Congress response to redesigning the PIP - CAAC · 2 1. Introduction This response to the...

CongresssubmissiontotheRedesigningthePracticeIncentiveProgramconsultation

Summary

ThisresponsetotheCommonwealthDepartmentofHealth’sRedesigningthePracticeIncentiveProgram(PIP)consultationpaperhasbeenpreparedbytheCentralAustralianAboriginalCongress(Congress).

CongressisthelargestAboriginalcommunity-controlledhealthservice(ACCHS)intheNorthernTerritory,providingacomprehensive,holisticandculturally-appropriateprimaryhealthcareservicetomorethan13000AboriginalpeoplelivinginandnearbyAliceSprings,includingsixremotecommunities.

Inprinciple,CongressissupportiveofaredesignedPIPthatsupportsqualityimprovementpracticesinprimaryhealthcare.AsanACCHS,Congressalreadyhasawell-designedContinuousQualityImprovement(CQI)programwhichislikelytobeenhancedbytheoutcomesoftheredesign.

Congressfullysupportstheintentiontoretaintheruralloadingincentive;theafterhoursincentive;theteachingpayment;andeHealthincentive.Theseareimportantpaymentstosustainqualityservicesforourpopulation.

OverallthePIPisavitalfundingsourceforCongress.PIPrevenueisreinvestedbackintothecomprehensiveprimaryhealthcareservicesprovidedbyCongresswhichaimtoclosethegapinhealthoutcomesbetweenAboriginalandnon-AboriginalpeopleinCentralAustralia.AnyredesignofthePIPshouldnotcompromisethisrevenue.

Thereareanumberofprinciplestoconsiderintheredesignprocess.Theseinclude:

1) MaintainingrecognitionofIndigenousdisadvantagebykeepingtheexistingIndigenousHealthPIPorweightingthecostofIndigenousdisadvantagewithinastreamlinedQualityImprovementPIP

2) Administrativeprocessesincludingdatacollectionandreportingthatislessonerousthanexistingprocesses

3) Maintainingafocusonmanagingchronicdiseaseasthisaccountsfor80%oftheLifeExpectancygaphereintheNTbetweenAboriginalandnon-Aboriginalpeople.

4) Transparentuseofdataforbenchmarkingagainstpeersandpublicaccountability

5) MaintaintheClosingtheGapIndigenousChronicDiseaseCo-Payment

6) ContinuetoallowforflexibilityinhowpracticesusetheirPIPrevenue

7) EnsurethereisongoingconsultationwithACCHSsinthePIPredesignandmodelling

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1. Introduction

ThisresponsetotheRedesigningthePracticeIncentiveScheme(PIP)consultationpaperhasbeenpreparedbyCentralAustralianAboriginalCongress(Congress).

CongressisthelargestAboriginalcommunity-controlledhealthservice(ACCHS)intheNorthernTerritory,providingacomprehensive,holisticandculturally-appropriateprimaryhealthcareservicetomorethan13000AboriginalpeoplelivinginandnearbyAliceSprings,includingsixremotecommunities;Amoonguna,NtariaandWallaceRockhole,LtentyeApurte(SantaTeresa),Utju(Areyonga)andMutitjulu.

2. Contextforresponse

Whilethegapinsomehealthoutcomeshasdecreasedinrecentyears,Aboriginalpeoplestillexperienceadiseaseburdenthatis2.3timeshigherthannon-Aboriginalpeople.IntheNorthernTerritorytheconditionsthatcontributemosttothehigherburdenofdiseaseforAboriginalpeopleinclude:cardiovasculardiseases,mentalandsubstanceusedisorders,injuries,kidney&urinarydiseases,infectiousdiseasesandendocrinedisorders(whichincludesdiabetes).1Chronicdiseasesareresponsibleformorethan80%ofthegapindiseaseburden,whichisworseinremoteandveryremoteareas.

