A Case Study of the Hunter Region, New South Wales 1974 -1989

Contextualizing Implementation of the Community Health Program: A Case Study of the Hunter Region, New South Wales 1974 -1989

Shirley Schulz -Robinson

RPN, RGN, ADNE (Arm), BA (Hons) (Newcastle)

This thesis is submitted in fulfilment of the requirements of the Degree of Doctor of Philosophy, School Public Health and Community Medicine, University of New South Wales, 2006

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Acknowledgments

Many people have contributed to this research. It would not have completed without my supervisors Drs Stephanie Short, Anna Whelan and last, but certainly not least, Jan Ritchie, who have been unstinting in offering support, encouragement and ideas especially during those times, familiar to all higher degree students, of euphoria, despair and anxiety. Thanks must also go my first co-supervisor Colin Grant, who provided me with personal copies of difficult to obtain documents. I owe a debt to Professors Mary-Lou McLaws, for her sense of humour and sage advice, and Debbie Black for her sensitivity. Over the years many people have provided support and encouragement and shared ideas, recollections and insights which would have been impossible to gain from records. Special thanks go to Professor George Palmer, Dr Sidney Sax, Ian Lennie, Denise Fry, Allen Owen and Mark Griffith who willingly shared their knowledge and insights regarding implementation of the CHP at a national and state level. I owe a debt to Dr Geoffrey Olsen for his insights into developments in the Hunter Health Region. Many people encouraged me before I began this research. Robyn McMellon, my first senior community nurse, Lee Bowden, colleague and fellow traveller in learning about community health, deserve particular mention as do Professors Michael Carter and John Bern who encouraged a mature age undergraduate student. Thanks must also go to Drs Peter Khoury and Fran Flavell, colleagues in the truest sense, who read drafts and offered insightful comment. Friends have contributed: Janne Lee, a social activist, involved me in social justice issues; Jeanette Martin, a psychiatrist, and Margaret McEneiry, Professor of Nursing, and Brian Hennen, Dean of Medicine, debated health care; Kathy Lawrence, Lydia Duncan, Dennis McIntyre, Ross Morrow, Nancy North, Pat Burke, and Ann Woodford, encouraged me. My family, especially my husband Ralph Robinson has been unfailing in his love and support as I have tried to juggle a career and complete this doctorate. Thanks must also go to my sons, Rodney and David, who have long endured a mother preoccupied with her ‘work’. Final thanks must go to my parents whose deaths preceded completion of this work. My need to maintain relationships with family and friends during times of difficulty, theirs and mine, has led me to focus on their needs and to let this work take a backseat. To all, my heartfelt thanks. It is done.

Newcastle, August 2006

ii TABLE OF CONTENTS

Figures ix Tables ix Appendices ix Abbreviations x

Abstract xi

Prologue: The researcher up-front xii

1. INTRODUCTION

A National Community Health Program Policy 1 Background to this study 2 Political Controversy 3 Health Policy 3 Community Health Centres 4 Evaluation rather than Research 5 The Importance of Context 6 The Context of Community Health Centres 7 Structure and Culture 8 Organisational Environments 8 Process and Orientation 9 Generalist Community Nurses 10 Federal and State Issues 10 Multiple Stakeholders 11 Reform Agenda 12 Impetus for this Study 12 Purpose of the study 13 Contribution of Thesis 13 Structure of the Thesis 13

2. CONCEPTUAL UNDERPINNINGS FOR A STUDY OF A COMMUNITY HEALTH POLICY

Introduction 15 Public policy 15 Influences on Policy Making 17 Policy Implementation 18 Organisations, Structure and Culture 22 Health and Health Policy 23 The Scope and Practice of Public Health 25 Environments, Populations or Individuals 26 Determinants of Health and Illness 27 Theoretical Perspectives on Prevention 28 Primary Health Care 31 In Summary 32

iii 2. OVERVIEW OF THE COMMUNITY HEALTH CENTRE AND COMMUNITY NURSING LITERATURE

Introduction 33 Innovative Projects which met People's Needs 33 Community Activism 35 Governments Driving Change 36 Australian Studies 38 Failing to Achieve the CHP Policy's Goals 39 A National Study 39 NSW CHCs’ More Preventive than Other Services 40 Determining Focus and Administrative Processes 42 Community Nursing and Social Work 44 Teamwork, Conflict, and Service Development 50 Gaps in the Australian CHP Policy Literature 58 The Orientation of Practitioners by the Late 1980s 60 In Summary 61

4. THE METHOD OF INQUIRY

Introduction 62 Purpose of this study 62 The research approach 63 A qualitative case study 63 Strengths of Case Studies 64 The Study Design and Research Questions 65 Definition of Terms and Data Sources 66 Selecting the State and the Region 67 Selecting Community Health Centres, Practitioners and Teams 68 Selecting Practitioners and Administrators 69 My Stance as Researcher 69 Data Sources 70 Documents and Archival Records 70 Interviews 71 Participant Observation 72 Conducting the Study 72 Identifying Literature Sources 72 Gaining Access 73 The Data Collection Process 74 Creating a Data Base 76 Data Analysis 77 Attribution of Sources 78 Research Standards ― Trustworthiness 78 Ethical Issues 79 In Summary 79

5.THE NATIONAL AND STATE HEALTH POLICY CONTEXT: TRYING TO TAKE CONTROL

Introduction 81 The Australian Health Care System 81 Costly, Maldistributed and Fragmented 82 Contemporary Health Problems and Illnesses 83

iv Healh Care: Institutionally Focused, Curative and Unresponsive 85 General Practitioners 89 National H&HSC Review of Hospitals 90 Professional Education 91 CHCs a Solution to Contemporary Problems 95 New South Wales CHP’ Proposals 97 Expectations of Community Nurses 98 Expectations of Administrators 100 The Australian Labor Party's Health Reforms 102 A National Community Health Program 105 In Summary 111

