The MoU between SADI , DHS and Divisions in SA

In 2002, a Memorandum of Understanding (MoU) was signed by SADI, Divisions of General Practice in SA and the South Australian Department of Human Services.  The MoU was developed to strengthen collaboration and partnership between general practice and the Department of Human Services (now Health) and acknowledges the importance of integrated care in delivering a better health care system to South Australians.

The second year Workplan (for 2003-2004) addresses areas of activity under four themes: integrated systems of care, population health, medical workforce and policy and strategy development.  The duration of the Workplan has now been extended to June 2005, to enable the revised MoU and new Workplan to be developed and implemented from 1 July 2005.  It is planned that the new MoU will include the regional Boards, thus adding a further 10 signatories.

The MoU is a positive step towards developing a much closer working relationship between all parties and ensures that this is founded on clear, agreed principles and shared aims and objectives.  In addition, the MoU ensures that there is a commitment to involve general practice in the decision-making processes of the Department.  The Workplan provides a focus and the means of monitoring progress towards these aims and objectives.

GP Obstetric Shared Care

Early in 2003, SADI received funding from the State Department of Human Services to implement a State-wide framework for GP obstetric shared care.  The objectives are to provide ongoing and sustainable obstetric shared care services for women who wish to have antenatal and postnatal care provided by their GP with delivery at a public hospital; an ongoing accreditation program for GPs who wish to participate in an obstetric shared care program; and appropriate data maintenance and evaluation of services to ensure equal or better than traditional hospital care, as evidenced by maternal and neonatal outcomes and patient and GP satisfaction surveys.

The program commenced in April 2003 and has been implemented in all five urban Divisions and the five major public metropolitan hospitals.  A uniform guidelines and protocols booklet has been developed and distributed to accredited GPs across SA to assist them to care for women in accordance with current evidence based antenatal practice.  The overall aim is to extend the program across SA ensuring continuity of care and caregiver for women experiencing a low risk pregnancy.

SADI was advised in June 2004 that the program is now recurrent.  The program?s GP Director is Dr Diana Cox, who is contracted by SADI to carry out this role.

Medical Workforce

The urgency of the workforce issues in rural and outer urban areas of SA, and the uniqueness of some aspects of these issues have been powerful drivers for action, both in terms of lobbying and in bringing this to the attention of decision-makers, within the universities and Commonwealth and State governments.

SADI continues to work closely with the Rural Doctors Workforce Agency in jointly convening workshops for Division staff and GPs with workforce as the focus. Significant work is being undertaken in SA in the area of orientation of overseas trained doctors with the manual developed by one rural Division now available to all.

Data collection difficulties, especially the lack of resources for this work, has hampered a full illustration of the extent of the workforce shortage in outer urban areas.  However, collaboration between urban Divisions, SADI, the State Department of Health, the regional GP training consortia, Rural Doctors Workforce Agency and other stakeholders is now beginning to provide an evidence base to highlight the extent and nature of the outer urban workforce shortage.

Primary Mental Health Care

SADI's work continues to assist Divisions in the implementation of the Better Outcomes in Mental Health Initiative.  There was a steady growth in the numbers of GPs registered with the initiative as well as those taking on extra training to complete their level 2 education.  South Australia is now the state with the second highest percentage of GPs trained to level 1 status.  SA has 18% with the national average being 15.8%.  This was achieved through State-wide training, coordinated by SADI, and supported at the local level by Divisions.  The Allied Health Services component of the Initiative is well advanced with all Divisions in SA now funded.

SADI's Mental Health Advisory Committee, with GP representation from Divisions and stakeholder representation including consumers and carers, meets on a regular basis. This builds important partnerships and service integration with the State mental health reforms and with mental health agencies promoting primary mental health care in South Australia.  The Advisory Committee meets regularly with community psychiatrists.

The Divisional mental health network meets regularly at SADI enabling support, information sharing and innovation, and has been crucial in the implementation of the Better Outcomes Initiative, coordinating and facilitating training for GPs and supporting those GPs registered with the initiative.

