Application of primary health care standards to a developing community health group: a rural case history Mary Sheehan

Thomas Doolan Practice Principal, Kilcoy Medical Centre, Kilcoy, Queensland

Craig Veitch

School of Social Science, Queensland University of Technology, Brisbane

North Queensland Clinical School, University of Queensland, Townsville

Abstract: The development of community health groups in rural settings involving pri- vate general practitioners and other health care workers has been relatively rare. This case history examines the activities of such a group and the views of its participants over a 12-month period. It considers whether the principles of primary care and the relevant Community Health Accreditation and Standards Program criteria can be applied in such a setting. The centre was able to meet most of the primary care criteria; however, some other important elements that could be helpful to further developments emerged in the research process. These included the sensitivity of a rural community to an indi- vidual case or patient focus in a case conference setting and the high level of acceptance of population or healthycommunity goals. Other key issues included the strength (in terms of advocacy for health service provision) of an intersectoral group in a rural set- ting. Positive benefits were perceived to accrue from the increased professional and intersectoral communication. The role of the private general practitioner was focal, but the participants did not believe this necessarily had to be a leadership role. The initia- tion of such a conference and its leadership could be undertaken by any interested and appropriately skilled member. Organisation, administration, continuity and cost are important practical issues which need to be examined in early stages of development and taken into account in evaluation. (Aust N 2 JPublic Health 1996; 20: 201-9)

here have been few evaluations of primary care in. the private health sector. This is partly T because it has been only 20 years since com-

munity or primary care was first promoted in Australia.’ The Alma Ata Declaration provided the impetus for it to emerge from what was perceived as a relatively radical movement to the point where pri- mary care is found in the policy and strategic plan- ning of federal and state go~ernments .~*~ During this development phase there has been considerable debate about not only in-practice indicators of the contributing principles but about the roles of the different professional disciplines and the range of health related activities encompassed by primary care. It is probable that these divergent elements and the political and ideological dimensions of the issue have made evaluation strategies more difficult to define. The definition of primary care in action and the appropriate focus of the model have been relevant issues. There has been concern (not always explicit) over the extent to which primary care is about defining a new approach to clinical contacts and disease prevention with individual patients, or

Correspondence to Professor Mary Sheehan, School of Social Science, Queensland University of Technology (Carseldine), Beams Road, Carseldine, Qld 4034. Fax (07) 38G4 4503.

about the population as the ~ l i e n t . ~ Another related issue is the promotion of new initiatives and new approaches to primary prevention. Growing out of these questions have been attempts to define the function of interdisciplinary teams and intersectoral activities and to specify their interface with general practice consultations which have been re-identified as primary are.^,^ Another issue has been the defin- ition and effectiveness of what are called ‘commu- nity development’ initiatives. There are major concerns about the ways in which all these activities can be funded and whether they belong in the p u b lic- or private-sector health care delivery

All these issues have relevance to the role of pri- vate general practitioners and raised questions for them in practice. In earlier phases this challenge involved the management of the individual patient and was expressed in concern that the free service provided by community health centres and later, women’s health programs, might freeze them into constricted roles in diagnosis and the treatment process. The growth in numbers of independent and allied health professionals further complicated role definitions. As a result, much of the evaluation literature on health groups has been concerned with the effectiveness of centre and team activities as models of care for individual clients.-

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More recently, the report of the Committee of Inquiry into Medical Education and Medical Work- force stressed the need for future medical training to skill undergraduate students in preventing illness, developing teamwork and working with allied health professional^.^ These imperatives focus closely on the doctor and individual patient dyad of what is presumably a private service model of primary care. Explicit involvement of privately practising general practitioners in strategies for community change is rarely considered. Any such role is most commonly assumed to be in a team association with salaried allied health professionals within a government funded community health centre.1°

There is frequently an individual client consulta- tion focus in both government and research initia- tives proposing that general practitioners provide disease prevention and health promotion.”J2 The premise is that the optimal model for dissemination of disease prevention and health promotion strate- gies is through an individual consultation or coun- selling session. This has been justified in efficiency terms on the grounds of number of patient contacts. However, in other areas of primary care the individ- ualised focus is seen as expensive and not necessar- ily the best way to introduce positive changes at the community level.3 Future studies may show that the concerns of general practitioners about the time and costs of such activities are well grounded. The individualised client-focus screening model of pre- vention may benefit from being integrated more directly with the community-development and com- munity- or group-process ideologies of the primary care literature.