6. THE HUNTER REGION: RESOURCE RICH ― HEALTH POOR

Introduction 112 Rivers, Coal and Convicts 114 Steel, Industry and Immigrants 114 Poor Living Conditions 115 Reduced Opportunities 116 Changing Economic Profile 116 Dependent but Defiant 117 Health Risks for All 118 Social and Leisure Activities 119 A Disadvantaged Region 119 Socio-demographic Variations 120 The Hunter Population's Need for Health Care 124 Hunter Health Services 127 Hospital Admissions 127 Hospitals: Schedule 2,3 and 5 130 Ambulatory Care, Domiciliary and District Nursing 131 Some Gruelling Daily Schedules and Little Control 132 Schedule 5 Geriatric and Psychiatric Hospital Outreach Services 134 Psychiatric Nurses' Roles Began to Expand 136 Hunter Regional Services 136 Local Government and Private Domiciliary Services 137 Maternal and Child Health Services 137 Nurses' Responsibilities 139 Distribution, Access and Costs 140 Education of the Region's Health Professionals 142 In Summary 143

7. ESTABLISHING CHCS DURING A PERIOD OF FISCAL AUSTERITY: PROVIDING PEOPLE WITH A RELEVANT OPTION

Introduction 145 An Inauspicious Beginning 146 Differing Professional and Cultural Concerns 147 Dissent as to Purpose 147 Conflicting Concerns 148 Missed Opportunities 148 Choosing Locations for CHCs 150 Space Matters 150 Accessibility and Useability 151

v The Most Basic of Facilities 151 Totally Inadequate 152 Shabby and Uninviting 153 Business Hours and After Hours 153 Finding Practitioners for CHCs 154 Recruitment was Difficult 155 Whom to Employ 155 Seconding from Other Services 156 Co-locate and Assimilate 157 Divide or Split 157 Mostly Experienced 159 More or Less Committed to the CHP Policy 160 Erratic Growth, Continuous Vacancies 161 Anyone Will Do 162 Unstable and Changing 162 Vulnerability 163 Mostly Nurses but Not Really a 'Nursing Service' 163 Large Catchment Areas 164 Reducing the Size of Catchment Areas 165 Services, Centre-Based and Outreach 165 Location and Time, Away from CHCs at All Hours 166 Access, Near Universal 166 Clients of CHCs: Who Sought Assistance? 167 Purpose, Improving People's Circumstances 167 Provider/s, One or Many 168 Some Continuity of Provider 168 Indirect Services, Finding Someone Else to Help 168 Differences Between CHCs 169 Differences Between Disciplines 169 Generalist Nurses Initiated Most Preventative Programs 170 In Summary 170

8. THE APPROACH OF ADMINISTRATORS ― DOING WHAT YOU CAN ON THE SMELL OF AN OILY RAG

Introduction 171 A Window of Opportunity 172 Spreading the Word with Missionary Zeal 173 Unreasonable Demands on Senior Officers 179 Communities Unaware of CHCs 179 Declining Support for CHP Policy and CHCs 182 Planning Underestimated Local Needs 184 Bad Timing and Slow Decision-Making 185 Regional Autonomy and a Cult of Personalities 186 Conflict Over Resources and Populations 188 Advisers or Opponents 189 Delicate Relations 190 Nothing Much Left to Cut 191 Media Reports Precipitated Change 193 A Beneficial Upheaval 194 Generalist Teams Unsustainable 195 Educative and Preventive Services Needed 196 A Strategic Plan for a 'Chaotic and Confused' CHP 198 Generalist Nurses' Inadequate Preparation 199

vi Integration Prior to Change 200 Restricting Nursing Practice 202 In Summary 202

9. PRACTITIONERS' APPROACH TO ESTABLISHING CHC SERVICES: FLYING BY THE SEAT OF THEIR PANTS ― UNTIL CONSTRAINED

Introduction 203 So Many Needs and Service Gaps 203 A New Perspective was Presented 204 Orientation to CHP Policy and Health for CHC Recruits ― Missed Opportunities 204 Nurses Enlightened as to Possibilities ― Centre Managers Missed Out 206 Expected to Swim with Minimal Assistance 206 Nurses' and Managers' Expectations Diverged 207 Nurses' Roles Redefined, a Unique Freeing Experience 208 GCNs Reached Out to Learn about their Areas 209 Knocking on Doors to Learn about Service Gaps and Raise Awareness 209 Relationships and Links 210 CHCs, A Welcome Addition or an Interloper 210 Liaison Leads to Representation 211 Opportunities Open Out for Health Promotion in Schools 211 Acceptance of CHCs was Related to Need 212 Sources of Resistance and Hostility 213 Restructuring Forced Interaction between CHCs and General Hospitals 213 Democratic Administrative Structures and Processes 214 Team Meetings Fostered a Sense of Belonging 215 Correspondence Overload 215 Opportunities to Respond 216 Reports of Change and Problems 217 Anxiety Provoked Not Reduced 217 CHC Team Meetings Present Needs and Solutions 218 Growing Dissatisfaction with CHC Team Meetings 219 GCNs' Work with Clients Just Grew 220 Multi-disciplinary Learning Routine 221 Multiple Responsibilities Meant More Planning 222 Some Practitioners Juggled Huge Workloads 224 GCNs Faced Unreasonable Demands 225 Strategies for Containing Growing Workloads 226 Tensions between Generalist and Specialist, GCN and HACC Nurses 226 A Poor Solution to Inequitable Workloads 227 Too Many Cars Then Too Few 228 Most Practitioners Focused on Clients 228 Administrative Innovations 229 Concern about Client Needs and Progress Lead to 'Case Review' and 'Intake' 229 Helping People Help Themselves 230 Continuity and Dependence 232 A Community Perspective 233 CHC Work expands Nurses' Responsibilities and Awareness 233 Clients' Expectations 234 Teambuilding and Interdisciplinary Collaboration 235 Working with Volunteers 236 Impact of Area Boards 236 In Summary 237

vii 10. CONCLUSION: POLICY IMPLEMENTATION BUILT SOCIAL CAPITAL IN A DISADVANTAGED REGION

Introduction 238 Reflections on Key Findings 238 Implementing the CHP Policy 239 Aspects of Context 241 Consideration of Processes 243 The Role of Generalist Community Nurses 244 Unanticipated Aspects of Implementation 245 Significance of the Findings 246 Limitations 250 Implications for Further Research 250 In Summary 251

