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Primary health care (PHC) is recognised as an efficient, effective and equitable approach to health service delivery1,2 and successful PHC is integral to a sustainable and accountable healthcare system, and ultimately improved population health outcomes3. Internationally there is a move towards strengthening and improving the quality of PHC4,5. Nowhere is this more important than in rural and remote areas where, compared to metropolitan settings, there is poorer access to quality health care, and a disproportionate and preventable burden of morbidity and mortality6. In light of the ongoing reviews of the Australian GP Super Clinic Program7and Medicare Locals8, it is timely to consider what we can learn about health service performance, sustainability and quality from a longitudinal study of a rural Australian PHC service.
The Elmore Primary Health Service (EPHS) is a single-entry point private-public PHC model that provides services to its local and surrounding communities. The EPHS has been the focus of a longitudinal evaluation of its performance and sustainability for the past 6 years9. Elmore is located 46 km north-east of Bendigo and 170 km north of Melbourne, the capital city of the state of Victoria, with a population of approximately 66810. The current EPHS model was designed to meet local health needs following the closure of the town's hospital 8 years earlier.
The evaluation framework for this 6-year longitudinal study drew on Donabedian's quality of care paradigm that linked structure (health system performance), process (health service utilisation and satisfaction) and outcome (health behaviours, outcomes and community viability)11,12, together with a conceptual framework for primary healthcare performance assessment based on the 2002 National Health Performance Framework13. The details of these have been reported previously9,12.
Drawing on international and national health service research and policy documents14-18, several sentinel indicators for each important service domain were selected based on their technical merits, validity, likely longevity, applicability and the fact that these data were routinely collected and could be reliably extracted from primary care service and medical records. All quantitative data were extracted by an EPHS staff member and were collated in a de-identified and aggregated form for the university research team in order to ensure privacy and confidentiality of service and patient medical records. The Monash University Human Research Ethics Committee approved the study. To date, six annual data collection cycles (2007-13) of the EPHS have been completed.
Health service performance
The study sought to use routinely collected data to examine health service performance in terms of several key dimensions, including accessibility, appropriateness and continuity3.
Accessibility is defined as the ability of people to obtain appropriate health care at the right place and the right time irrespective of income, cultural background or geography. Several proxy indicators were used, such as 'bulk-billing' (ie no co-payment by patients) and service expansion within its catchment area19. Results to date show that, over the 6-year period, the proportion of 'bulk-billed' consultations increased to more than 80%, and all patients who required emergency care were seen on the day of contact, regardless of the time of day. Moreover, the service expanded from one central site to include three regular outreach GP services, so that patients previously presenting at Elmore were then able to access appropriate quality care at an alternative location closer to their place of residence.
Appropriateness is defined as a service that meets a patient's specific needs. Two key indicators that were used as proxy measures of appropriateness were number of full-time equivalents (FTE) of allied health professionals and female general practitioners (GPs). While these are only minimal indicators of every aspect of appropriateness, they are nevertheless seen as essential elements in service delivery in rural Australia where there are well-documented shortages of female GPs and allied health professionals20,21. Since the initial data collection in 2006-07, the number of FTE allied health service providers doubled to 1.2FTE while the female GPs FTE per 1000 women increased by 0.8 to 2.7.
Continuity, defined as uninterrupted, seamless and integrated care that is provided across the continuum of care, was measured through completion of GP management plans and 'cycles of care' (CoC)19. Over the 6-year period, CoC or GP management plan completions for the proportion of patients with asthma increased, and they decreased for patients with diabetes. Similarly, the proportion of active patients (≥75 years) who received health checks decreased. Importantly, service records indicate that the same reminder and recall system remained in place over this period.
Health service sustainability
Health service sustainability was monitored using proven indicators developed in relation to the key elements of workforce, funding, infrastructure, linkages, leadership, governance and management identified in previous research22. Staff profiles and funding sources are two particularly important indicators. During the study period the EPHS was actively engaged in recruiting and retaining staff and maintaining funding through several different sources. Over the 6-year period, the catchment population per GP FTE increased from 1159 in 2006-07 to 1552 in 2012-13. The number of practice nurses remained relatively stable (0.6-0.8 FTE) while the number of administrative staff decreased from FTE 7.0 in 2006-07 to 4.8 in 2012-13. As reported above, the FTE of allied health staff and female GPs both increased. In terms of funding during the study period, the proportions of total income diversified from more than 10 different sources, but remained relatively stable in total with two-thirds of income coming from Medicare.
Health service quality
Service quality was assessed using indicators relating to primary and secondary disease prevention and treatment goals. For example, from 2008-09 (data were not available for 2006-07) to 2013, the proportion of patients with recorded secondary prevention activities remained stable (>90%) for smoking status and for blood pressure. For the same timeframe, body mass index recordings increased from 46% to 59%, while treatment goal activity of haemoglobin A1c recordings increased from 75% to 80% amongst patients with diabetes mellitus.
