Models of multidisciplinary working: international review

Appendix 2: Australia Documents for Case Study

1) Literature Review prepared for the Northern Territory PHN: Models for practice and primary health human resource stability in rural and remote locations

Introduction

• Rural care is facing a crisis due to the current unsustainable health service delivery model, so a literature review was undertaken for possible alternative models.
• A theme across the research is that "the 'one coat fits all' model does not exist".
• The Literature Review identified 48 articles to include in their final set of recommendations.

Discrete Services model

• Discrete services were identified as a potential model for walk in/walk out clinics, particularly in rural areas.
• The Rural Doctors Network (RDN) in New South Wales analysed the effectiveness of this model in 2003.
• In this model (much like the planned model of SG rural care) practices were sublet to general practitioners by the local council. However, it was the GPs themselves who managed practices rather than delegating this to consultants/directors as suggested in the SG model. Any corporate decisions though still lay with a Board of Directors.
• This model proved fairly successful, with an increase in the number of resident doctors from 3 to 9, increase in outreach services and enhanced relationships including new strategic partnerships.

Integrated Services model

• There was no formal structure for developing this, so there was no pooling of resources as such.
• This model also had management at each site by a community-controlled board of proprietary company; general practitioners (GPs) acting as private practitioners with a proportionate contribution to practice management costs; allied professionals employed by the health authority; and effective consultation and collaboration to support integrated care.
• This model would work well in other settings. As the authors Taylor (et al) conclude, "Independent organisations can collaborate in the provision of integrated health care if they see mutual health benefits".
• However, as this model is quite new, at the moment it is too recent for its impact to be assessed.

Main challenges for primary health care (as identified by David, Macdonald and Williams)^[1]

• Lack of clear and consistent policy directions throughout the sector;
• Poorly integrated service planning; and
• Difficulty in accessing coordinated multidisciplinary and multisector care.

Comprehensive PHC Services

• These are broader in scope than most integrated service models and "include primary clinical care, preventative health promotion activity, as well as education and development in relation to workforce training and governance/community capacity building".^[2]
• The main example of a comprehensive PHC Services provider in Australia are the Aboriginal Controlled Community Health Organisations (ACCHO).

Aboriginal Controlled Community Health Organisations (ACCHO)

• Advantage: provision of comprehensive primary health care often encompassing emergency care, outreach services, acute health services, counselling and a range of educative and preventative programs.
• Has over time (with right connections) been able to maintain community support with a consciousness of social and cultural demands.

Outreach Services

• May include "Fly-in, Fly-out" (FIFO) models of delivery.
• Benefits included positive health outputs, increasing access to health specialists in remote areas and mitigating health professional's feelings of isolation.
• Concerns arising through these services include how outreach services had previously been delivered; factors contributing to the poor retention of Allied Health Professionals; and integration with other health providers.

Specialist Outreach

• This outreach aims to break down the barriers faced by Indigenous people in accessing health care services, such as geographical remoteness, poverty and health service structure.
• There will always be a cost associated with this in that as the patient is dealt with by outreach, the hospital-based service will need to take on more work as a result. This is known as an 'opportunity cost' – Gruen et al (2002).
• The benefits of specialist outreach in the Northern Territory of Australia include no need for patients to travel large distances, specialist interaction with primary care practitioners, and cost.

"Hub-and-spoke" models

• There were a number of benefits identified in this model, such as the opportunity to increase cultural sensitivity, local ownership and strong local linkage to the service.
• However, there is very little information on hard financials and the cost/benefit analysis of this model (and most of the other models in the literature review).

Fly-in, fly-out (FIFO) services

• There is some negativity around the costs of these services. Margolis notes (2012, p3) that the high cost of travel imposes an additional cost on health and aged care services.
• Some community members did identify an increased likelihood of confidentiality (noting that the FIFO professional does not reside in the community). Further research was also suggested by the authors on exploration of rural community views on the model.
• Wakerman (et al) in 2016 conducted a new study to assess the impact and cost of FIFO professionals, or the short-term health workforce across 54 remote clinics managed by the Northern Territory Department of Health. However, as this study is relatively new, it is too early to come to a conclusion.