ACCHSs,suchasCongress,functionwithintheframeworkofacomprehensiveprimaryhealthcare(CPHC)service,whichaimstoaddresshealthinequitiesandclosethehealthgapbetweenAboriginalandnon-Aboriginalpeoplethroughprovidinghighquality,accessible,multidisciplinaryclinicalcareaswellastakingactiontoaddressthebroaderunderlying,socialdeterminantsofhealth..ACCHSs’servicepopulationsthathavesignificantlymorecomplexhealthneeds,andfrequentlyliveinrural,remoteorouter-suburbanareaswhereprivatepracticebusinessmodelsstruggleandserviceaccessisaparticularchallenge.ACCHSsprovideacomprehensivemodelofcarethatgoesbeyondthetreatmentofindividualclientsfordiscretemedicalconditionstoinclude2:

• afocusonculturalsecurity;

• assistancewithaccesstohealthcare(e.g.patienttransporttotheACCHSandsupportandadvocacytoaccesscareelsewhereinthehealthsystem);

• populationhealthprogramsincludinghealthpromotionandprevention;

• publichealthadvocacyandintersectorialcollaboration;

• participationinlocal,regionalandsystem-widehealthplanningprocesses;

• structuresforcommunityengagementandcontrol;and

• significantemploymentofAboriginalandTorresStraitIslanderpeople.

TheevidencepointstoACCHSasahighlyeffectivemodelforaddressingAboriginalandTorresStraitIslanderhealthandtheyarethereforerecognisedasthebestpracticemodelforprimaryhealthcareservicesforAboriginalpeopleinallthekeynationalstrategydocumentsincludingtheNationalAboriginalandTorresStraitIslanderHealthPlan(NATSIHP).Akeyrecentstudyconcluded:

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...somestudiesshowingthatACCHSareimprovingoutcomesforAboriginalpeople,andsomeshowingthattheyachieveoutcomescomparabletothoseofmainstreamservices,butwithamorecomplexcaseload3.

Inparticular,ACCHSscontributesignificantlytoreductionsincommunicabledisease,improveddetectionandmanagementofchronicdisease,andbetterchildandmaternalhealthoutcomesincludingreductionsinpretermbirthsandincreasesinbirthweight4.

ThekeyroleofACCHSsissupportedbythefactthatAboriginalpeopleshowaclearpreferencefortheuseofACCHSs,leadingtogreateraccesstocareandbetteradherencetotreatmentregimes5.

TheroleofACCHSsisparticularlyclearintheNorthernTerritory,wheretheircomprehensivemodelofservicedeliveryandadvocacyforpublichealthandsystemreformhasbeenthefoundationformuchoftherelativesuccessofthatjurisdictioninreducingmortalityrates.6

FurtherdetailoftheCPHCframeworkandcoreservicesisatAppendixA.

3. ContributionofthePIPtoACCHSandthedeliveryofcomprehensiveprimaryhealthcareservices.

PIPpaymentsareavitalcontributiontoCongress’incomeandannualbudget.CongressisaccreditedundertheRACGP’sStandardsforGeneralPractice,andisthereforeeligibleforPIPincentives.Asgrantfundinghaslargelybeencapped,PIPincentives,alongwiththeMedicareBenefitsSchedule(MBS),arethemajorsourceofgrowthfunding.ThisgrowthfundingenablesCongresstomeetincreasedneedandreviewanddevelopservicesinadynamicway,withouthavingtogothroughacumbersome,budgetappropriationprocess.ThishelpstoimproveaccesstoservicesforAboriginalpeopleinremoteareasaswellasencouragebestpracticeinareassuchasscreeningandchronicdiseasemanagement.Itisavitalwayoffundingthecareprovidedtothe3000AboriginalpeoplewhoutiliseCongressserviceseachyearwhodonotliveinourhealthserviceareaandarethereforenotincludedinourgrantfunding.

Congress’servicesandclientprofilemeanstheserviceiseligibleforanumberofPIPincentives,inparticularIndigenousHealth,Diabetes,CervicalScreening,Asthma,eHealth,Ruralloading,AfterHoursandTeaching.Forinstance,Congressseesapproximately2400patientseachyearinAliceSpringswhoareeligiblefortheIndigenousincentive.Over30percentofCongressresidentclientshaveatleastonechronicdiseaseandover44percenthavecomorbidities.Around1500patientsareeligiblefortheDiabetesincentive.Congressalsorunstheonlyafter-hoursclinicinAliceSpringswhichisopenonweekendsandpublicholidays,inadditiontoprovidingamajorgeneralpracticeteachingprograminpartnershipwithNorthernTerritoryGeneralPracticeEducation(NTGPE).

