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Table 1 Steps taken by EPHS to address external and internal threats to service sustainability

From: How do small rural primary health care services sustain themselves in a constantly changing health system environment?

Core health service sustainability requirement

Threats to service sustainability

Impact of threats on sustainability

Elmore health service responses and outcomes

Addressing EXTERNAL threats to environmental enablers

Supportive policy environment

Changes in IMG legislation/regulations

• Recruitment and appointment process for IMGs is more difficult

• Targeted recruitment of potential doctors by EPHS staff

• Greater dependence on assistance of Rural Workforce Agency Victoria (RWAV)

 

• Changes in funding arrangements (e.g. after-hours services)

• Affects total amount and mix of funding available to service

• Broaden income base through more education and training, research and incentive funding

 

• Changes in government funding schedule and service indicators

• Attempts by government to reduce the 'red-tape' requirements have complicated service performance monitoring and associated quality improvement

• Strengthen link with research evaluation team to identify and maintain sentinel indicators for measuring performance

Clearly-articulated Federal-State roles and responsibilities

• Announcement of nation-wide orientation to PHC models and organisations (Medicare Locals)

• Implementation distracting service staff and workforce agencies from 'core business'

• Service is positioning itself with key agencies and authorities to maintain its role and visibility in new regional organisational arrangements

Strong community involvement

• Changing demography; impact of natural disasters (floods, bushfires) in the catchment area

• Population change due to ageing and in- and out-migration make it difficult to engage broad population in early intervention and results in need for different services

• Establishment of a single-point-of-entry to comprehensive PHC ensures access to the range of integrated services providing acute and chronic care, health promotion and disease prevention

• Regular consultation with community about service changes

Addressing INTERNAL threats to service sustainability requirements

Workforce supply and mix

• Rapid expansion of EPHS catchment (i.e. into surrounding regions: 'hub-and-spoke' model of visiting services and establishment of permanent services in surrounding region)

• Risk of expansion beyond workforce capability and service capacity, high cost of ongoing recruitment

• Targeted recruitment ensures prospective staff are well-matched to service

• Use of one doctor to provide locum relief across all sites

 

• Ongoing dependence on IMGs

• Risk of short length of stay and need to re-recruit as IMGs relocate to metropolitan areas for cultural and family reasons

Staff retention maximised by:

• Good matching of recruits to the service

• Strong supervision and support for continuing professional development

• Capitalising on the full range of workforce incentives

• Critical mass of GPs means after-hours work is not too demanding and enables part-time work

• Multidisciplinary teamwork reduces isolation and workload

 

• Growth of GP 'superclinic' in nearby large regional centre [23]

• May provide a more attractive alternative practice location for doctors

• Existing service maintains comprehensive whole-of-patient and community care activities that provide many professional opportunities and career satisfaction

 

• Older staff seek retirement or career change

• Need for pro-active succession planning to minimise impact of loss of experienced staff

• Links to Monash University and RWAV as a teaching practice for medical students and registrars

• Proactive succession planning

i. Linkages

• New leadership and change within partner organisations and government authorities

• Established relationships can be threatened by new arrangements that do not meet local needs and the complex public-private mix of services, ownership and investment arrangements

• Close collaboration with partners and ongoing involvement with established research team

ii. Infrastructure

• Infrastructure renewal required to accommodate organisational change and additional services

• Remodelling existing 'hospital' infrastructure can result in perceived 'loss' of services by some community residents

• Capitalising on infrastructure grants (e.g. new payment facilities, remodelling of infrastructure and 24/7 emergency care)

iii. Funding

• Dependence on fee-for-service funding and high level of bulk-billing

• Changes to funding arrangements for after-hours service

• Diversification of financial sources required to ensure viability (i.e. total funding and blended-payment funding)

• Service capitalises on full range of financial incentives on offer (e.g. additional funding for after-hours service)

 

Alternative services available in surrounding communities

• Patient attrition (e.g. following "usual doctor" to another practice, minimising the distance travelled by 'one-stop-shopping' in larger centres) affects income stream

• The comprehensive integrated range of services minimises patient leakage and maximises practice income

iv. Governance leadership and management

• Leadership changes (e.g. principal GP expands practice to other towns; new Chief Executive Officer recruited to key partner organisation [BCHS])

• When organisational leaders reduce or withdraw their services, the community may experience a sense of "loss" and perceive the quality of the services to have declined

• Potentially weakened relationships between key partners

• The need for pro-active leadership succession planning within the health service is recognised

• Mentoring new staff for clinical leadership roles

• Practice manager shares expertise with and devolves responsibility to other administrative staff

• Use new developments (e.g. building works) as an opportunity to revitalise relationship with key partners and extend opportunity for joint service provision