The issue of effective strategies to use when the community is the client remains relatively unex- plored and without models or indicators for evalua- tion. The major criteria in this area are those proposed in the Community Health Accreditation and Standards Program (CHASP) Manual which includes a section on community liaison, participa- tion and advocacy.13 These guidelines are primarily for health centres; however, to the extent that the standards operationalise primary care principles, they may be appropriate for more general commu- nity outreach programs. At the same time, other fac- tors contribute to the scarcity of outcomeevaluation indicators for population strategies for better health care and health promotion. It is difficult to establish appropriate measures of change for such interven- tions and there are methodological problems of control and confounding. It is not unusual for any one of a variety of players in any community-based intervention field to initiate activities that may have a direct or indirect impact on the change that the community intervention is trying to promote. Finally, community change may require long lead times, and most evaluation studies are concerned with short-term changes.

At this stage, even the development and applica- tion of short-term process-evaluation measures would be useful, particularly if they stimulate more interest and activity in this field. One source of potential indicators is the established key principles of primary care:

achieving equity focus on prevention a population focus an intersectoral approach community participation a range of health care providers organisation of health services appropriate techn~logy.~ At least conceptually, it would not be difficult to

examine the activities of agencies and groups to determine whether they pursue these principles. At this stage, it is probably not feasible to allocate mea- sures of degree or levels of achievement to such indi- cators, given the paucity of comparable material and information to use as normative standards.

The operationalised criteria for some of these principles are the standards proposed for ‘health promotion’ and ‘community networking’ in the CHASP m0de1.l~ These core evaluation criteria, which draw heavily and explicitly on primary care principles, are:

policy and resources to promote and protect

health promotion programs with clear goals and

to address the main health promotion issues of

to facilitate consultation to promote the health of the community in a com-

to evaluate the effectiveness of its health promo-

comprehensive knowledge of community net-

liaison with agencies to inform the community activities are accessible and available to. the

community participation community management advocacy for health (section 4, pp. 15-21).13 Three principles are not explicitly addressed in

the CHASP criteria. These include an appropriate range of health providers, which is no doubt assumed in the application of criteria to health cen- tres. The organisation of health services may be out of the range of direct action by centres or local health groups, although it may be impinged upon through advocacy. Similarly, the issue of use of appropriate technologies falls directly into govern- ment policy and planning, although it may also be subject to modification through advocacy. The third edition of the CHASP standards (1993) defines advocacy as:

The process of defending or promoting a cause. Advocacy for health means participating in public debate and activity in order to promote and/or protect the health of communities or large populations (p. xiii).I3

In this study, advocacy is used in this specialised sense and in its more usual way.

In more recent years the growing government interest in developing explicit goals and targets for health care services provides potential content- directed types of indi~at0rs.l~

This paper attempts to examine the applicability of these primary care evaluation measures to the

health

appropriate strategies

the community

prehensive way

tion activities (section 3, pp. 10-14)

works

community it serves

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development of an intersectoral community-ori- ented primarycare initiative involving a general practitioner working in private practice in a rural community setting. It uses a case history to describe the model being developed by the group over a 12- month period and assesses the activities undertaken and the perspectives on the activity held by the dif- ferent participants. The relevance of possible mea- sures and standards to the evaluation of noninsti- tutional intersectoral approaches to health care are examined for applicability in this context.

Background The community health conference team was located in a small rural town and involved a private general practitioner working with allied health professionals and persons from related sectors outside the struc- ture of an institutional health centre. The team was established of local health and welfare workers, with the common goal to improve the health and wellbe- ing of the community and to focus on community health education.

Aims The study aimed to examine the activities of the community health conference team to provide information for developing standards for evalua- tion. To do this the following issues were examined: 1. the relevance of the activities of the conference to

the primary health care model 2. the applicability of the CHASP standards to a non-

government community care team 3. the extent to which the issues addressed by the

team were defined by regional, state and national targets

4. the role of a private general practitioner in the intersectoral team

5. the applicability of such a model to rural settings.

Method The rural community is in the hinterland, 100 km northwest of Brisbane. At the time of the study it had one full-time and one part-time private general prac- titioner and a small local hospital in which the full- time general practitioner functioned as Medical Superintendent with right of private practice. The community conference was held in the major town in a shire which in 1991 had a population of 3130.15 Conference meetings were held about nine times over the 12-month investigation period from June 1992. They were held at the general practice surgery in the lunch break, lasting for about three hours, although occasionally informal discussions between members continued.