Althoughtheincomeisvital,administrativeprocessesareaburdenforbothstaffandpatients.Thismeansthateveniftheworkisdone,theincentivesarenotalwaysaccessedandrevenuereceiveddoesnotnecessarilyreflectoverallactivity.However,withimprovedprocessesandasystematicdrivetoincreaseitsuseofthePIP,CongressisontracktoreceiveaprojectedPIPincomeof$1.45millionin2016/17.Itisexpectedthat$1.2millionwillcomefromfulluseoftheIndigenousHealthPIP.

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AswithallincomereceivedbyCongress,thePIPpaymentsarereinvestedbackintotheexistingservicesandactivitiesinprevention,clinicalandsocialsupportservices,continuousqualityimprovement,workforce,educationandtraining,allofwhichcontributetoClosingtheGap.ThecombinationofPIPandMBSpayments,alongsideprimaryhealthcaregrantfunding,providesaleveloffundingthatisclosertomeetingtheneedforprimaryhealthcareservicesasdeterminedbytheNorthernTerritoryAboriginalHealthForumsCoreFunctionsofPrimaryHealthCare(seeAppendixA).Thereisstillaneedforadditionalprimaryhealthcarefundinginsomeareas.

ItisessentialthenthatthereisnoreductioninthisincomestreamasaresultofaredesignedPIPscheme.Congress’participationinanationalschemewouldbecontingentonfurtherunderstandingofpotentialrevenuecomparedwithcurrentrevenue.4. ACCHSqualityframework

AsanACCHS,Congressusesaccreditation(generalpracticestandardsandISO9001),CQI,andperformancereportingtodriveimprovementsinthequalityandsafetyofitsservicesandoutcomesforitspatients.Congresshasawell-developedCQIprogramanddedicatedCQIsectionwhichassistsmanagersandtheexecutiveleadershipbyprovidingreliabledatafordecisionmaking.QuantitativedataisalsousedtoreportonNTAboriginalHealthKeyPerformanceIndicators(NTAHKPIs)andnationalKPIs(nKPIs).Thesubmissionofthesedataiscompulsoryandresultsarepublicallyreported.

Congress’CQIteamsupportsongoingserviceimprovementandsupportsevidenced-informeddecisionsacrossallCongressprograms.TheCQIteampresentsbi-annualnKPIandNTAHKPIreportstoCongressclinicteams.Thesereportsareusedbyprogrammanagerstodevelopnewoperationalplansandtoidentifyareasrequiringimprovement.ThefundamentalaimsoftheCQIframeworkinclude:developingCQIcapacity;aPlan-Do-Study-Act(PDSA)improvementcyclethatprovidesastructurefortestingchangestoimprovethequalityofservices;andteamwork.

Forexample,inoneyeartheanaemiainchildrenlessthan5yearsPSDAcyclehasreducedanaemiaratesfrom18to13percentinurbanclinics,andfrom13to2percentinaremoteclinic.Improvementshavebeenduetoacollaborativeeffortbyclinicstaffincludinggoalsetting,outcomemeasures,evidenced-basedclinicalinterventions,innovativeorganisationalandpracticechange,andreviewingoutcomestoseehowtheyhaveworked(seeAttachmentA).

TheCQIprogramalsositswithinthebroadersystemofclinicalgovernanceywhichincludes:

§ TheCQIClinicalgovernancecommitteewhichundertakesarootcauseanalysisofincidentsandcomplaints,leadsCQIpriorityareasandoverseesthedevelopmentandreviewofclinicalpoliciesandproceduresessentialforCQI.

