arrangements flowed out of the forum including between RDN and the Australian Government, RARMS and the State Area Health service, and the Division of General Practice and the Australian Government.
Figure 1: TUFH pentagram
The beginning of RARMS created a platform for primary care. While still being based around the GP surgery, additional services included a much expanded role for practice nurses, employment of an Aboriginal Health Worker and a variety of allied health professionals. It also allowed uptake of Commonwealth funding for population health activity through RARMS, with GPs and other health workers involved in population chronic disease surveillance and management. The contract between RARMS and the Area Health Service for RARMS to manage GP services for the hospital has laid the basis for further integration of all primary care services, and a more formal integration of individual and public health services. The RARMS practice in Walgett has gone from one GP and a part-time receptionist in 2001 to three GPs, a practice manager, receptionists, practice nurses and visiting specialists including medical and nursing specialists and an exercise physiologist in 2006. While this has been led by the energy of one GP, it has been made possible by the Commonwealth funding for GP-based population and public health activities.
With separate funding from the Australian Government, RARMS and RDN have developed a web-based patient record system that articulates with the doctors electronic health records and allows viewing and input to patient records from any computer with web access.
Over five years, there has been a stability in GPs in a notoriously hard to recruit to area. There has been a substantial increase in services provided by other health professionals. For people living in the area, there has been a sustained increase in services provided in the community setting, and a corresponding decrease in primary care services provided inappropriately in the hospital. As is seen in Table 1, the commencement of RARMS in the last quarter of 2001 resulted in a rapid increase in GP services provided in the community Primary Care setting, and a corresponding decrease in GP services provided in Walgett Hospital.
Table 1: GP services in Walgett and Lightning Ridge 2000-2005
Anecdotally, there has been a substantial decrease in hospital admissions and in community morbidity.
Twelve new skilled jobs have been created locally. There has been a flow on effect in purchasing of services such as consumables and laundry locally. RDN estimates that the increased employment and services have resulted in A$2 million flowing into the town from outside, much needed local income at a time of severe drought.
The Walgett and Lightning Ridge experience was born out of crisis. It has been important to share the processes that led to success as well as those that did not work out with communities, health organisations and policy makers who are also looking for different directions in providing primary health services. Over the years, RDN has made available the details of the experience through:
- its website which includes details of process as well as details of position descriptions, contracts and office procedures (GP Entity Resources, 2006).
- two conferences bringing together health organisations, communities and policy makers who have been building similar alternative systems or who are looking towards doing it. The Practice Made Perfect? summaries are also available on the RDN website (Practice Made Perfect, 2006).
The State and Australian Governments have also used the Walgett and Lightning Ridge experience in developing new policy direction in primary health care.
In 2003, the NSW Government committed A$2 million to supporting GP entities similar to RARMS. In 2004-05, the NSW Government announced a major change to its primary care policy, with support for the development of Integrated Primary Health and Community Care Services (IPHCCS). These will bring together primary care services currently funded from State and Australian Government sources. Still there exists a fractured system where the State funds community health activity that includes allied health and nursing services to the whole community with an emphasis on both individual care and population health. The Australian Government funds, either directly or through Medicare, a large range of primary care activity, usually through General Practice. The development of IPHCCS provides an opportunity to integrate some of these activities. This would happen through locally developed governance structures that would include health organisations, practitioners, community and, in many cases, academic institutions.
The Australian Government is supporting with the States an approach to primary care which will lead to more integration of service delivery and a more coherent path for people accessing health services. The focus has been on providing a greater range of nursing and allied health services through General Practice. It has included strategies to reward GPs for an array of population health activities to complement the GP’s individual health role.
While the Walgett and Lightning Ridge experience cannot claim all the credit for these new policy directions, it is acknowledged by both Governments that it was a major influence in developing new policy.
- The TUFH pentagon of partnership had a dramatic effect in providing the consultative basis for building sustainable health services from crisis. The pentagon needs an anchor organisation, in this case RDN; but it could easily have been other organisations.
- From crisis, developed a project with opportunity to build and test structures which encouraged and used a move from ad hoc to more formal and contractual partnerships, health information and increased quantity and range of services
- The increase in the level of partnership led to a platform for integration of individual and population health, and of diverse service providers.
- The TUFH principle of measuring outcomes is essential if isolated projects are to become more generalised policies.
This was never easy. In a poor and remote area, the provision of all services, including health, will always be fragile. The principles of TUFH have helped in guiding and giving form to what happened. Much detail, including the things that did not work out, adaptations made along the way and regression to a more traditional structure has not been discussed here. However the project has led to a much more stable health workforce, an increase in health services, the beginnings of integrated primary health care and has influenced State and National policy direction.
The NSW Rural Doctors Network received funding from the Australian Department of Health and Ageing to establish RARMS.
Australian Bureau of Statistics (2001). Census Data. Available at http://www.censusdata.abs.gov.au/ABSNavigation/prenav/PopularAreas?&collection=Census&period=2001&&navmapdisplayed=true&textversion=false (accessed October 2006).
Boelen, C. (2000). Towards Unity For Health: Challenges and opportunities for partnerships in health development. A Working Paper, World Health Organisation, Geneva, Switzerland, 2000. Also available at http://www.the-networktufh.org/download.asp?file=aboutbrochure_pdf2.pdf (accessed October 2006).
GP Entity Resources. (2006). http://www.nswrdn.com.au/site/index.cfm?display=1509 (accessed October 2006)
“Practice Made Perfect?” (2006). http://www.nswrdn.com.au/site/index.cfm?display=39282 (accessed October 2006)