What new knowledge has this study generated?
Several messages emerge from this study - specifically (i) the value and problems associated with using routinely collected data to monitor service performance, sustainability and quality, (ii) the benefits of working with health authorities and related jurisdictions to benchmark and use primary health service evidence to formulate policies and programs designed to meet population healthcare need, (iii) the importance of a longitudinal study design, and (iv) the importance of systematic service performance evaluation.
Challenges of using routinely collected data to monitor service performance and sustainability
The evaluation undertaken in this study illustrates the capacity for any small rural PHC service to monitor its own trends in performance, sustainability and quality. For example, the results show that the EPHS achieves high levels of patient accessibility as measured by an increased proportion of bulk-billing, seeing patients in a timely manner and the number of outreach services. However, while the EPHS is a multidisciplinary PHC service, some of the programs are provided by other agencies, and researchers do not necessarily have access to all the data collected by those services. This may compromise the comprehensiveness of the service evaluation and, potentially, consumers' experience of care23. Moreover, while from the outset of the study, every effort was made to select valid and reliable indicators likely to have longevity, this research strategy is not flawless in a rapidly changing health system environment. For example, changes to the funding of after-hours services, the reporting of site-specific immunisation coverage data and residential aged care facilities policy have meant that several of our indicators of health system performance (particularly effectiveness) are no longer available in a consistent and replicable manner necessary for longitudinal monitoring. Performance monitoring remains a challenge for both service providers and researchers whenever routinely extracted measures are changed to meet new policy and reporting requirements.
Working with health authorities and related jurisdictions to benchmark and meet population need
This longitudinal study has focused on one PHC service and its capacity to engage in and contribute to health system research. Its inception emerged from close synergies between the aims of the research team, the health service itself, the principal healthcare providers and the funding body. However, without other comparative sites or a population capitation system, it is difficult to rigorously evaluate the transferability of the evaluation framework that was used in this study or to determine how well the particular service responds to the health needs of its local community. In Australia, PHC network organisations such as Medicare Locals have an important role in ensuring that, collectively, services within that catchment are adequately meeting population health needs through the provision of high-quality, sustainable healthcare services. They will also play a key role in assisting services with data cleaning, linkage and analysis for the purpose of quality improvement and feedback to stakeholders.
The changing nature of the EPHS workforce to an increasing proportion of nurses and allied health professionals reflects greater diversity in health service delivery that, from our measures, has helped to increase the ability of the service to improve access to care and still maintain high-quality care. Further investigations into the relationship of how health care is provided and the quality of that care (as measured both normatively and from the perspective of consumers) should be considered in future research to improve our understanding of the potential for role substitution to address rural health workforce shortages23.
Importance of a longitudinal study design
Longitudinal PHC service studies such as this one are rare in Australia. Indeed, most evaluations of rural PHC services are conducted at a single point in time24. Such cross-sectional studies are significantly more limited in their usefulness, because it is not possible to examine trends over time and to link these to important changes that occur as a matter of course, both internally (eg service expansion or changes to the staffing profile) or externally in the policy and funding environment (such as changes to Medicare funding and the political importance of PHC in the complex Australian health system).
However, while the longitudinal data such as those presented here provide useful information relating to service performance, sustainability and quality, invariably they do not tell the full story. For example, while our measures of secondary prevention activities suggest improved quality of care, we were unable to link these to treatment goals. It is important also to take into account other information when interpreting apparent statistical trends. The evaluation of the EPHS collected and analysed a number of other sources of data (including community surveys and staff interviews) to assist our understanding of the trends shown in the service and medical record data. Importantly, this was done independently of the EPHS and we did not actively recruit frequent service users as research participants. Internationally, patients' perspectives are recognised as an important component of PHC service monitoring and evaluation25,26 and plans for ongoing work include engaging more closely with service users.
Importance of systematic service performance evaluation
Increasingly, evaluation of service performance is recognised as one important factor in ensuring there is consistency of quality PHC care to communities. Such an activity is integral to the ongoing collection of information required of health services by health authorities and government agencies. Identifying an appropriate but adaptable evaluation framework to guide the collection of data can facilitate an efficient and reliable process that enables performance monitoring for both internal quality improvement purposes as well as external benchmarking, so that services can learn from each other about how best to deliver efficient and effective care to their patients.
Conclusions
Sustainable, accessible PHC has a key role to play in health service provision for rural populations, and can help to guide policies designed to overcome some of the disparities in health outcomes experienced by rural Australians when compared to their metropolitan counterparts. It is essential to understand the key principles required for the provision of responsive, sustainable rural services in which longitudinal studies can play an important role. The framework and indicators developed for this 6-year study have proven to be useful in the provision of objective, relevant and comprehensive information and could be further refined for future rural PHC services research.
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