§ Staffcredentialingandregistration§ Complaints,incidentsandsuggestionsandCQIregisters§ Clinicalaudits§ Developmentandreviewoftheclinicalinformationsystem(Communicare)§ DevelopmentofoperationalplanswithappropriateKPIsforallprogramsandservices

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5. Overallcommentsonredesignproposalandoptions

5.1. QualityPracticeImprovementIncentivePayment

Inprinciple,theconceptofaQualityPracticeImprovementIncentivePaymentbyconsolidatingmainstreamPIPitemsissupported.Congresshasawell-developedCQIprogramwhich,underthesuggestedchanges,willberewardedandencouraged.Thereisgoodevidencethatthiswillleadtoabetterqualityprimaryhealthcaresystemoverall.7

ThechangessuggestedintheconsultationpaperwillenhancetheaimsandprinciplesoftheexistingCQIframework.Theproposedredesignsupportsadata-driven,innovation-focusedqualityimprovementmodel.Thisispartofaworldwideshiftfromvolume-basedhealth-caretoafocusonvalue-basedhealthcarewithincentivesdrivingqualityandinnovation,ratherthanquantity.8CongresshasbeenpractisingthisapproachformanyyearsnowandsupportsthemovetoincentivisethistypeofsystemsapproachtoCQIratherthanindividualdiseasemanagement.

GiventhatACCHSsundertaketheirownrigorousCQIprograms,CongressissupportiveofdesignOption1-theadministrationofthePIPQualityImprovementIncentivebybuildingonexistingactivities.Option2,PIPadministeredthroughathirdpartyproviderwouldnotbesupported.TheexperienceofathirdpartyproviderinthenationalKPIsystemforAboriginalhealthhasnotbeengoodanditisalmostcertainthattheredesignedsystemwillonlymakeuseofappropriatespecialistpublicinstitutionssuchastheAIHWtoovercomethesedifficulties.

5.2. Retainingfourexistingincentivepayments

Congressfullysupportstheintentiontoretaintheruralloadingincentive;theafterhoursincentive;theteachingpayment;andeHealthincentive.Thesearevitallyimportantpaymentstosustainqualityservicesforourpopulationandneedtoberetainedatthesamerate,forexampleremoteloadingiscurrently25percentforAliceSpringsand50percentforremotecommunities.

5.3. Keyconcernsandrecommendations

ThereareanumberofconcernsthatwillalsoneedtobeaddressedinthefurtherdevelopmentoftheredesignedPIP.Theseinclude:

1) MaintainingrecognitionofIndigenousdisadvantage.

TheredesignofthePIPwillneedtotakeintoaccountthecomplexityofAboriginaldisadvantageandhealthoutcomes.ApaymentmechanismshouldcontinuetobeinplacesothatthereisstillafocusonclosingthehealthgapbetweenAboriginalandnon-Aboriginalpeopleandthatthereisnofurtherdisadvantagethroughlossofservices.Optionsinclude:

§ KeeptheexistingIHPIP,atthecurrentpaymentof$500perpersonperyear.

§ Alternatively,weightingthecostofAboriginaldisadvantagewithinastreamlinedPIPincentivebyatleast$500pereligiblepersonperyearsothatnorevenueislost

Additionally,astheHealthCareHomes(HCH)trialevolves,identification,selection,enrolmentandsubsequenttieredpaymentswillneedtoaccountandcostforAboriginaldisadvantage.Atthisstage

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inthedevelopmentandtestingofriskstratificationtools,measuringtheadditionalimpactofdisadvantageofAboriginalpeopleonhealthrisksrcanbeestimated.Forexample,itisknownthatriskcalculators,suchastheFraminghamCardiovascularRiskCalculator,underestimatethecardiovascularrisksforAboriginalpeople,sointheCentralAustralianRuralPractitioner’sAssociation(CARPA)Manualanadditional5percentloadingisaddedontocreateanAboriginalspecificcardiovascularriskcalculator.ThishasalsobeendonetogetanappropriatecardiovascularriskassessmentforMaoripeopleinNewZealand.IthasnotbeenpossibletoidentifyexactlythereasonsfortheincreasedriskotherthantogivealoadingforAboriginalpeopleasthereasonssuchas“lackofcontrol”aretoohardtomeasureanyotherway.