Bibliography 252

viii Figures, Tables, and Appendices

Figures Figure 3.1 Evaluations Conducted In Australia Between 1979 and 1986 38 Figure 3.2 Proposals made by SCHRU following a Pilot Study in 1985 41 Figure 3.3 Studies of Community Nursing Conducted Between 1976 and 1991 44 Figure 6.1 Map of the Hunter Region illustrating its location and size 113 Figure 6.2 Population growth and decline by LGA and CHC catchment area 121 Figure 6.3 Changes in marital status amongst the Hunter Population between 1974 and 1989 122 Figure 7.1 How Practitioners were obtained for CHCs 1974-1976 154 Figure 7.2 Creating new CHCs, divide and split 158 Figure 8.1 NSW Health Commission Responsibilities in 1974 171 Figure 9.1 Types of Correspondence Received by CHC Teams 1975 – 1989 215

Tables Table 6.1 Hospital Separations and Diagnosis for 1977-1978 and 1979-1983 128 Table 6.2 Hospital Separations and Diagnosis for 1977 1978 and 1979-83 129 Table 6.3 Schedule 2, 3 and 5 hospitals bed numbers 1974 - 1988 130 Table 6.4 Home Nursing Services provided by Schedule 2 and 3 Hospitals 1974-1984 134 Table 8.1 Speakers, Topics, Health Commission of NSW Conference, Rankin Park Hospital, February 26-28, 1974 174 Table 8.2 NSW Conference February 26-28, 1974. Summary of participants’ suggestions for solving problems arising from regionalisation, rationalization of hospitals and emphasis on prevention and provision of domiciliary nursing 175 Table 8.3 Speakers, ‘Planned Health Care for the Hunter’, Stockton Hospital, 27-28.11.1974 177 Table 8.4 Responsibilities by positions as identified in Duty Statements prepared by the Bureau of Personal Services, June 1975 181 Table 8.5 Regional Reports concerning the CHP between 1984 and 1989 201

Appendices Appendix 4.1 Interview guide 335 Appendix 4.2 Correspondence granting permission to conduct research 336 Appendix 4.3 Interviewees’ professional background and work experience 339 Appendix 4.4 Date of interviews, code allocated, position 340 Appendix 5.1 Selected chronology of key federal and state events relevant to this study 344 Appendix 5.2 Selected chronology of services employing community nurses in Australia 1880 to 1975 351 Appendix 5.3 NSW NRB Psychiatric Nurses Registration examination 352 Appendix 6.1 An example of a ‘depression’ house occupied into the 1950s 354 Appendix 6.2 The Hunter Population: demographic and socio-economic profile 355 Appendix 7.1 Vacancies in the Hunter Regions CHP 359 Appendix 7.2 Westlakes CHC Annex floor plan 360 Appendix 7.3 Changes in CHC team leaders from 1975 to 1989 361 Appendix 8.1 Proposed Regional Structures 362 Appendix 8.2 GCN Statement of Duties 364 Appendix 8.3 Political and organisational changes affecting CHCs 1975-1989 366 Appendix 9.1 Generalist Nurses’ Guidelines 1975 367 Appendix 9.2 Ideal and actual population to CHC practitioner ratios 370 Appendix 9.3 Selected examples of CHC practitioners local activities and services 371 Appendix 9.4a Meeting structure and processes from 1975 until 1989 376 Appendix 9.4b Newcastle CHC New Programme Proposals 377 Appendix 9.4c Newcastle CHC Staff Education Sessions for 1992 378

ix Abbreviations

ABS Australian Bureau of Statistics ACHA Australian Community Health Association ADHHSC Australian Department of Health and Hospitals and Health Services Commission AHS Area Health Service ALP Australian Labor Party AMA Australian Medical Association BHC Baby Health Centre BHP Broken Hill Propriety Ltd CDH Commonwealth Department of Health CEO Chief Executive Officer CHASP Community Health Assessment and Standards Program CHC Community Health Centre CHESS Community Health Evaluation Standards System CHP Community Health Program CMHN Community Mental Health Nurse DHSRP Division of Health Services Research and Planning, Department of Health and Hospitals Commission, NSW DHNSW Department of Health, New South Wales (replaces DH NSW, HD, HDNSW, NSWHD) DPH Department of Public Health NSW DRS Doctors' Reform Society ELTM Eastlakes Team Meeting GCN Generalist Community Health Nurse GP General Practitioner HACC Home and Community Care HAHS Hunter Area Health Service HCNSW Health Commission of New South Wales HCNSWHR Health Commission of New South Wales, Hunter Region H&HSC Hospitals and Health Services Commission HHSU Hunter Health Statistical Unit HVRF Hunter Valley Research Foundation JCC Joint Consultative Committee of representatives of, Hunter Regional Office, NSW Nurses Association and Community Nurses Hunter Branch NSWNA LGA Local Government Area NH Newcastle Herald, newspaper of record for the Hunter Region. NHS National Health Service NSWCHA NSW Community Health Association NSW DGPH NSW Director General of Public Health NSWNA CNHB NSW Nurses Association, Community Nurses Hunter Branch. NWTM Newcastle West Team Meeting OPCS Office of Population Censuses and Surveys, GB RANF Royal Australian Nurses’ Federation RDNS Royal District Nursing Service SCHRU Southern Community Health Research Unit SEIFA Relative Index of Social Disadvantage SOC Senior Officers Conference TLM Team Leaders’ Meeting UNICEF United Nations International Children E Fund VRDNS Victorian Royal District Nursing Service WHO World Health Organisation WLTM Westlakes Team Meeting WTM Windale Team Meeting