Telehealth/telemedicine

• Telehealth did have good benefits, but it should not be used as a substitute for the provision of one-to-one health care.

Key issues for model and workforce sustainability

• Impact of globalisation, privatisation and depopulation on rural communities
• Stakeholder engagement on model and workforce planning in rural settings

"Core" primary health care services

• These featured very strongly in the literature review of each model.
• Across the research sourced and studied in producing this literature review, a broad range of authors agree on the need for a set of principles on which primary health care services and delivery models are built. Although the specific principles and their priorities differ across the spectrum.
• The literature makes reference to this set of commonalities when addressing a range of delivery models.

Conclusion

• The "one size fits all" model will not work and does not exist.
• Financial analysis is sparse.
• That said, there is a wide range of models that can be implemented, which is "limited only by imagination". These could be analysed and taken forward to shaping rural practice in Scotland (as these are just as relevant to Scottish rural areas as Australia).
• There is not the cultural issue of avoiding the doctor/health care in Scottish culture when compared to aboriginal culture in Australia.

2) NTH Strategic Health Plan (all slides)

Dr Hugh Heggie, Chief Health Officer, Department of Health

Strategic directions

A: Prevent illness

Goal of this strategic direction is to invest in and deliver health promotion across the lifespan, initially targeting reduction in at risk behaviours.

B: Focus on each person

Goal of this strategic direction is to create innovative and evidence-based models of health service delivery that deliver excellent patient experiences and improved outcomes in the context of the many unique challenges for service delivery.

C: Redesign to improve access

Goal of this strategic direction is to reduce duplication of service provision.

D: Lift performance towards excellence

Goal of this strategic direction is to create a reputation for being a workplace and environment where people want to come to work, live and learn.

E: Embed research

Goal of this strategic direction is to effectively and based on evidence achieve service delivery.

F: Systematise effectiveness and efficiency

Goal of this strategic direction is to pursue organisational excellence through effective systems.

Strategic Factors over the next 4 years – ACACIA (Core Clinical Systems Renewal Project)

10 National Standards (First Edition)

• clinical and organisational governance for safety and quality
• partnering with consumers
• preventing and controlling healthcare associated infections
• medication safety
• patient identification and procedure matching
• clinical handover
• blood and blood products
• preventing and managing pressure injuries
• recognising and responding to clinical deterioration in acute health care
• preventing falls and harm from falls

These are being revised to 8 in the Second Edition of National Standards through the gap analysis. The 8 in the Second Edition are:

• clinical governance
• partnering with consumers
• preventing and controlling healthcare associated infections
• medication safety
• comprehensive care
• communicating for safety
• blood management
• recognising and responding to acute deterioration

New & Proposed Actions

• 50 new actions introduced in the Second Edition of National Standards include public access to My Health Record, nutritional care and greater use of deteriorating patient response and recognition systems.
• Proposed key strategic action areas include a clinical governance framework for partnering with consumers and support of effective communication
• For the accreditation scheme, repeat assessments and assessor training have been proposed

Clinician Engagement

• There are three main clinical networks: a network for cancer care, for rehabilitation and for renal health.
• There is also a clinical senate.
• be beneficial for rural Scotland? Or should there just be a focus on patients as there are different health issues in rural areas?

Australian Northern Territory (NT) Health Clinical Quality and patient safety incidents, Jan 2015 – June 2018

• Concerning behaviour (incidents reported on a severity scale of 1-5) is a major issue across Australia
• This system requires better definitions to improve accuracy and analysis
• Staff should be better and more widely informed as to how to report such incidents

Hospital Acquired Complications (HACs)

• A hospital acquired complication (HAC) is "[a] complication acquired in hospital for which clinical risk mitigation strategies may reduce (but not necessarily eliminate) the risk of that complication occurring".
• These are assessed according to the following criteria: preventability; patient impact; health service impact; and clinical priority.
• Tests between 2014 and 2015 found that the HAC rate is 2.91 per 100 episodes
• From 1 July 2018, Australian Govt funding adjusted in line with HACs and risk of occurrence