Promotion, prevention and early intervention (PPEI) are increasingly recognised as crucial in primary mental health care service delivery and two school-based mental health initiatives launched in South Australian schools in 2003 take this approach.  Auseinet, the national PPEI Clearing House based in South Australia is collaborating with Divisions in conducting a scoping study of current practices in promotion, prevention and early intervention for mental health in the general practice setting.

In 2003, SADI, in collaboration with Helen Mayo House (part of Women?s and Children?s Hospital) submitted a successful proposal for  State Department of Health funding in the area of perinatal and infant mental health.  The officer subsequently appointed, Ms Wendy Thiele, works from SADI?s offices one day a week, which has been valuable in building collaboration between general practice and the project.

National Suicide Prevention Strategy - Pathways to Care

Following the completion of Phase One of this program, which identified issues relating to current practice and barriers to comprehensive and continuous quality of care for people presenting with issues of attempted suicide or self harm, SADI was selected to auspice Phase Two.

This commenced in September 2003 and includes program development activity which addresses the following recommendations: standardised assessment, referral and follow up processes; utilisation of evidence based minimum standards; information management structures that accurately identify deliberate self harm and education and training for primary health care providers and their supporting agencies.  Following an application and assessment process, four Divisions were selected to carry out two-year pilots addressing aspects of the recommendations with SADI to provide central coordination and assistance in the development and delivery of training across the state in the third year of the project.

GP Peer Support (Mental Health)

In 2002, SADI responded to an approach from the Department of Health and Ageing with a proposal to develop and establish a training program for GP peer support.  GP peer support was defined as provision of support in small groups by GP colleagues, facilitated by GP peer leaders who would assist the group members to help each other. 

Twenty GPs from across SA attended the training workshops, with the program and manual evaluated and modified with their input.  The manual has been printed and distributed with guidelines for the establishment of peer support groups to Divisions.  Five Divisions have indicated initially that they would be establishing peer support groups, with three continuing activity after the project finished in August 2003.  The project team, comprising the project officer and the two consultants from the Department of General Practice, University of Adelaide, anticipate that in future GP peer support groups will be a valuable mechanism for assisting GPs to work more confidently in this difficult area.

GP Access to Psychiatrists

Mental health is a common and significant problem addressed by general practitioners. A recurrent source of frustration identified by GPs in the management of patients with mental illness is the lack of easily accessible advice. The fifth arm of the Better Outcomes in Mental Health Care Initiative (BOiMHC) seeks to address this issue by focusing on increasing GP access to psychiatrists. The Australian Government Department of Health and Ageing has funded SADI to trial an innovative urgent advice service (UPASA) for 12 months in partnership with the Royal Australian and New Zealand College of Psychiatrists. This trial will conclude on 26 January 2005 when SA GPs will then able to access this service through the national call centre.

UPASA was available to all GPs in South Australia and aimed to:

• enhance GP management, knowledge and skills in mental health
•  increase GP confidence
• promote prevention through early assessment and intervention
•  improve the private sector?s response to primary mental health care
• strengthen networks between GPs and private psychiatrists.

 Centrally coordinated through SADI, the service provided GPs with:

• a consultant opinion by telephone within 24 hours of a request
• a one-off face-to-face consultation-liaison assessment if appropriate and agreed to
• feedback regarding a management plan.

Twenty-seven psychiatrists were recruited and inducted, agreed communication protocols established, on-call rosters produced, operational barriers identified and addressed and an extensive GP awareness campaign undertaken. GPs and psychiatrists have received the advice service positively. Data was collected on users and usage, nature of requests, usefulness of advice, satisfaction with the service and implementation difficulties. Clinical impact on GPs and psychiatrists and the project?s impact on their networks and relationships are being externally evaluated by the Adelaide University Department of General Practice on completion of the trial.