The community health conference was estab- lished by the general practitioner and other local health professionals in 1991, and research involve- ment began in 1992. A research assistant was appointed and trained for the project through the university; this person monitored the conference meetings (transcribed for analysis) and interviewed participants individually. She lived in the community but was independently appointed, trained and debriefed by the university team.

The transcription of the meetings was analysed both in terms of the background and the discipli- nary areas of the people attending, and on the issues arising in the meetings and their resolution or ongo- ing development.

All members of the conference were interviewed about their roles and expectations. Other relevant local health professionals, and where possible, visit- ing regional health and welfare staff also were con- tacted and interviewed. All were assured of the confidentiality and anonymity of their comments and are not identified in this report. The general practitioner was a member of the research team and agreed to the identification of his comments.

Interviews with participants were organised inde- pendently of the meeting. The interview proforma was unstructured, but covered the following:

the way in which participants had become involv- ed with the conference the reason they became involved issues covered in the conference perceptions of their own roles other persons or organisations who should be

benefits to the community future directions for the conference, and the role of the general practitioner in a team of this type. As the study proceeded, it became clear from both

data sources that organisational (administrative) issues and the area of professional growth and development needed more attention than had been given in the original conceptualisation of the study. The following issues were then given more focus:

the organisational structure and management that would be best for that particular group, including frequency of meetings, minutes and agendas, time limits, constraints on type of group professional benefits and disadvantages of the conference. Consultations were held regularly with the

research team members. The university staff researchers took prime responsibility for interpret- ing the data because of the participation of the research general practitioner as a member of the health conference team.

involved

Results The information based on the conference meetings was used to examine the extent to which the princi- ples of the primary care model and the standards used by CHASP were realised, or could be mea- sured, in an activity of this kind. The interview data were used to explore the role of the general practi- tioner in the process and the issue of professional development. Both sets of data were used to exam- ine the question of the organisational strategies required for an effective conference in a rural set- ting. Three sets of information are analysed and pre- sented: the participants, the content of the conference discussions and the content of the inter- views.

Participants A broad range of health care providers and repre- sentatives from a variety of sectors participated in

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the conference meetings over the 12-month period. They included the core members: a physiotherapist; a member of the Blue Nursing Service; an aerobics and fitness worker; the hospital Director of Nursing; a domestic violence counsellor; a Uniting Church minister; the medical centre nurse and practice manager; a private practice nurse; a community health nurse; a member of the Nursing Mothers’ Association; the supervisor of the senior citizens’ home, an Anglican priest and the full-time general practitioner in the town.

The core group of health related workers lived locally and many were active in other local commu- nity groups and initiatives. The shared knowledge and understanding of the community was broadly based.

Others attended for special meetings, seminars and regional consultative meetings. These people represented a wide variety of government, non- government and community organisations. They included the Director of the Regional Health Authority and various staff of the Health Authority, a Shire Councillor, the shire environmental health officer and members of various services such as meals-on-wheels, ambulance, kindergarten, play- group etc.

In their representation of community, hospital and regional contacts, participants had the potential to provide an integrated response to at least primary and secondary levels of care. They had a compre- hensive knowledge of community networks, and to an extent they facilitated community participation both actively and passively in their concomitant roles as consumers.

Some other workers who were mentioned in inter- views as potential participants in the conference included: police liaison workers, the local pharma- cist and the visiting school community health nurse. The main reason given for their absence was time constraints.

The conference did not explicitly involve con- sumers of any of the services other than the health worker participants and members of groups such as meals-on-wheels and nursing mothers. There was some discussion of the need for more consumer involvement by some people in the interviews and this may have developed further as time has pro- gressed.

Focus of the cmfmence A wide variety of issues was addressed in the meet- ings. It would be impossible to quantify the amount of time spent on each. Moreover, priority and per- ceived importance are not always directly relevant to time spent in discussion. However, it is possible to rank them in terms of the number of meetings at which they were raised and discussed.