x Abstract

How health care is best provided remains topical, contentious, and political. Debates continue over funding allocation and the weighting placed on preventive, curative, institutional and community services. Such debates were evident in 1973 when a new Federal Labor Government began to reform Australia's health system by implementing a national Community Health Program policy. Implementation led to the establishment of community health centres and multi-disciplinary teams. Studies have generally concluded that community health centre teams have ‘failed’ to achieve the goals of this policy. This study sought to answer one broad question. How was the community health program policy implemented, in what context did this event occur, what processes were used and why, and how did generalist community nurses participate? This case study of the Hunter Region, New South Wales, between 1974 and 1989, was based on data collected from four sources: over five hundred documents and archives, including relevant literature, epidemiological studies, centre records, official government and newspaper reports; 69 in-depth interviews with practitioners and administrators; and participant observation. The findings revealed that implementation was hindered by political, administrative and professional impediments. However, practitioners established and provided a broad range of relevant new services by changing the way they practised. Generalist community nurses worked with non-government, private and public organisations offering health, educational and social services. As boundary riders they filled structural holes and created social capital. Conclusions drawn were first, that context strongly influenced how public health policies were implemented and the services offered by different discipline groups. Second, teamwork would have been improved had pre-service health professional education fostered a common understanding of the aim of health care and the broader determinants of health. Third, a preventive orientation needed reinforcing via an organisational context, administrative processes, ongoing learning opportunities and leadership. Fourth, generalist community nurses’ commitment to a preventive approach was embedded in a growing understanding of people's circumstances and health problems. Finally, while policy implementation was constrained in the Hunter Region during the study period it achieved what its architects intended, that is, a broader mix of accessible services, and collaboration between organisations and groups as the boundaries that maintained their separation were bridged.

Prologue: The Researcher Up Front

This thesis explores how a national community health program policy was implemented in the Hunter Region, NSW, Australia, between 1974 and 1989. My interest in community health began in 1974 when I applied for one of the fourteen generalist community nurse positions offered for the first time in the Hunter Region of New South Wales. Accepting the offer of a position at Maitland Community Health Centre (CHC) in early 1975 was an important decision, professionally and personally. I applied for entry into a midwifery program at the same time. Choosing community work, partly because of the more family-friendly hours, would change my views about the work health professionals needed to do. My work experience to this time had been in institutions - psychiatric and general hospitals. I had worked in psychiatric hospitals in the early 1960s as group and social milieu therapy and community care replaced custodial care. Many long-term residents of psychiatric hospitals were discharged into group houses and hostels where they remained with assistance from nurses. This was prior to the Richmond Scheme which led to many residents being discharged into community housing. When I began general training I found it at first difficult to adjust to a more hierarchical system, where mental health and social issues were basically ignored. I adjusted and even grew to feel important in my uniform and veil as I hastened around the wards. At my hospital, registered nurses were frequently responsible for the medications on two floors because a student was ‘in charge’ on one. I got on well with the doctors with whom I worked and was regarded as competent enough to be invited to work in intensive care. When a colleague showed me an advertisement for generalist community nurses, I applied. At my interview the position described sounded exciting although I realised my professional training had not prepared me for one of its roles which was to provide marriage counselling. My work as a generalist community nurse evolved. I worked with a myriad of professionals − health education officers, social workers, speech pathologists, psychologists, hospital based registered nurses, medical specialists, directors of nursing and chief executive officers, employees of non-government organisations, school teachers, general practitioners, politicians and other generalist community nurses. From the beginning I found the team environment challenging, confronting, threatening and exasperating although more collegial. My work was flexible, I could use my initiative and I learnt daily. Although I had nursed the broken bodies of miners in hospitals, as a generalist nurse I learnt much about clients’ lives, mining as an industry, strikes, death, poverty, poetry and politics. Theo, an elderly Welsh miner, a widower, who had TB, taught me much about the history of the coal fields, capitalism, politics and poetry. On occasion he would greet me by reciting Omar Khayyam. I learnt that many elderly people lived in abysmal circumstances, in small dark cold houses, with toilets located in their gardens, without running hot water. Some, ignored by their families, welcomed us for social as well as medical reasons. They were lonely. They wanted time, no rushing. I met many women raising large families with little support, some with their partners in jail. The elderly people I met had their own troubles but most noticed if their nurse was tired or otherwise affected. I recall being touched one Christmas when an elderly couple bought me