Requests for advice steadily increased each month. By mid December 2004, 150 individual GPs had accessed the service. The main area in which advice was sought was medication and the main diagnosis was depression.

The project was supported by a Steering Committee and by Dr Anne Sved-Williams as the Psychiatrist Consultant and Dr Peter Frost as the GP Consultant.

Information Management

The continued decline, uncertainty and subsequent loss of IM funding in December 2001 have reduced the capacity of Divisions to help general practice to take the next steps in computerisation.  This has led to the continual loss of dedicated IT/IM staff from Divisions and a reduction in the number of Divisions participating in the IT/IM network convened by SADI.

In 2003 SADI coordinated and analysed data collected by Divisions for the second State-wide IT/IM practice survey, the final report providing a valuable resource for planning and reporting. SADI continued to coordinate the development of the Divisions Database which now has 42 Divisions as subscribers. Coordination and partnership arrangements enabled many subscriber Divisions to make a smooth transition to NexOZ, the database developed by Adelaide Northern Division. The remainder will be contacted in late February 2005 to determine the best course of action.

The SADI Informatics Advisory Committee is made up of the major stakeholders in general practice and IT/IM with representation from Divisions, AMA, RACGP, University of Adelaide and State Department of Health.

At the local level Divisions have been generally turning their attention to the areas of data aggregation, electronic messaging, hospital integration and facilitating e-health in other program areas within their Divisions.

The focus now seems to be directly funding General Practice and vendors via a series of incentives to encourage the take up of Medicare Australia Online, Broadband and, in the near future, HealthConnect. South Australia will be one of the first two States to see HealthConnect implemented State-wide by July 2007. In order for this vision to see reality General Practice and Divisions will need to be centrally involved and adequately resourced. It remains to be seen how the newly proposed patient held smart cards (from the Department of Health and Ageing) will play a role in the SA HealthConnect implementation.

From August 2004, SADI has had specific funding from the Australian Government Department of Health and Ageing for a full-time officer to support Divisions in their work with practices, increasing their access to broadband.  This is an essential platform for proposed developments in connectivity. This work has highlighted the importance of ensuring that general practice is fully informed about their security needs in this area.

GP Registry

In November 2002, SADI received funding from the State Department of Human Services (now Health) to develop a GP Registry.  The Registry seeks to improve the care of patients by providing high quality, accurate and timely communication between hospitals and GPs as this relates to patient care (i.e. admission notification and discharge summaries and health alerts).  The Registry is linked with the State Department of Health Oacis computer system and the work done by the Department in developing effective separation summaries.

The Divisions Database (and now NexOZ) are central elements to the GP Registry as the latest versions provide for an automatic notification over the Internet when a consenting GP's details change.  This will provide a true end-to-end electronic transmission from Division to subscribers ensuring accuracy of the contact details.  The GP Registry commenced operation in September 2003 and was formally launched the following May.

Chronic Disease Management Initiatives

SADI's Chronic Disease funding supported continued activity by SADI in seven areas: asthma, diabetes, mental health, cervical screening, practice nurses, Enhanced Primary Care and information management. This funding finished in June 2004 with reduced capacity to support work in these areas.

Linkages with Division staff working in these areas provides an effective information conduit from local level through to national decision-making with SADI an active participant in the national Chronic Disease Management network, convened by ADGP with representation from each state and territory.  SADI's work in supporting Divisions in building practice capacity is an important element of future developments.

Asthma

In 2003, SADI gained funding from the National Asthma Council to coordinate the education and to provide support for the rollout of the Asthma 3+ Visit Plan.  Seven Divisions in SA, three rural and four urban applied to SADI to conduct the education sessions for GPs and practice nurses, with the education provided by members of SA's 'A' team.  An asthma forum was held with a focus on indigenous health and a practice nurse session conducted for metropolitan practice nurses.  SADI continues to provide information to those working in the area of asthma within Divisions.