The following section reports on activities organ- ised or reported at the conference during the study period. They are presented in order of the fre- quency of meetings at which they were considered. Health education-prevention. All meetings includ- ed group discussions about health promotion and health education activities. The group regularly con- sulted the calendar of health events put out by the Queensland Health Promotion Unit and undertook

a series of preventive and health promotional activi- ties in accordance with this calendar. In addition, the conference members were actively involved in various promotions, for example, selling red noses for Sudden Infant Death Syndrome Day, and talks by the general practitioner in Asthma Awareness Week and Under-Eights Week. Interested group members conducted video and discussion sessions on demen- tia for community members and organised a series of public meetings and health education seminars, which included a nursing mothers’ talk given by the hospital nursing staff and talks at play groups, preschool and the hospital. A major activity was the running of the Annual Health Expo in conjunction with the hospital fete. The conference members gained the support of the local radio station, media, schools and teachers for the Expo which involved 40 stalls. Attendance was high and a twoday stand- alone Expo was initiated for the following year. Professional development. This was a core element of the conference. It included such activities as dis cussions about the advantages and possible disad- vantages of the development of General Practice Divisions. Members reported on the National Rural Health Conference and other conferences they attended. The general practitioner advised the group about his liaison and advocacy on behalf of the community at the regional level. Finally, consid- eration was given to establishing the conference as an incorporated body. Community health. New developments in commu- nity health were discussed and changes in funding and potential cutbacks as a result of regionalisation were considered. New staff who had joined the Regional Health Authority were invited to the meet- ing and members examined the Regional Strategic Plan from the point of view of community health. During the research period a number of community interventions were undertaken. The Shire Coun- cillor, who was a member of the conference, advised about falling immunisation levels and an action plan was developed. Exercise classes for the elderly were developed and transport organised with local ser- vice clubs to help people attend them. As part of the conference community outreach, local community services such as Red Cross and Country Women’s Association were approached and became involved in the different programs. In response to an identi- fied community need, antenatal classes were begun and publicised and problems with attendance were monitored. Aged care. Representations were made to the Regional Health Authority regarding the regional Strategic Plan for Aged Care. A senior citizens’ week activity was organised and community speakers and entertainment were provided. The conference initi- ated representations to Home and Community Care about the need for extensions to services and accommodation for local aged persons. Among other initiatives, video afternoons were organised and programs such as the healthy aging classes pre- sented at the senior citizens’ centre. Time was given at a number of meetings to examining issues related to the high staff turnover at the centre. Liaison with Regional Health Authority. Visits by members of the Authority, the regional board and community health staff were orgdnised and a united

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conference front prepared. At these visits, local p u b lic sector health needs were raised, and advice on resources, assistance and available grants discussed and debated. For example, the removal of control of the local ambulance service from the town to a regional centre was hotly debated with the authority. Arising from these representations, the Authority promoted and agreed to fund a ‘link-a-friend’ tele- phone contact for isolated elderly people who were carers. Advertisements were placed in local papers and the conference became actively engaged in determining community interest in the initiative. The response indicated that elderly people did not feel that such teleconferencing was necessary. Domestic violence. A new regional domestic vie lence unit was established in the region (about 45 km away) by the Regional Health Authority. A r e p resentative came to the conference and gave infor- mation about the new service (including the 008 number) and provided printed resources including the Domestic violence ABC fwpofesssionals. The confer- ence also promoted and supported a six-week com- munication skills course which was run in conjunction with the police liaison for health pro- fessionals and the police. Towards the end of the study period, the representative from the domestic violence unit joined the conference as a regular member.

Analysis of the interuiaus There was a broad range of information and mater- ial from interviews relating to the issues covered in the conference activities. This analysis provides data related to primary health care organisational and professional issues. Role of the general practitioner. The general practi- tioner was involved in initiating the conference, provided the venue and informally moderated meet- ings, but the activity grew out of a group primary care orientation and probably could not have begun without a core of interested professionals.

Got involved in one sense because other people were pre- pared to be involved. It’s not something that any individual could presume to perform by themselves. By definition it involves other professionals and other people in the commu- nity who have some input into the provision of services. [gen- eral practitioner]

The consensus in the interviews was that general practitioners would be vital members of such groups because they have contact with so many people in the community.

A general practitioner is probably more in touch with the needs of the community and sees a larger number of people than one of us would.

There was also a perception of the general practi- tioner as having a broader frame of reference and more wide-rangmg sources of information.