xii some perfume called Heaven Sent. The non-nurses with whom I worked, graduates with degrees in arts, social work, education and psychology, changed the way I saw the world by sensitising me to social justice issues, inequality, feminism, welfare services, women’s refuges and rape crisis centres. Becoming involved with the management committees of a women’s refuge and a family support service gave me a new perspective on what people wanted and needed from service providers. Marital problems were something I understood though I didn’t know how to resolve them. Completing a family planning certificate and working as a sessional clinic nurse increased my understanding of women’s health issues. Learning about health, health care and communities helped me learn more about myself, my relations with others and my profession. My biggest discovery at this time was the book Community Health Nursing (1979) by Warring and McLennan. It spoke to me and to my generalist nurse colleagues. I felt validated. It connected me with my past experience of nurses, health visitors, community midwives and school nurses in the United Kingdom as a child. To a fledgling community nurse it offered guidance. Working as a generalist nurse made me acutely aware that I lacked understanding of social and family problems, Australian culture and history. I spoke English but I was still an immigrant, a foreigner. My roots lay in Europe. My mother had endured the London blitz, working in a munitions factory, and had cared for her grandmother. My father, a soldier, had survived internment in Singapore, in Changi prison camp. Both lost a parent as they approached their teenage years. My in-laws were German. My father-in-law, also a soldier, had been a Russian prisoner of war. My mother-in-law had worked for the German army. After World War II they immigrated to Cape Town in the Republic of South Africa. My husband grew up in South Africa, under apartheid. They immigrated to Australia following the Mui Mui uprisings. Arriving in Australia in 1959 my parents, brothers and I lived in migrant camps at Wollongong (Berkeley) and Newcastle (Mayfield). I met my husband at the latter. My family included my parents, brothers, friends, a husband and my sons. Most of my friends were European immigrants. Some had been refugees. My extended family lived overseas, in England. Close extended families whose members lived and worked in one place, often at one job for their whole life, remained outside my experience. By the time I left England, aged eleven, I had attended five schools, in three local government areas, hundreds of miles apart. As a generalist nurse I attended a formal twelve-week community nursing course conducted by the State government and a family planning course, and I also learnt much informally from clients and colleagues. My hospital-based education in psychiatric, developmental disability and general nursing and nursing administration had not, in my view, prepared me adequately for community work. I knew a great deal about the effects of disease but I wanted to learn more about communities and about health. With college-based community nursing courses inaccessible to me I enrolled in a diploma in nursing education, then a BA majoring in sociology (social theory and medical anthropology) and philosophy. Studying, working and raising two sons as a single parent following a failed marriage was exhausting and difficult, but also exciting and satisfying. Dissatisfied with my shrinking community nursing role and annoyed that too little discharge planning was occurring especially with elderly people, I decided to seek a teaching position.

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My first attempt to gain a position teaching failed because of my lack of recent hospital experience (for a director of nursing on my panel this was essential for a position at a Regional School of Nursing). I remedied this problem by applying for a year’s secondment to a psychiatric hospital to gain experience in admission, day clinics, geriatrics, domiciliary care and education. A Regional Director of Nursing, who had been my senior community nurse, took 48 hours to arrange my secondment. Within a year I was teaching (psychiatric, general, community) after almost 20 years as a clinician and manager. This was a major change. As I was gaining my feet as a teacher the NSW State Government announced it would transfer all nursing education to Colleges of Advanced Education (CAEs). Five teachers from the Regional School of Nursing became foundation members of the Nursing Department at Newcastle CAE and I was one of them. The process of translating a new curriculum into a new nursing program was stressful. This was partly because I became acutely aware that many of my colleagues who were hospital based registered nurses were prejudiced against community nurses. Trying to develop new subjects with new colleagues was difficult because we lacked a common framework and a language to discuss nursing practice. Diversity in academic backgrounds across the physical and social sciences created an environment fraught with misunderstandings. Tenacity, innovation and good will won out but in the process two camps evolved: general hospital oriented traditionalists and the others who had mostly worked in psychiatric and developmental disability nursing. Some, like me, straddled these two camps. My first department head, changed by her experiences in Vietnam, taught me about international developments in nursing and primary health care (PHC) some of which was integrated into our teachings. A highlight was writing a Graduate Diploma in Primary Health Care in collaboration with representatives of community health centres and non-government organisations and, with a colleague, accompanying student nurses to Indonesia, where they were able to see how what they had been taught applied at health centres in a developing country. Restructuring of the nursing division led to curriculum change. Partly in response to the demands made by directors of nursing and academic nurses the course became more biomedical and more focussed on acute hospital care. For me this change was distressing. In 1990 I applied for and was appointed as Clinical Director responsible for the clinical experiences of almost 1000 undergraduate students as Newcastle University and Newcastle College of Advanced Education amalgamated. I took the opportunity to influence where students were placed and ensure some placements were with community health centres and non-government organisations. In 1992/1993, as an elected Assistant Dean Undergraduate Programs, I invited nurses to meetings to discuss curriculum development issues and resolve problems arising with clinical placements. One outcome was that hospital-based nurses’ awareness of the work being done by their community-based colleagues increased. Non-nursing colleagues assisted greatly. Some nurse academics and hospital-based nurses viewed community nursing in the same way they viewed psychiatric nursing, as irrelevant and as not really nursing. Yet my experience in hospitals −in medical, surgical, intensive care, psychiatry, and family planning − suggested otherwise. Community nursing, like aged care nursing and general medical practice,