TheHCHtrialriskstratificationtoolshouldthereforeinitiallyincludeAboriginalityasacriteriatoaccountforsocioeconomicdisadvantageandhigherserviceneedsofAboriginalpeoplewithoneormorechronicdiseases,toatleastthelevelofthecurrentPIP(i.e.plus$500perpatient).

Thisshouldensurethereisnolossofrevenueandrelatedserviceandshouldcontinueuntil:

§ TheriskstratificationtoolcanmoreaccuratelyassessthecomplexityofAboriginalhealthdisadvantageandindividualneed;or

§ thehealthgapcloses.

2) Administrativeprocessesincludingdatacollectionandreportingthatislessonerousthanexistingprocesses

ThedatacollectionprocessforaredesignedPIPincentiveshouldbelessonerousthantheadministrativeburdenofthecurrentPIP.Itshouldalsobeusefulforlocaldecision-making.ThecurrentAHNTKPIreportsandnKPIreportsthatCongressalreadyproducesshouldbesufficienttomeetthedatarequirementoftherevisedCQIPIPprogramandsuchsystemsofreportingonkeyhealthserviceperformancedatashouldbeextendedtomainstreamgeneralpractice.CurrentlythepurposeofAHNTKPIandnKPIdataisto‘improvethedeliveryofprimaryhealthcareservicesbysupportingcontinuousqualityimprovement(CQI)activityamongserviceproviders’9.However,itisimportantthatdatacollectedalsosupportslocalCQIactivitiesandthatservicescanindependentlyaccesstheirowntrendinformationaswellascomparetheirdatawithpeers10.

3) Maintainingafocusonmanagingchronicdisease

Cautionisneededinbundlingdataandpaymentssothatafocusonkeychronicdiseasesisnotlostaltogether,divertingattentionfromaspectsofcarenottargetedbyincentivese.g.eyechecksonpatientswithdiabetes.Thefocusonimprovedchronicdiseasemanagementshouldcontinue,thoughassessedthroughoutputandoutcomemeasuresratherthanjustprocessmeasures,toencouragecollaborationandteamcare.

4) Transparentuseofdataforbenchmarkingagainstpeersandpublicaccountability

Overtime,practiceCQIdatashouldbetransparentandpublicbutthiswillneedappropriatefurtherconsultationandnotberushedaspartoftheimplementationofthereformedPIP.Thiswillincreaseaccountabilityandassistpracticestoimprovebycomparingdatawithotherpractices.11However,datacomparisonswillneedtotakeintoaccountpopulationdemographicsthatinfluenceprocesses

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andoutcomeindicators(e.g.socialdisadvantage,age,diseaseprevalence)whereclientswillhavepoorerhealthoutcomesandserviceusageotherpopulations.

5) MaintaintheClosingtheGapIndigenousChronicDiseaseCo-Payment

TheIndigenousHealthPIPislinkedtotheClosingtheGapIndigenousChronicDiseaseCo-Payment(CTG)whichallowsAboriginalpeopletohavetheirPharmaceuticalBenefitsSchemeco-paymentreducedfromthegeneralco-paymentratetotheconcessionalrate.PrescribersmusteitherbefromanaccreditedGeneralPractice,orfromanon-remote(i.e.nonSection100approved)AboriginalHealthServices.TheremovaloftheIndigenousHealthPIPwillimpactontheGTPco-payment.OnesolutionwillbetodelinktotheCTGprescriptionsfromtheIndigenousHealthPIP.

6) ContinuetoallowforflexibilityinhowpracticesusetheirPIPrevenue

OrganisationsshouldnothaveconditionsorlimitationsonhowPIPrevenueisreinvestedbackintotheprimarycareservice.Thisshouldcontinuetobesomethingthatlocalhealthservicescandeterminetobestmeetthelocalneedsforimprovedandenhancedservices.