A general practitioner is also provided with a lot of informa- tion from various state and commonwealth departments and probably has a reasonable idea of what is on offer. A general practitioner is in a fairly central position because they are aware of the medical issues, problems and changes; they would be aware of the level of alcohol use, drug depen- dence and family problems. Particularly in the case of a one- doctor town-really aware of everything that is going on.

General practitioners were seen as a valuable resource in terms of their knowledge of and contacts within the health care system.

They tend to be on various committees and boards and there- fore have a wide appreciation of health service issues.

However, many participants did not think that it was necessary for the general practitioner to have the central or controlling role within the group.

General practitioners should be a member, not have a domi- nant role. I think where physical health and the operation of a hospital is being discussed they have a fairly important role. Apart from that I don’t see them as being any more prominent in the group than any other member; naturally any profes sionals will have areas of expertise which the group would nat- urally defer to.

Some respondents also thought that the general practitioner’s role was important because of what the general practitioner could learn from other health professionals.

They need to know where everybody is at and what resources are available to them in the community. Sometimes they need to get other people in to do the counselling-like the drug and alcohol people; they need to know about other people who are specialised in a field; give them awareness of where other people can go not to just keep coming back to them.

However, members generally believed that the general practitioner should not command higher status than other members and that there should be democracy within the community health group.

I think the general practitioner should be pretty much equal to everybody else. I don’t think they have to be a facilitator or a leader or the per- son to establish the group; that could come from elsewhere if there was initiative.

The general practitioner did not see himself as nec- essarily taking a major role in the conference but rather saw the model as being democratic.

If he exeru himself into the community health group as a piv- otal figure in a persistent and demonstrable fashion, then the group will become dysfunctional. It’s really just as if anyone else attempts to do it then the same thing would happen. In reference to other models that have been vied and failed, it has invariably been because one or another community health service or person therein has attempted to run the show and by putting other people on the outer caused a lack of goodwill and the failure of the group to function properly. [general practitioner]

Interviewees saw there could be a potential for prob lems in areas with more than one general practice. However, such problems would apply to some extent where more than one member of any health profes sion was also in practice. Professional development. A core issue in recent discussions of primary health care in Australia is the need for ongoing professional development in pri- mary care ~ki l ls .~ This issue was spontaneously raised by respondents in the earlier interviews and subse- quently it was included as a standard probe in all interviews. It may have particular relevance for work- ers in a rural health setting.

The group’s role as a professional support and development group was commonly noted and appreciated.

You often are the only one from a particular professional group so you don’t get the support that you would get from departments. It’s like the next best thing, it’s really as good as having the sort of support from people who are working in the same sort of area as you. You also can learn from other people. Working as a group I feel as though we’re all friends and [I] can call on them any time if I do need help.

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Professional feedback, also The support, a network is a two- way street; you can support others in whatever they are doing and pass information on, and the same thing from the other direction. I get support if I have the need. A broadening of my knowledge and understanding of rural health care and meeting people in general. Getting to know how other sections of the community work which undoubtedly would have a benefit in my own dealing with people. Better liaison with health professionals.

It was also seen as a way to broaden professional skills.

An added dimension to The way I have been able to practise medicine and see health care provided in this community and it has been an extremely satisfying activity to be a participant in. Not the least aspect has been to see the enfranchisement of other health workers in terms of responsibility for community health care. [general practitioner]

Some members of the group cited additional bene- fits that they thought would help them to come to better terms or to better serve their clients.

Some contacts if I need to refer a member who has a particu- lar problem. Locally, I’m getting to know people beyond my own [refer- ence group] and I’m thus becoming part of the community and not something apart from it. Just to be involved professionally . . . simply that you’re seen . . . also gives contact with other people so that you’re aware

of the resources if you need them . . . of where to go.

Principles of primary care. What was particularly interesting about this primary care group was that only one person at the beginning, namely the gen- eral practitioner, had direct experience working with the primary health care approach.

A perception that there was a need for such a structure to meet a need within a rural community. To some extent that was related to my previous experience with Aboriginal and Islander community controlled health services as being a very effective vehicle for the overall transmission of health care to a community who were a group within a community. [general practitioner] General practice should be more than playing catch-up, and simply treating the conditions as they present. If we are to achieve anything to help practice, then we should be aiming at the principles of primary health care and all it entails in terms of preventive health care and health education. [general prac- titioner]

Advocacy. Participants saw the group’s advocacy role as trying to provide a voice for a rural community with the Regional Health Authority which had been recently established.