Diabetes

SADI supports a network of Division staff working in the area of chronic disease (including diabetes) which provide the opportunity to discuss issues and keep up-to-date with developments at State and national level.  Working with key stakeholders remains an important part of SADI's role in diabetes.  An endorsed SADI GP representative was a long-term member of the DHS Diabetes Strategic Management Group, providing input to the State's strategic plan for diabetes as well as identifying opportunities for collaboration. This Strategic Management Group has now been  sub-sumed by the Chronic Disease Strategic Management Group on which SADI is represented by its Medical Director.

With funding from the Department of Human Services, SADI produced and disseminated a type 2 diabetes management guide.  This guide has been distributed to all GPs in SA, and following strong demand, to allied health professionals.  Available in hard copy and electronic formats (CD and website) it provides up-to-date evidence-based management guidelines in an easy to follow format. It is planned that the contents of the hard copy resource will be updated in 2005.

Clinical Nursing in General Practice

SADI's key achievements in nursing in general practice include: the development and strengthening of communication and education networks; through assisting Practice Nurse Networks in each Division, the provision of greater support to general practice, in particular making opportunities to work with GPs, practice nurses and other practice staff to explore role definitions and job descriptions, clarify skill related issues, legal issues and workloads; monitoring and facilitating continuing education for skill development and career enhancement for practice nurses; and identification of workforce issues, especially recruitment and retention.

Immunisation

SA is unique in Australia with the State Government, through the SA Immunisation Coordination Unit, funding the positions of local Immunisation Coordinators in every Division in South Australia.  This allows for intensive work at practice level to keep immunisation rates high, to maximise incentives for practices and provide education to GPs, practice nurses and practice staff, to provide clinical advice and to support practices to achieve optimal cold chain management.  The Australian Government General Practice Immunisation Incentive funding (at this stage guaranteed to June 2007) contributes to these positions and the work undertaken, and funds SADI's Immunisation Coordinator.

SADI convenes the quarterly state-wide meetings of all local Immunisation Coordinators.  This includes professional development with topics including Q Fever, Meningococcal C program, legal issues and hard-to-reach groups and is developed in close collaboration with SAICU.  An education program addressed changes recommended in the new Handbook when it was published late in 2003.  Achievements in immunisation in SA since the commencement of the State funding in 1998 were formally evaluated in 2003.  SADI is also involved in raising issues in immunisation, for example concerns about the two-tier schedule.

Population Health

In addition to population health activities reported elsewhere, SADI has also conducted a State-funded Physical Activity project which included the development of a physical activity information pack for GPs and Divisions.  This included an information module containing education material on the role of physical activity in disease prevention and management, physical activity guidelines, information on behaviour change strategies and use of physical activity prescripitions.  Divisions are able to utilise this resource in the development and delivery of the continuing professional development program and in other work supporting  practices and improving population health outcomes.

SADI assisted developmental work in the area of osteoporosis and supported an application by Osteoporosis SA for a State-funded project which developed and implemented a re-fracture prevention pathway.  The intervention focused on patient education, self-management skills and post-fracture follow-up for appropriate treatment and management.  It is being trialled in the hospital setting and, upon successful evaluation,  its implementation in general practice will be explored.  SADI supported a further funding application for this work which was submitted in late  December 2004.

Smoking Cessation Initiatives - SADI is a member of CHAMPS, a coalition of agencies with seeks to progress the uptake of smoking cessation interventions in a primary care setting.  CHAMPS  was established by QUIT SA.  SADI's Medical Director chairs the GASP Advisory Group which is working to increase the identification of smokers and delivery of smoking cessation advice in general practice.  Phase 1 developed an implementation package of supporting materials and GP training with Phase 2 including a randomised controlled trial to assess the efficacy of the implementation strategies.

Healthy SA is a Department of Health web site, providing a portal to health care information on the internet.  Aimed at the consumer, the web site provides links to information on a broad range of health topics and SADI was actively involved in this development.