xiv required well-honed assessment skills and a capacity for independent clinical decision-making. Community nursing in my view required real nursing skills. A sabbatical spent with community nurses and general medical practitioners in Canada and the United Kingdom in 1994 revived me. The importance of community nursing was recognised. Nurses in London and Ontario exposed me to different ways of practising and to general practitioners who valued community nurses. I visited nurses making innovative contributions to service development. One who ran clinics for homeless people at refuges and shelters was in the process of establishing a midwifery service for homeless women after finding some had delivered their babies on the street. A family health nurse had begun working with a woman to assist her to cope with her pre-teen daughter’s development. The woman had schizophrenia, like her abusive ex-spouse, but the child was bright and high achieving. The nurse’s concern was the woman’s day-to-day concerns, her feelings, anxieties and responses, rather than her disease. She helped her gain employment and a volunteer position teaching reading at her daughter’s school, which both aided her confidence. This was the type of nursing practice I believed in and felt committed to. Teaching a professional discipline requires awareness of work environments. I maintained contact with practitioners by teaching registered nurses, working as a casual registered nurse on a medical ward at a general hospital and at a community health centre where I ran psychiatric clinics and made related home visits. I was also a member of the New South Wales Community Health Association (1985-1998), serving as Chair (Hunter Branch), a Board member and NSW President, a Fellow of the Royal College of Nursing Australia and the NSW College of Nursing and a member of the Public Health Research and Development Committee (PHRDC) for one triennium (Australian Community Health Association representative). In this period I also sat on Nurses' Registration Board Tribunals and professional conduct committees and presented at national, international, community health, nursing, public health and sociology conferences. These professional experiences led me to develop a perspective on Australia’s community health program (CHP) policy, community health centres and community nursing which was not reflected in the community health centre and nursing literature and to question the findings, conclusions, philosophical and ideological underpinnings of such studies. Teaching registered nurses and nursing students saw my experience of nursing and views about nursing challenged by students, peers and colleagues whose own experience was limited to working at general hospitals. Teaching also caused me to question the readiness with which researchers attributed failure to achieve Australia’s CHP policy goals to practitioners, mainly to nurses, whose work with individuals focused on secondary and tertiary rather than primary prevention. Questions arose for me about how critics and researchers had interpreted the purpose of the CHP policy. Working in hospitals, community health centres and family planning clinics had exposed me to differences in nurses’ autonomy and interdependence, and their relationships with other professionals and clients in different settings. As an educator teaching community nursing I encountered Australian registered nurses arguing in tutorials that ‘nurses don’t do that’ while community nurses were saying ‘but we do’. Nurses practise differently. Individual nurses do not, however, create their practice environments. Reflecting on

xv my experience as a generalist community nurse I realised my colleagues and I had developed services, increased local resources, focussed on prevention, and engaged in planning, decision making and networking. Nurses in large hospitals, as I was constantly reminded, have few similar experiences. In an honours thesis I began to wonder why the CHP policy had not achieved what was expected of it. Questions arose about the degree to which employers and managers of generalist community nurses had influenced how this policy was implemented. The CHP policy led to much that was new. The NSW Health Commission, my employer, influenced my work and that of my peers, by specifying our responsibilities. As a generalist nurse I had more control over my practice than I had had as a hospital nurse. I had opportunities to create my work but not always in directions or under conditions I or my colleagues chose. History and local circumstances were influential. As Marx argued in The Eighteenth Brumaire of Louis Bonaparte, people make ‘their own history, but they do not make it just as they please; they do not make it under circumstances chosen by themselves, but under circumstances directly encountered, given and transmitted from the past’ (1970, p.96). The circumstances in which the CHP policy was implemented had implications for what was done, what was achieved and how services were provided. This was also the situation in hospitals. My family, and those of my friends, have been ‘healthy’. Our reliance on health services has mostly been limited to use of general practitioners. Until recently, few had been hospitalised. I have practised and taught nursing with limited personal experience as a recipient or as a relative or friend of a recipient. The last decade has brought me into close contact with hospitals. I have watched parents and friends with a sense of futility as they have received treatment and recovered or died. I have encountered doctors, nurses and social workers who have been largely professional and caring. A few, seeing themselves as infallible, have been unprofessional and inept. Distress, anger, fear, a desire to protect loved ones from poor care and inadequate, uncaring assessment has created a sense of impotence. Misdiagnosis, inappropriate care, harm and death have been the outcome for some of those closest to me. It seems the focus of some nurses in some hospital units has been reflecting a return to a past I believed long gone. My general practitioner, a counsellor (an ex-colleague), and many friends have helped me survive my existential crisis and the depression it triggered. Giving birth to this thesis has been a cathartic end to a challenging period.

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CHAPTER 1 INTRODUCTION

Typically health policy studies have almost omitted process-orientated analyses… (Milio 1991 p.11).

Introduction Health policies have the potential to affect the lives of entire populations. How health policies are implemented is an interesting field of study that can provide insights into how health systems evolve and change. Most policy changes tinker with supporting the status quo and facilitate incremental rather than dramatic or radical change. Rarely do Western governments try to implement a policy that will radically change how a health care system is structured or how a particular professional group practices. When such situations do occur they are worthy of study to gain insights into the circumstances and pressures under which policy implementation occurs and into the dynamics of health care systems. This thesis explores, as a case study, how the national Community Health Program (CHP) policy was implemented in Australia. It concentrates on how this significant event occurred in one region of New South Wales (NSW) over fifteen years, from 1974 to 1989. The CHP policy was written in early 1973 and implemented almost immediately, without the benefit of legislation, in different states and territories by different organisations. In NSW, unlike most other states, participants in this process, practitioners and administrators, were employees of state governments. The manner in which this policy was implemented had implications for all health professionals. Its impact on nurses, however, was significant and without precedent. How nursing is practiced is inextricably linked to health and social policy (Bergen & While 2005 p.1). The CHP policy provided more registered nurses with the opportunity to work outside of hospitals in a newly created position of generalist community nurse (GCN). This change saw medical control over nurses’ practice decline and their exposure to and contact with allied health practitioners increase. This original case study fills a gap in information about individual CHP projects by taking a socio-historical approach to enable exploration of how and why practitioners, especially GCNs, their managers and regional administrators implemented this policy over time. It reveals that a complex coalescence of events, difficulties and obstacles influenced the processes used and what was achieved, and importantly, also lost. This study makes the activities of generalist nurses, previously submerged in a literature focusing on ‘community health workers’, more visible and understandable.