There is a benefit that the community will not perceive at the moment and it may be a long time before they do, but that is that our community has demonstrated to the public sector authorities that we will not be taken lightly when it comes to provision of health services-and that we expect equity of access. The group has been active in respect of looking at what health resources there are in the town. . . . been active in making its opinion felt about the provision and adequacy of services. We’ve taken a stand with the nurses in regard to the fact that there is no member of our Regional Health Authority who comes from this shire. In fact there is no one in that regional office who is west of the coastline. We take a great umbrage to this given the fact that rural health prob- lems are often a world apart from the health needs of people who live in urban coastal environments and it is virtually impossible for those people to understand rural needs appro- priately, let alone lobby for them. We have taken up the problems of access to ambulance ser- vices in our area following regionalisation of the ambulance service, and we are raising our concerns, particularly in respect of the dangerous practice of central taking of calls as opposed to local.

The interviewee from the Regional Health Authority was also aware of the potential for the group to have an advocacy role:

I think there is good representation and a variety of commu- nity-based interests, so it certainly has the potential for people to get together and look at further development. I think it can be useful to have a group or network set up which is not attached to any particular organisation and which can in fact become a useful planning lobby group.

Another benefit noted by Regional Health respon- dents was that the conference provided a contact group or point for the regional health or other gov- ernment department officers to discuss policy or other issues:

It’s not a problem fitting the meetings in; the advantage is that it is usually a set date or time of the month . . . it’s good to go to that particular meeting; you’d take the opportunity and call in; you actually have an identifiable group to discuss issues with. I wanted to find out from the group . . . what they wanted and how we could modify our services to make them relevant to them.

Organisational strategies. As the year progressed and the research assistant provided records of meet- ings in the form of minutes, members began to see this formalisation of the agenda and action plans as very useful. Another important and commonly men- tioned consideration was the need for a preliminary meeting to agree on the group’s terms of reference, framework, structure and guidelines. Another organisational issue was the cost of the meeting in time and accommodation.

. . . arrive at a mutually agreed framework as a guideline oper- ation. . . . reach agreement about what they want to provide.

Consumer involvement. Another issue raised was the extent to which nonprofessional members were involved. Respondents raised the issue of consumer participation. Given the goals for primary care ini- tiatives, this was important. However, in a rural set- ting the professional may also assume the role of a consumer.

It would be nice to have ordinary citizens there . . . because they could actually have a lot of input.

There was no explicit discussion in this develop- mental phase as to how to involve consumers on a regular basis, but many visitors, such as the mem- bers of the local playgroup, were effectively con- sumers. ‘Community‘ or ‘individual patient’. The partici- pants believed that a patient-focused model for a case conference could be inappropriate in a rural area. Although this was not explicitly considered in the terms of reference or during the development phase, i t emerged as a relevant issue relatively early. The reasons given were primarily related to per- ceived patients’ concerns regarding anonymity and confidentiality and their fears that problems might be discussed with people other than the initial con- fidante. Examples of this were psychological and social problems, not physical disorders. This may be a chance finding or could reflect the social con- straints and stigma of psychological or social p roh lems in a rural community. The professionals saw the issue in terms of ethics and respect for commu- nity values. The CHASP standards propose a model for such a conference that proceeds with the

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explicit permission of the clients. Such a confer- ence did not evolve here.

It shouldn’t be discussing people; it should be discussing issues rather than personalities. Maybe there are some issues that shouldn’t be aired in front of some people. We are a small community and you can’t go and just do things willy-nilly. You have to be careful of people’s feelings and their attitudes and that sort of thing. It is the community we are serving and we should not go beyond the bounds that are accepted by the community. She [parishioner] made derogatory remarks about the health conference discussing people’s personal life situations or med- ical or whatever situation. I very much doubt if we would dis- cuss anybody’s medical concerns. Some of this stuff [personal comments] can be very malicious or otherwise by saying that we are interfering and trying to get rich.

On the other hand, improved community-oriented care was explicitly mentioned and readily examined.

It creates an atmosphere . . . that means a more health con- scious city or a more healthy community. . . . good idea to have a group working for community health. I’m interested in that area and wanted to be involved.

