Internationally, models of primary care have evolved over the last decade with some common elements. Evidence suggests that organisational structures such as joint ventures and alliances can support achievement of health outcomes while ensuring sustainability of business models.15
While the nature of the models differs, most developed nations have attempted to implement organisational structures to support development and coordination of local primary care services.16 Evidence does not exist to support a particular organisational model, with variations in type of organisation, governance, legitimacy and capability.16 Commonly, co-location of multiple services under one organisational clinic structure has developed in various forms to deliver more integrated care, particularly for people with chronic diseases.4 Regardless of the model, it has been identified that new organisations in primary care need time and stability to build capability, trust, culture and systems in sustainable ways.16
Trends in models of primary health care have also seen an increase in organisations that provide comprehensive services to particular populations. 7 These services are provided by multi-disciplinary teams, with enhanced roles for nurses, pharmacists and other providers.7 There has also been an increased emphasis on health promotion, disease and injury prevention, and management of chronic illnesses.7 Workforce and organisational model trends in general practice have seen shifts from single to multiple GP practices, from single to multi-disciplinary practices, and from practitioner autonomy to greater accountability.4,16
Funding of general practice and primary care has seen a shift towards payment structures which reflect broader system requirements and a move from general practitioner focused fee-for-service payments to blended payments incorporating elements of capitation, patient co-payment and incentive payments.9 Payments for specific activities have also been used to increase provider activity in certain areas.16
In Australia there have been many initiatives designed to address some of the pressures in general practice and in primary care. However, many of these have been localised and not sustained.16 Organisational models reflected in Divisions of General Practice or Networks have limited capacity to improve integration and coordination of care and to improve health outcomes for the local population in the absence of health system reform.16
Recent emphasis in models in the United Kingdom have been driven by the need for greater flexibility and shifting the balance of power to primary health care, to the practice level and to consumers.16 There have been three key changes in the way primary care is delivered in the United Kingdom: patients are now registered with a practice not an individual GP; out-of-hours care is not provided by the GP but rather is provided by primary care organisations, some of which may sub-contract to GP practices; and 25% of GP income now relates to the quality targets of the United Kingdom’s Quality and Outcomes Framework which provides additional financial rewards to those practices that deliver agreed levels of patient care, based on a points system.16
Evidence for the effectiveness of primary care provided under service models such as those provided through GP Super Clinics suggests various impacts.17 Outcomes related to patient experiences of communication and coordination, and health outcomes for chronic disease and for quality and efficiency have been demonstrated under health services which are structurally integrated and provide a continuum of services.17 Higher quality of care in group general practices is reported compared with single or small practices, and in those accredited as training practices.18
4 Imison C, Naylor C, Maybin J. Under One Roof:Will polyclinics deliver integrated care? London: King's Fund 2008.
7 Romanow R. Health Care and Education Reconciliation Act of 2010: Building on Values: the future of health care in Canada - Final Report. Commission on the future of health care in Canada. 2002.
16 McDonald J, Cumming J, Harris M, Powell Davies G, Burns P. Systematic Review of Comprehensive Primary Care Models. Sydney: Australian Primary Health Care Research Institute;2006.
17 Singer S, Burgers J, Friedberg M, Rosenthal M, Leape L, Schneider E. Defining and Measuring Integrated Patient Care: Promoting the Next Frontier in Health Care Delivery. Medical Care Research and Review. 2010;68(1):112-127.
18 Ashworth M, Armstrong D. The relationship between general practice characteristics and quality of care: a national survey of quality indicators used in the UK Quality and Outcomes Framework, 2004-5. BMC Family Practice. 2006;7(1):68.