A National Community Health Program Policy The importance of the CHP policy lies in its contemporary relevance, both in 1973 and now. Its purpose, as stated in A Community Health Program For Australia (H&HSC 1973), was to extend the range of publicly funded primary care services available to communities. By international standards this was not a radical policy. It reflected contemporary understandings of health and illness and changing expectations of what Western governments of the time expected of health service providers. Essentially it represented a

1 paradigmatic shift away from a tradition of reliance on hospitals and recognition that community services were essential to contemporary health care. In 1978 the World Health Organization (WHO) legitimised this shift in emphasis in its Alma Ata Declaration which promoted Primary Health Care as a philosophy, a model and an approach to developing and providing population focussed services. Similar themes were raised in The Ottawa Charter for Health Promotion (WHO 1986) and The Jakarta Declaration on Leading Health Promotion into the 21st Century (WHO 1997), the latter being proclaimed after the period of concern to this study. What the CHP policy proposed was consistent with developments occurring in North America (Alford 1975; Church 1993; Ginzberg & Others1 1971) and the United Kingdom (Hall, Land, Parker & Webb 1975). By promoting the expansion of non-hospital, non-medical, public services via capped federal grants, the CHP policy departed from a tradition of governments supporting private-for-profit curative medical and general hospitals via a relatively open-ended funding formula (ABS 1973; Palmer 1971,1981; Sax 1972a, 1984). Significantly it also offered registered nurses an opportunity to gain employment working with populations outside of acute hospitals. It fostered expansion of a community based public sector and brought into focus an area of practice previously seen as peripheral to the ‘real’ or acute health care system.

Background to this Study Histories and critiques of Australia’s health care system reveal a pattern of ad hoc, rather than planned, growth since Europeans invaded and settled from the late 1700s into the 1970s (Deeble 1968, 1970; Dewdney 1972; Lewis 2003; Sax 1972a, 1984). Growth had been driven by a conservative institutional, curative, medico-centric view of health (q.v. Bates 1983; Sax 1972a,b, 1984). This ideological position fostered expansion of private medical and hospital care while limiting development of ambulatory care and the types of community nursing services (public health, bush, district/domiciliary) that were operating in Canada, the United States of America, and the United Kingdom by the late 19th and early 20th century (Brainard 1985; Corwin & Taves 1963; Luker & Orr 1992; Reverby 1987; Stewart, Innes, Searle & Smillie 1985; Swanson & Nies 1997). When the CHP policy was written most health professionals worked for general hospitals. A few doctors, registered nurses and midwives worked in schools, clinics, people’s homes and/or as employees of governments or non-government organisations (ABS 1973; Dewdney 1972; Gandevia 1978; Hamilton 1988; Lewis 2003; Palmer & Short 2000; Reverby 1987; Strachan 1996; Sax 1972a). Community nurses have received little attention in Australia where they remain almost invisible to the public and importantly to their own profession (Keleher 2000; McMurray 1990, 1991; St John 1991, 1996). Keleher (2000) attributes this situation to the continuing ‘hospital-centrism’ of Australian nursing organisations and their ‘blindness’ to the importance of public health nursing (p.279). General medical practitioners (GPs), by contrast,

1 Hereafter referred to as Ginzberg et al.

2 despite their falling rather than increasing numbers, have remained a highly visible group even if undervalued and/or misunderstood by their specialist colleagues (Dewdney 1972; Palmer & Short 2000; Sax 1972a, 1984). The invisibility of community nurses is significant for this study because the CHP policy fuelled rapid growth of a traditionally small, relatively silent group of nurses (H&HSC 1973, 1976). This growth occurred within a context of political and social change for nursing and for nurses.

Political Controversy When the Whitlam Labor Government was elected in 1972, the first non-conservative national Australian government in twenty-three years, it had a reformist agenda. Despite a short tenure, and the controversy leading to its demise in November 1975, this government managed to establish numerous social policies (ABS 2004; Freudenberg 1977, 1987; Palmer 1979; Patience & Head 1979). Some reflected the concerns of a previous Coalition Government (Scotton & Ferber 1978, 1980). Others, like the CHP policy and Medibank, a national health insurance program, were new and they remain what some might consider this government’s most enduring legacy. These policies aimed to limit or remove two barriers known to hinder peoples’ access to relevant timely health care − cost and location (H&HSC 1973; Sax 1972a, b; Scotton & Deeble 1968; Scotton 1970, 1974). Implementation of both policies began while the Whitlam Labor Government was in office. After its removal from office, as a result of a constitutional crisis, implementation continued but with different outcomes, under the Fraser Coalition Government. The CHP policy, while starved of funds, survived due to its high level of support amongst the constituents of Coalition politicians, rural and non-metropolitan communities (Milio 1983b, 1986). Medibank by contrast was progressively dismantled before being terminated in 1978 and then resurrected as Medicare in 1984 by a newly elected Hawke Labor Government (Barer, Nicoll, Diesendorf & Harvey 1990; Gray 1984; Milio 1983c). These controversial, historically, socially, politically and professionally significant policies changed the Australian health care system dramatically. The CHP policy in particular, as this study reveals, expanded the scope of the practice of nurses and other non-medical professionals.

Health Policy The significance of a health policy relates to its ability to impact on a health care system (Salter 1998). Both the CHP policy and Medibank had a major impact. The works of historians, economists, political scientists and policy analysts have increased our understanding of Medibank, why it was developed, what it sought to achieve, and why it was so divisive (Deeble 1982; Duckett,1978; Gray 1984; Lewis 2003; Palmer 1979, 1981; Scotton & Ferber 1978, 1980; Scotton & McDonald 1993). The Medibank and CHP policies are interrelated, however my concern lies with the latter. The CHP policy has rarely been explored to the same depth or from such different perspectives as Medibank, largely because researchers focussed on evaluation. To date the focus of evaluation internationally has been on goal achievement (Guba & Lincoln 1994)

3 Health policy is inevitably political and influenced by values and beliefs about health, illness, health care and society. The CHP policy was initiated by a new federal government and written by a new interim national Hospitals and Health Services Commission (H&HSC). It reflects the ideological position of the Commissioners who wrote it, including the Chairman Dr Sidney Sax, and medical members of parliament in the new Labor government. Its stated purposes were to:

• broaden and extend Australia’s primary care sector so curative and preventive services were more readily accessible especially for those populations living in areas of ‘health scarcity’ • reduce dependence on hospitals • extend nurses’ and allied health professionals’ responsibilities • and foster coordination and teamwork between public, private, non-government, institutional and community services (H&HSC 1973).