Group process. The group was in the development stage during the period of study and gradually became more structured. At all meetings communi- cation strategies were oriented towards participa- tion, involvement and collaboration. Thus, on most issues that involved debate rather than information exchange, all members would be invited to con- tribute. This was also the case with visitors, and given the relatively opendoor policy of the conference, most meetings included one or more visitors or members who were not able to attend regularly. The need for group organisation and structure that this relatively liberal approach demonstrated was clearly expressed.

I think it needs to be a bit more controlled so that we don’t wander off on to any tangent and don’t really achieve any- thing. It never actually gets said ‘you do this and you do that’ and it ends up falling on the laps of the same people.

The group was also used by different members to alert participants to their own particular service and/or to enlist support and interest.

I have a very minimal role . . . can’t always get to meetings. I feel as though part of my role is to drum up, t ry and encour- age more involvement in the workplace. [aged care service] Being involved in the health conference is a means to store information and to advise other members of the development up there and also to seek their encouragement and support and so on.

This is not to say that all discussion could be com- pletely open and uncensored.

. . . I can’t be as outspoken as I might want to be at times. It hasn’t really stopped me that much.

Some people were thought to dominate the discus sion too often.

It can be monopolised . . . I know that [XI had a monopoly on it once and apart from anything else it would be utterly boring for somebody. . . You want to keep it fair, have an equal input.

Members saw the interaction as positive and pro- ductive and as a way to reduce territorial protection. The issue of particular professional responsibility and ownership of problem areas or patients was never directly discussed in the conference meetings but was alluded to in the interviews.

There is a certain amount of resistance to committees because they are not formal enough. The health conference has the role [of formalising issues] . . . it’s there to generate, to pro- vide information so that we are not doing things at odds with each other. . . not running around wasting your time trying to get something that somebody else can do, or that you can do together. That’s why I suggest we should have some liaison with them so that they don’t think we are taking over their job.

Boundaries of group membership. A related issue concerned the role of other health professionals and agencies who were not active members of the conference. In general, there was a feeling that some workers were not interested in liaison because of personal or work conditions, or because of g e e graphical distance from the community.

But clearly being a local was very important. I’m not sure that they would be allowed, that is from their side, not in terms of us letting them in. I think that theyjust haven’t got the time to be at the meeting. They are traditionally territorial, and despite repeated invita- tions to participate in community activities they have persis tently failed to do so. They’ve come from outside our community areas and they hold little feeling for the community’s sensitivities.

Another possibility that was canvassed was that the group itself had developed a degree of exclusivity as an outcome of the conference meetings.

There is this thing in a group of affiliations that may discour- age other people from entering it if they are not actually asso- ciated or familiar with the group.

The issue of membership and recruiting strategies was difficult to resolve from the information pro- vided. Country communities are small and readily lend themselves to group activities. At the same time, the issue of optimal size and possible problems that could arise from the failure to enlist interested persons who might feel left out also are potentially serious in a small rural community.

Discussion and evaluation This study aimed to document whether the issues defining primary health care policy and the 1991 CHASP standards could be applied in the develop ment of a rural community health care conference (section 4, pp. 15-21).13 It also aimed to explore the role of a private general practitioner in such a con- ference. The model of primary health care that developed with the conference was that the commu- nity rather than the individual was the client. This was frequently mentioned by participants who iden- tified with the local region and who adopted the ‘healthy cities’ analogy to describe the focus of their activities. The findings suggest that it should be pos sible to use the CHASP standards or at least system- atic evaluation measures of compliance with relevant population-based primary care principles. In the data provided by this case history, for example, the broad principles of liaison, intersectoral networking and advocacy were all able to be measured. A rating of the conference using CHASP and primary health care standards is given in Table 1.

The conference met most criteria, and more importantly, the criteria were relevant to the group. It was also possible to begin to conceptualise other measures that could be included in an evaluation of such initiatives. These are summarised in Table 2.

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SHEEHAN ~l A.

