Author: Claire Verrall
Verrall, Claire, 2023 Health Care Homes and the role of the practice nurse: an exploration using case study methodology, Flinders University, College of Nursing and Health Sciences
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Using a case study approach, this thesis examines the impact of the Australian Federal government’s trial of Health Care Homes (2018-2021) on the role of practice nurses using Alford’s (1975) structural interest theory and Carol Bacchi’s policy analysis as the analytical lenses. Health Care Homes is one of the most recent in a raft of reforms instigated by the Federal government over the last two decades to create a more organised and coordinated primary health care system and to reorient general practice towards population-focused, patient-centred, multidisciplinary care for those with chronic conditions.
Underlying this thesis are three assumptions. Firstly, over the last two decades, the Federal government has attempted to reorient general practice through a series of initiatives, none of which have fully achieved the stated policy objectives. These have taken the direction of monetary and other incentives for general practice as well as the formation and funding of primary care organisations to assist general practitioners to take a population health approach that enhances the coordination of care. Examples of these organisations are Divisions of General Practice, Medicare Locals, and Primary Health Networks. While each of these initiatives has some differences, a common aim has been to support the primary health care sector by enhancing care coordination and improving access to care for those with chronic conditions. It was hoped that these initiatives would assist in preventing unnecessary hospitalisations and relieve the pressure on an already burdened acute system.
The second assumption argues that these policy directions have had an impact on the professional status, role, and position of practice nurses, mostly contributing to an expanded and enhanced role. The third assumption aligns with Alford’s theory on the role of competing structural interests in health policy reform, suggesting that those with ‘dominant’ interests will ensure that any policy reform that does not align with their views will be resisted or manipulated to meet their interests.
Further analysis of the Health Care Homes initiative is made using Carol Bacchi’s framework of policy interrogation, using ‘problematisation’ to explore how people create and identify problems and make sense of them within policy. Data supports the underlying premise of Alford’s theory, demonstrating that individuals and groups act
according to their own interests. Any attempt at reform in general practice is challenged by the prevailing nature of private business and an intrinsic fee-for-service business model.
The case studies used for this thesis showed that the role of the practice nurse when assisting people to manage their chronic conditions was essentially unchanged during the trial. The greatest influence on the nurse’s role was their relationship with the general practitioner and the ability of the nurse to demonstrate initiatives that resulted in creative and new ways of working.
Forty-seven years on from the development of Alford’s theory, I have demonstrated that his basic argument remains. Over these years, the landscape of general practice has changed to include more nurses, increased use of information technology. and a variety of health care professionals. This altered structure and context has done little to change the power dynamics within the general practice context. The application of Alford’s theory to general practice today has demonstrated through the Health Care Homes initiative that the role of the general practice nurse, despite many attempts at health reform, remains relatively unchanged.
Keywords: practice nurse, primary health care, chronic disease, health care homes, health reform
Subject: Nursing thesis
Thesis type: Doctor of Philosophy
Completed: 2023
School: College of Nursing and Health Sciences
Supervisor: Emeritus Professor Eileen Willis