Safety and Quality Reporting Framework

• Safety and quality reports already published by each area and help to promote quality improvement and governance

NT Health Strategic Plan 2018-2022 – Priority themes and recommendations

• Australian Primary Care Collaboratives and national KPIs have already helped to improve standards and data and continue a high quality/standard of service
• Barriers include lack of awareness and funding uncertainty (much like Scotland model)
• Hugh recommends that "There needs to be an overarching policy, framework and implementation of performance monitoring and CQI processes across the whole Primary Health Care sector and across the country".
• He also recommends that leadership supports governance, and leadership also supports management.

3) Advice to the National Rural Health Commissioner on the Development of the National Rural Generalist Pathway

Introduction

• This advice is a proposal to develop a Pathway to encourage doctors to become rural generalist practitioners and, more importantly, retain them.
• Tailored selection that involves the community is important and integral to this recommended pathway as it allows a better connection between health care staff and the community.

The Collingrove Agreement

• In January 2018, the two General Practice Colleges of Australia (the Australian College of Rural and Remote Medicine (ACRRM) and the Royal Australian College of General Practitioners (RACGP) came together at the invitation of the Commissioner to agree on what it means to be a Rural Generalist.
• This is known as the Collingrove Agreement, and states that:

A Rural Generalist is a medical practitioner who is trained to meet the specific current and future healthcare needs of Australian rural and remote communities, in a sustainable and cost-effective way, by providing both comprehensive general practice and emergency care and required components of other medical specialist case in hospital and community settings as part of a rural health care team.

The National Rural Generalist Taskforce

• In May 2018, this was set up to guide development of the rural Pathway and to "harness the broad-based expertise of the rural health sector".

Taskforce Recommendations

1) That the structure below is adopted by the Australian Health System.

2) That there is a holistic and integrated understanding of health and importance placed on the word "country".

3) That certain elements (see p11 PDF) are identified for development as part of the National Generalist Rural Pathway.

4) That certain Educational Outcomes (see pp.11-12 PDF) are adopted for the National Rural Generalist Pathway.

5) A funded evaluation programme monitors the impact and outcomes of the Pathway on trainees and supervisors within the rural medical workforce.

6) That the two General Practice Colleges support the national recognition, as a protected title, of a Rural Generalist as a Specialised Field within the Specialty of General Practice.

7) The development of endorsements to provide a public register of Rural Generalists' additional skills.

8) Functions for case management (such as tailored training) are added to the pathway.

9) Methods of continuous employment (e.g. a training contract with one employer) should be added to the business case for the pathway.

10) Clinical governance and genuine peer review, as part of this Pathway, is costed and implemented in a consistent way throughout Australia.

11) Consideration given to a tiered reform of the General Practice Rural Incentive Program (GPRIP), using the key standard that medical workforce incentives should recognise and reward working in more remote locations.

12) Support of a capital purchase by the rural community through 'front loading' of the GPRIP.

13) Widen the review of the Procedural Grants Program to include rural generalists.

14) Keep the existing indemnity process.

15) Locum access and professional development made available to all rural GPs throughout Australia.

16) Access to specialist items (including telehealth).

17) Increase of relevant Medicare provision and rural loading for all rural generalist services.

18) Rural hospital teaching and research is recognised in the Hospital Funding Agreements.

19) Recognition of a state certified Rural Generalist.

Relevance to Scotland?

• Recommendations 7, 9, 11, 12 and 16 seem most relevant to Scottish practices. The definition of 'rural' here is different and there are not the same cultural divides in the rural community

4) Core functions of primary health care: a framework for the Northern Territory

• Scotland could adopt many of the functions identified in this framework, such as providing effective management and leadership and developing staff. However, the cultural element is quite different, so the focus should be on allowing the rural community to purchase property and training medical staff to incentivise them to stay in this setting rather than move back to town.
• This is a stressful job, so emphasis should be placed on holistic, family orientated GPs which have measures in place for mental health.