Table 1: Evaluation using standards of the Community Health Accreditation and Standatds Program ~~

Criterion Comments Rating

Policy to promote and protect health Develop a healthy Community + a

Resources to promote and protect health Limited, voluntary, unfunded a b Health promotion programs with clear goals and appropriate strategies Main health promotion issues of the community are addressed Facilitate consultation Some limitations Promote the health of the Community in a comprehensive way Evaluote the effectiveness of its health promotion activities Comprehensive knowledge of community networks Liaison with agencies To inform the community Activities are accessible and available to the community it serves Community participation

Discussed, planned, reported

Community Aanagement Advocacy for health Equity Population focus I ntersectoral Range of providers

Confined to health services Not explicit but underlies activities

+ + +-‘ + +O + + + + + + 0 +O + + +

Nofe: (a) + criteria met by the conference . (b) - criteria not met by the conference. (c) o criteria inappropriate to the rural privote context

Table 2: Indicators for a communiiy-based conference

Criterion Comments Ratina

Organisational structure Emerging - Transferable model Cost an issue + Professional development I mportant + Responds to national targets Indirectly only -

The concept of national or state targets was added to the evaluation indicators after they emerged in 1993.14 This particular conference did not overtly or strategically respond to national goals and targets, although the state calendar of target activities was followed. Rather, concerns were clearly related to grassroots issues. A small example is the telephone link-a-friend initiative proposed by the Regional Health Authority; it was in line with regional plans but could not be sold to the community. On the other hand, the more personal and locally defined exercise group for elderly people was readily organ- ised. As the conference developed it moved into a

model of community-based health promotion. Strong liaison and communication links between the members were developed and strengthened through supporting each other’s initiatives (such as the antenatal classes) and promoting outside pro- grams seen to be potentially helpful to the commu- nity (such as the domestic violence program).

The Health Expo took a central place in the group’s deliberations. This involved a much wider range of community groups, such as schools, hospi- tal and Regional Authority in exhibits and activities. In a small rural community, the establishment of a clear identity and the perception that action will be taken is extremely important. It provides a political forum or a community voice and more importantly increases the likelihood that the voice will be heard. All these activities fit within the guidelines provided by the Ottawa Charter for health promotion and provide the basis for improving the health of such small communities.

Although many of the participants were aware of the primary health care approach through reading and training, the general practitioner was the only professional who mentioned previous direct experi- ence in this context. What is clear is that primary health care strategies and principles, as exemplified in the conference, are optimal and readily accessible approaches to health care and promotion in such rural communities.

The conference was actively promoted by the gen- eral practitioner, who filled an important and valu- able role. It also included a variety of local health professionals involved in primary and secondary hospital and community based care. It explored and promoted links between levels of care. Intersectoral liaison was established with local clergy and with the Shire Council. Links were also developed with the Regional Health Authority.

The issues covered were not exclusively local but they were defined predominantly by local needs rather than central targets. The group placed par- ticular emphasis on its role in promoting and pro- tecting the health of a small rural community by defending its needs for local and responsive ser- vices. The primary health care concepts of equity and accessibility have a very real meaning to persons facing geographical barriers and accelerating cen- tralisation of resources, sometimes without sufficient consultation and justification to local people. The principle of advocacy was established and the con- ference gave the Regional Health Authority a point of focus for contact regarding policy and strategic plans. It also provided a cohesive lobby group to work actively in pressing forward its own policy ini- tiatives and an avenue for quick and rational responses to visiting policy experts. As the conference developed through the year the

need for a formalised structure, including a minutes secretary, action plans and a chair and treasury func- tions, also became evident. An effective organisa- tional structure should be established early and could be included within the evaluation criteria for such a group. It also provided an opportunity for

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professional development and support, which could be considered a vital goal in a rural health setting.

Finally, if one were to provide an overall evalua- tion of this community conference using a compos ite of the measures derived from CHASP and related primary care principles, it would be rated as a well- functioning primary care structure.

The role of the general practitioner in such a group remains unclear. It is particularly difficult in this study (which involved only one conference and one involved general practitioner) to attempt gen- eralisations about transferability. At the same time, the value of this approach in a rural setting supports previous research findings.16

The introduction of rural divisional funding p r e vides a means to include general practitioners who are in private practice. The extent to which they ini- tiate or participate in such approaches will be deter- mined only by training and experience. The organisation and impetus (and originally the expe- rience of primary care principles in practice) for this particular case conference came from the general practitioner who had previous experience in the development and administration of Aboriginal and Torres Strait Islander communitycontrolled health services. It was accepted enthusiastically by other health professionals and it is likely that with more extended training in primary care or similar back- ground work experience, such interventions will be generated by them.

Acknowledgments We wish to thank Mrs Gail Close who undertook the data collection for the study and the GPEP Grants Program which provided financial support. We also thank all conference members for their time and interest in the study.

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