Driving change

This bumper issue of the Australian Journal of Primary Health presents seventeen papers that were originally presented at the General Practice and Primary Health Care Research Conference, mostly in 2009 but a couple in 2008. By preparing their work for peer review and publication in this journal, the authors have ensured that their research can reach a much wider audience and contribute to the evidence base in primary health care.

The theme of the Melbourne conference in July 2009 was ‘Driving change’ (Primary Health Care Research and Information Service 2009). One of the Forum papers (Booth et al. 2010) draws attention to the image of cogs and wheels used in the General Practice and Primary Health Care Research Conference promotion, as an example of the use of a machine metaphor for health care. This way of thinking about health care implies a system with fixed parts interacting in a known or knowable way, so change can occur through redesign and re-engineering, with more or less predictable results. However, evidence does not support this metaphor, which Booth et al. conclude is not appropriate and of little use in a system where change results from the complex processes of relating among those involved. In fact, the conference promotion material included another image of people in the centre of the image of cogs and wheels driving change. The central importance of people in both research and reform is much more consistent with complex responsive processes, and also with the content of the papers in this issue of the journal, which illustrate the types of research that attempt to deal with a complex system.

As a collection, these papers illustrate the diversity and breadth of primary health care research and its relationship to change and reform. Evidence can inform different stages of the policy process: to clarify a problem, to frame options to address a problem and/or to address how an option will be implemented, according to Lavis et al. (2009). Descriptive primary health care research such as that by Yun-hee Jeon et al. (2010) clarifies the problems experienced by patients with chronic illness, to contribute to better models of care. Papers by Shah et al. (2010), Passey et al. (2010) and Patterson et al. (2010) go further, describing feasibility studies of possible options to address different problems in general practice and community rehabilitation. Later more definitive studies will potentially contribute to stronger evidence about different options and how they could be implemented.

Understanding relationships better is the common factor that links most of the papers in this issue, and is compatible with viewing primary health care as a complex system. Kay et al. (2010b) describe what sort of relationships doctors want when they are the patient, Shah et al.’s (2010) feasibility study has GP communication skills at its centre, and Elliott-Rudder (2010) reflects on how researcher networking drives change as she moves from being a medical graduate to a primary health care researcher. Other papers shed light on the importance of strengthening service networks for diabetes care (Moretti et al. 2010) and for mental health (Sankaranarayanan et al. 2010). Understanding service networks that go beyond health care is needed for developing a new model of refugee health (Kay et al. 2010a), and for strengthening hearing services in a rural community (Lower et al. 2010). Susan Johns (2010) describes primary health care collaborations in rural Australia, while Preston et al. (2010) question some of the assumptions around community participation in rural primary health care. Boyer et al. (2010), in the paper ‘Partner or perish’, describes how reform depends on researchers, policy makers, service providers and community members overcoming the many challenges of collaboration.

Last but not least are papers that acknowledge the complexity of workforce planning in primary health care. Two papers examine ways to understand specific aspects of the workforce, Se Ok Ohr et al. (2010) by looking at factors contributing to nurse migration and Gerber and Landau (2010) by describing the Medical Schools Outcomes Database, which will help develop models of workforce flow. The Forum paper by Lucio Naccarella et al. (2010) identifies the importance of asking the right questions if we are to strengthen both workforce evidence and its uptake into policy making. I commend this issue of the journal, as its substantial content contributes to our understanding of the systems we work in.

Elizabeth (Libby) Kalucy

Co-editor in chief