Melbourne School of Population and Global Health - Theses
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ItemCalling for the doctor: an evaluation of an after hours GP helpline in Australia( 2016)In Australia and other developed countries, the provision of after hours primary care is a challenging policy area. Limited access to after hours services, geographic inequities in provision of services, burden on hospital emergency departments, and workload for general practitioners (GPs) have prompted governments to implement after hours primary care reforms. Telephone triage and advice services have been introduced in many countries to help to improve patient access and better manage demand for both in hours and after hours health services. In Australia such developments have provoked controversy. In 2011 an after hours GP telephone advice and referral service was introduced as a supplement to existing nurse-provided telephone triage and advice services in Australian states and territories. This thesis examines the recent evolution of after hours primary care policy in Australia with a particular focus on the quality, effectiveness, and provider and consumer experience of the after hours GP helpline (the helpline) in the context of Australian primary care. Four layers of the health system - policy, service, GP provider and consumer perspectives are explored using a mixed methods realist evaluation framework. The thesis aims to identify the critical characteristics and contextual factors required to embed a GP telephone advice service in an integrated after hours healthcare system. Ten studies were conducted investigating stakeholder views, consumer utilisation, safety and quality in adult and paediatric population groups, impact on emergency department utilisation, cost considerations and GP provider and consumer experience of the helpline. Together these studies provide an in-depth portrayal of the way in which the service was conceptualised, implemented, used and experienced. The research found that the helpline was not wholly successful in integrating with or adding value to the after hours primary care system in Australia during its first two years of operation (2011-2013). Multiple theories of action were developed, identifying current and possible pathways for helpline interaction at multiple levels in the health system. These theories of the way the world works identified contextual factors and causal mechanisms that can be modified to improve the helpline’s contribution to the Australian health system. At the policy level, supportive settings that reframe the policy narrative around the helpline as a service that assists the GP workforce, as well as consumers, will increase stakeholder acceptance and consolidate political support for its continuation. Service characteristics that promote continuity of care and greater uptake by community-based GPs and high need consumers will increase reach with consumers and the acceptability of the service to GPs. Continuation of quality improvement processes that support safe and appropriate advice will increase confidence in the helpline and improve demand management in the after hours period. Recognition of a new telephone GP provider role will lead to employment opportunities and professional recognition of GPs, young and old, seeking work-life balance in a telephone clinician role. Effective communication in telephone GP advice that reduces consumer dependency and empowers consumers to make appropriate health care choices may contribute to improved health literacy in the population. With these modifications to the context and characteristics of the service, the AGPH could both contribute to, and be part of, better integrated after hours care in Australia.