7) EnsurethereisongoingconsultationwithACCHSsinthePIPredesignandmodelling

Thereshouldbeanumberofconsultationsastheoptionsarefurtherdeveloped.AnymodellingofincentivesandpotentialrevenueshouldbecheckedagainstthepotentiallossofincentivestoACCHS.

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AppendixATheimportanceofcomprehensiveprimaryhealthcare

Theterm'primaryhealthcare'(PHC)gainedwidespreadcurrencyfollowingtheAlma-AtaConferenceheldbytheWorldHealthOrganisationin197812.ThedefinitionofPHCadvancedbyAlmaAtawascomprehensive:aswellastheprovisionofmedicalcare,italsocapturestheidealof‘wellness’asagoal,andprevention,healthpromotion,advocacyandcommunitydevelopmentasmajormethodstoachieveit.Itemphasisestheneedformaximumcommunityandindividualself-relianceandparticipationandinvolvescollaborationwithothersectors.

ThiscomprehensivedefinitionofprimaryhealthcareisnowbroadlyacceptedinAustraliaespeciallywhenitcomestoimprovingthehealthofdisadvantagedpopulationssuchasthatofAustralia’sAboriginalandTorresStraitIslanderpeoples13.

Awell-resourcedandrobustcomprehensiveprimaryhealthcaresystemisthereforeacriticallyimportantplatformfromwhichtoaddressthehealthofAboriginalandTorresStraitIslanderAustralians.

Coreprimaryhealthcareservices

Congressfunctionswithintheframeworkofacomprehensiveprimaryhealthcare(CPHC)service,addressinghealthinequities,andaimingtoclosethegapbetweenAboriginalandnon-Aboriginalpeople.Theeffectivenessofthismodelisduetothewideandinnovativerangeofstrategiesthatprovideequityofaccesstoculturallyappropriateservicesandprogramsthatareaffordableandacceptabletothecommunity,andholisticallycareforhealthandwellbeingofAboriginalpeople.

AnotherkeypartoftheprogressiverealisationoftheCPHCvision,whichhasbeenleadingthehealthimprovementthathasoccurredintheNorthernTerritory,hasbeenincreasingiterationsofwhathasbecomeknownas“coreprimaryhealthcareservices”whichtranslatethePHCnormsandprinciplesintothecoreoutputsofAboriginalprimaryhealthcarepracticeincludingarangeofclinicalservices,supportservices,socialandpreventativeprogramsandpolicyandadvocacyfunctions.Therehavebeenthreeiterationsofthecoreprimaryhealthcareservicesmodelwiththemostrecentandcomprehensiveversionproducedin2011inwhichtherearefiveservicedomains14:

1. ClinicalServices2. HealthPromotion3. CorporateServicesandInformation4. Advocacy,Knowledge,Research,PolicyandPlanning5. CommunityEngagement,ControlandCulturalSafety

Definingcoreservicesispartofdefiningtheprogressiverealisationoftherighttohealthastheobligationongovernmentstoensureaccesstoevidence-basedservicesandprogramsaccordingtoneedismademoreexplicit.AustraliahastheresourcestoensurealloftheservicesandprogramsoutlinedinthiscoreservicesmodelareaccessiblethroughACCHSs.Thisincludesservicesandprogramsinareassuchasearlychildhood,familysupport,alcoholandotherdrugtreatmentandagedanddisabilitycarealongwiththemorefamiliarclinical,maternalandchildhealth,chronicdiseaseandotherservices.ResourcingallofthecoreserviceswillenableCPHCtomakeitsmaximumcontributiontoClosingtheGap.Alongwiththedevelopmentofthesecoreserviceshasbeenthe

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correspondingdevelopmentcoreprimaryhealthcareindicatorsthatenableeachservicetotrackitsownprogressinkeyareasandreportthistotheircommunities.