Rural Issues

SADI offers additional assistance to rural Divisions in a wide range of areas including business and strategic planning, program development, assistance with submission writing, staff orientation and support, assistance with management principles and systems, lobbying and strategic linkages with key rural stakeholders.  Input on rural concerns is provided to SADI staff and management.  Secretariat support to the Rural Divisions Group is an important element of this role, as is regular participation by SADI?s Executive Director in the Rural Divisions Managers Network.

Quality Use of Medicines

SADI and the Drug and Therapeutic Information Service (DATIS) have developed a strong working relationship with the result that all Divisions have now gained funding from the National Prescribing Service to run their Quality Use of Medicines program.  This involves a partnership between Divisions and DATIS to provide academic detailing visits and presentation of case studies on topics developed by  NPS (e.g. antibiotic use, asthma management, dyslipideamia etc) to GPs in their region.

SADI's QUM Coordinator operates as a conduit for a variety of NPS initiatives to Divisional facilitators and has developed strategic linkages involving DATIS, SADI and the State Department of Health in considering strategic directions for QUM in this State over the next few years.

The Domiciliary Medication Management Review program in SA continues to develop through the strong network of Divisional facilitators and the positive partnership between SADI and the Pharmacy Guild of Australia (SA branch). All Divisions in SA have gained funding for a facilitator to promote DMMR in their regions.  The SADI Coordinator provides new facilitators with orientation and has developed an email discussion list for SADI and Divisional facilitators to share information  and solutions for issues that have arisen within Divisions.  This is further supported by the bi-monthly facilitator meetings convened by SADI.  The Coordinator is working closely with the Aged Care Development Officer in developing strategies which address the implementation of the new medication management items in residential aged care.

After Hours Primary Medical Care

The After Hours Primary Medical Care program concluded in December 2003. During the final six months of this program, the majority of work by the After Hours Policy Officer was centred around defining ways to progress the after hours agenda once the funding had ceased and articulating agreed statements and recommendations regarding after hours policy as the ?legacy? of the program in collaboration with the ADGP Policy Officer network. In addition, a final report on the program was written which also focussed on the learnings of the program and consequent recommendations.

During this period, support was provided to the Adelaide Central and Eastern Division, which convened an After Hours Symposium with key representatives from the urban Divisions of General Practice, the Department of Health and Ageing and the Department of Human Services (now Health). Information from this Symposium was useful in articulating the key issues and recommendations in greater detail.

One of the roles of the After Hours Policy Officer was to provide advice to the Department of Human Services regarding the establishment of a Health Call Centre in South Australia. Input into the scope and specifications of the Health Call Centre was provided to the Department to assist in the development of a business case that was put to the Treasury Department.

Following December 2003, the after hours portfolio continues with individual Divisions exploring the issue of after hours where appropriate with support from SADI when required.

General Practice Public Health Traineeship

Six positions nationally were funded by the Australian Government Department of Health and Ageing for GPs with a public health background to undergo a further three years advanced training towards the Fellowship of the Australian Faculty of Public Health Medicine.  After a successful application by an academic consortium in SA, one of these positions is based with SADI.  Dr Annapurna Nori commenced in this role in April 2003 and over the next three years will undertake a series of public health placements as well as involvement in specific projects.

Consumer Initiatives

SADI was involved in the formation of, and continues to be an active member of the Health Consumers Alliance which is viewed as the peak health consumers group in SA, bringing together the major consumer group stakeholders and health service providers in a strategic alliance.

SADI is also an active member of Health Reform SA which brings together those working in primary health care and consumer organisations to further advance the development of primary health care in this State.

Aboriginal Health

SADI is working with the Aboriginal Health Council to develop a formal MoU between the two organizations.  This is being assisted by work done at the local level by Flinders and Far North and Barossa Divisions.

SADI has also joined the EPC Reference Group, which supports the work of the EPC Project Officer based at the Aboriginal Health Council.  With SADI?s and Divisions? backgrounds in the EPC roll-out in 1999, this has been a valuable link. Eyre Peninsula Division was one of the presenters at the state-wide workshop convened by the Council in early November 2004.  Divisions have also been working in partnership with their local Aboriginal Health Services in the implementation of work funded through the Aboriginal Primary Health Care Access Program with SADI involved in workshops convened through this program.

Early in 2005, SADI is establishing links with the officer appointed by the University of Adelaide to establish a state-wide health professionals network for those working in Aboriginal health.  It is hoped that this initiative will help support the long-awaited network for GPs working in Aboriginal health.  SADI will also be working with the Council to actively promote MBS Item 710 which has provided a rebate for a full health check for Aboriginal people aged 15-54 but which has not been promoted.

Aged Care

In June 2004, SADI was advised of funding for a half-time officer to work with Divisions and aged care organizations to support the implementation of the GP Aged Care Panels.  A state-wide workshop was held in late June, a network has been established involving staff in all Divisions working in aged care, and a further aged care stakeholder meeting was held in November 2004.  A further state-wide workshop will be held in the first few months of 2005.  Funding for the role in SADI and in Divisions will reduce by half from July 2005, which has proved problematic in recruiting staff to these roles.

SADI was also involved in the establishment of the Advanced Community Care Association which provides the Acute Care in Residential Living Program and Metro Home Link.  SADI has a mandated position on the ACCA Board, with this position taken up by Dr Tori Wade. SADI?s Executive Director attends ACCA?s Operations Group meetings.  Late in 2005, SADI was involved in one tender for ACCA programs, and assisted a Division tendering for another program. 

Aboriginal and Indigenous Health Initiatives

Aboriginal Cervical Screening Program

Sharon Clarke from the Aboriginal Services Division of the Department of Health attended a Practice Nurse Network meeting to discuss with the group ways in which Divisions could support the distribution and dissemination of ?Principles of Practice, Standards and Guidelines for Providers of Cervical Screening Services for Indigenous Women?. Using the Practice Nurse Network proved to be an excellent way for Sharon to share information and seek support. The group was extremely responsive and has provided a variety of strategies to maximise this important initiative with general practice.

New Developments

Workshops were held by Commonwealth DoHA early in 2004 on the Aboriginal Primary Health Care Access Program. At the first one, Chris McRae (Murray Mallee) gave a presentation on the role of Divisions, with Valerie Williams (SADI) speaking at the second workshop. Speakers from regional Aboriginal health services were enthusiastic about how engagement with Divisions had significantly helped them to link with general practice. This initiative has the potential to improve access for Aboriginal people to mainstream primary health care providers, including general practice, and to support partnerships between Divisions and Aboriginal health services. The work by Limestone Coast, Adelaide Hills, Murray Mallee and Adelaide Northern was acknowledged by speakers at the second workshop with these speakers demonstrating a good knowledge of the role of Divisions.

Early in 2004-2005, representatives from the Aboriginal Health Council met with SADI to discuss the possibility of SADI working with them to develop an MoU between SADI, Divisions and the Aboriginal Health Council. Similar work has been undertaken in Victoria by GP Divisions Victoria (GPDV) (SADI?s counterpart) and Victorian Aboriginal Community Controlled Organisations (VACCHO) and nationally by ADGP and NACCHO. This is a long awaited development, with exciting possibilities, including the possibility of engaging at the regional level between Aboriginal Medical Services and local Divisions.

National Undergraduate Public Internship and Scholarship Scheme

In March 2003, SADI participated in the National Undergraduate Public Internship and Scholarship Scheme (NUPHISS) which is designed to expand public health teaching at the undergraduate level by building partnerships between health industry employers and universities.  SADI provided a field placement for a student in the third year of a Bachelor of Health Science at the University of Adelaide in the Public Health Internship Scheme.  The student participated in the evaluation of the Local Immunisation Coordinators program and was actively involved in the working life of SADI throughout the four months of her placement. A new student placement in the emerging areaa of aged care commenced in late August 2004.

August 2004