1AIHW2016.AustralianBurdenofDiseaseStudy:ImpactandcausesofillnessanddeathinAboriginalandTorresStraitIslanderpeople2011.AustralianBurdenofDiseaseStudyseriesno.6.Cat.no.BOD7.Canberra:AIHW.2ThompsonSC,HaynesE,etal.(2013).EffectivenessofprimaryhealthcareforAboriginalAustralians.Canberra,UnpublishedliteraturereviewcommissionedbytheAustralianGovernmentDepartmentofHealth,MackeyP,BoxallA,etal.(2014).TherelativeeffectivenessofAboriginalCommunityControlledHealthServicescomparedwithmainstreamhealthservice.DeebleInstituteEvidenceBriefNo.12,DeebleInstitute/AustralianHealthcareandHospitalsAssociation,NationalAboriginalCommunityControlledHealthOrganisation(NACCHO)(2014).EconomicValueofAboriginalCommunityControlledHealthServices.Unpublishedpaper.Canberra,NACCHO.3MackeyP,BoxallA,etal.(2014).TherelativeeffectivenessofAboriginalCommunityControlledHealthServicescomparedwithmainstreamhealthservice.DeebleInstituteEvidenceBriefNo.12,DeebleInstitute/AustralianHealthcareandHospitalsAssociation.Page64Dwyer,J.,K.Silburn,etal.(2004).NationalstrategiesforimprovingIndigenoushealthandhealthcare.AboriginalandTorresStraitIslanderPrimaryHealthCareReview:ConsultantReportNo1.Canberra,CommonwealthofAustralia.5VosT,CarterR,etal.(2010).AssessingCost-EffectivenessinPrevention(ACE–Prevention):FinalReport.Melbourne,ACE–PreventionTeam:UniversityofQueensland,BrisbaneandDeakinUniversity.6 AustralianInstituteofHealthandWelfare(2015)AboriginalandTorresStraitIslanderHealthPerformanceFramework2014report:NorthernTerritory.Cat.no.IHW159.Canberra:AIHW,page240 7 Sibthrope,B.,Garnder,K.andMcAullay,D.FurtheringthequalityagendainAboriginalcommunitycontrolledhealthservices:understandingtherelationshipbetweenaccreditiation,continuousqualityimprovementandnationalkeyperformanceindicatorreporting.AustralianjournalofPrimaryHealth,2016,22,270-275.8 Henke,N,Kelsy,T.,andWhately,H.,Transparency-Themostpowerfuldriverofhealthcareimprovement?HealthInternational.McKinseyhealthsystemsandhealthservicespractice2011. 9 AustralianInstituteofHealthandWelfare(AIHW)NationalKeyPerformanceIndicatorsforAboriginalandTorresStraitIslanderprimaryhealth:firstnationalresultsJune2012toJune2013.Availableathttp://www.aihw.gov.au/publication-detail/?id=60129546941&tab=2 10 Sibthrope,B.,Garnder,K.andMcAullay,D.FurtheringthequalityagendainAboriginalcommunitycontrolledhealthservices:understandingtherelationshipbetweenaccreditiation,continuousqualityimprovementandnationalkeyperformanceindicatorreporting.AustralianjournalofPrimaryHealth,2016,22,270-275. 11 Henke,N,Kelsy,T.,andWhately,H.,Transparency-Themostpowerfuldriverofhealthcareimprovement?HealthInternational.McKinseyhealthsystemsandhealthservicespractice2011.12 WorldHealthOrganization(1978).Alma-Ata:PrimaryHealthCare.13 AustralianMedicalAssociation.(2010)."PrimaryHealthCare."Retrieved22September,2010,fromhttp://ama.com.au/node/5992.;AustralianDivisionsofGeneralPractice.(2005)."PrimaryHealthCarePositionStatement."Retrieved22September,2010,fromhttp://www.agpn.com.au/__data/assets/pdf_file/0006/16269/20051026_pos_AGPN-Primary-Health-Care-Position-Statement-FINAL.pdf.NationalAboriginalCommunityControlledHealthOrganisation(NACCHO)."Primaryhealthcare."RetrievedSeptember2010,fromhttp://www.naccho.org.au/definitions/primaryhealth.html.14 Tilton,EandThomas,D2011NorthernTerritoryAboriginalHealthForumCoreFunctionsofPrimaryHealthCare:aFrameworkfortheNorthernTerritoryPreparedfortheNorthernTerritoryAboriginalHealthForum,Darwin.