The importance of this policy is that it represented, as the health sociologist Petersen observed, Australia’s ‘first definite attempt to implement a health promotion strategy’ and shift national priorities away from ‘ameliorative hospital-based interventions to preventative community-based interventions’ (1987 p.25). It sought to change how, when, where and why practitioners provided services and when and why populations accessed care.

Community Health Centres Reflecting trends in other countries (eg. Canada, Sweden, United Kingdom, United States of America) community health centres were chosen as the most appropriate organisational model for achieving the changes the CHP policy sought to achieve. There was however a difference between Australia and other countries where CHCs had been established. The latter all had national systems of non-government, private and government organisations providing community nursing services (Leahy et al 1972; Sines 1995; Stewart et al 1985; Turner & Chavigny 1988). Australia had hospitals, non-government and government organisations offering community nursing services but to different populations, for different reasons. These services were unevenly distributed and some were provided on a fee-for-service basis. These important differences affected how Australia’s hospitals were used. In the late 1960s Australia remained more inpatient-focussed, having more admissions and more acute beds per 100,000 population than similar nations (Roemer 1969,1971). Building up Australia’s community and primary care sectors was necessary, but also a new idea. By the time the CHP policy was written a growing number of health department administrators, academics and general practitioners, internationally, viewed community health centres (CHCs) as a credible model for organising and providing population focussed primary care services (Alford 1975; Andrews, Corlis, Forsythe et al 1972; Beloff & Korper 1972; Champion de Crespigny 1971, 1972; Ginzberg et al 1971; Hall et al 1975; Pang 1973; Pearse & Crocker 1943; Silver 1963). In Australia some members of government departments, politicians, medical academics and GPs were by then openly

4 supportive of CHCs (Andrew 1971; Andrews et al 1972; Barnes, Bishop, Craigie, Cushing et al 1972; Blacktown CHC 1972; Boyce, Briggs, Hyde & Westcott 1978; Champion de Crespigny 1971, 1972; Douglas 1979). Support was based on these centres being organised to provide doctors with ready access to community nurses and allied health practitioners and populations with access to practitioners who had local knowledge. Health centres provided a base for multi-disciplinary teams of primary care and public health professionals who provided relevant accessible services to defined populations. Administrative and management structures varied. Some were autonomous with boards of management while others operated as part of a regional system of health care services (Alford 1975; Ginzberg et al 1971; Hall et al 1975; Kohn 1983; Silver 1963). Understanding of how some centres operated overseas can be gleaned from case studies conducted from the 1940s to test hypotheses (Alford 1975), analyse historical events (Church 1993; Lomas 1985), explore outcomes for clients and staff (Pearce & Crocker 1943; Beloff & Korper 1972) and explore policy implementation (Hall et al 1975). Most provide detailed exploration of contextual and process issues.

Evaluation rather than Research Studies of CHCs conducted in Australia since the 1970s have had a more limited purpose with most being evaluations commissioned or funded by governments to establish whether the CHP policy’s stated goals had been achieved (CDH 1978; Duckett & Ellen 1980; Najman, Burns, Gibson et al, 1980; Najman, Jones, Gibson et al 1981; Najman, Gibson, Jones et al 1983). Most of these studies were conducted because the national Hospitals and Health Services Commission made funding available to academics and health departments to conduct research into health services. Until the late 1990s evaluations were generally conducted within a scientific paradigm leading to a ‘top- down’ approach to study designs and emphasising measurement of behaviour and goal achievement (Guba & Lincoln 1994 p.30-37; Swanson & Chapman 1994 pp.66-68). Australian studies of CHCs reflect this approach. Researchers categorised and quantified practitioners’ commitment to policy goals, the services they provided and the strategies they used to measure goal achievement. Gibson (1981) questioned if this approach had caused her to miss incremental changes in behaviour occurring at CHCs. By the 1990s some researchers were proposing the use of ‘fourth generation’ evaluation to overcome the problems inherent in the other approach (Wadsworth 1997). Guba and Lincoln (1989, 1989) coined this term to describe evaluation guided by an interpretive, constructivist, paradigm. This approach enabled all stakeholders’ perspectives to be considered instead of privileging those of program funders and managers above practitioners or clients (Guba & Lincoln 1989, 1994; Wadsworth 1997). However, despite this form of evaluation being advocated by various individuals, including some in government, (HCNSW 1974b) many health program evaluators remained resistant to the benefits offered by a qualitative approach.

5 The Importance of Context A top-down approach to program evaluation into the 1990s has limited understanding of processes used to implement the CHP policy. Practitioners’ insights are missing mainly because they fell outside the parameters of most studies and were not reported as findings. This approach has resulted in the views of those Prottas (1979), a policy analyst, describes as ‘street-level’ bureaucrats (their task is to translate policy/programs into action) being almost absent from Australia’s CHC literature. Additionally, consistent with international trends, most studies took an ahistorical, atheoretical and decontexualised approach (Swanson & Chapman 1994 p.68; Yin 1983 p.4). The quantitative ‘context-stripping’ approach adopted for most evaluations means scant attention has been paid to the context (cultural, economic, geographic, historical, organisational and political) in which policies or programs were implemented, nationally or locally (Guba & Lincoln 1994). This is significant as it allowed the context in which the CHP policy was implemented in various states and areas of those states to be ignored. CHCs were added to an existing mix of health services rather than in a service or policy vacuum. The evaluation approach which dominated the 1970s and 1980s ensured that the history, traditions and politics of long established services (eg. maternal and child health, district and domiciliary nursing services, hospitals); their administrators (eg. Chief Executive Officers, medical superintendents, directors of nursing); private doctors (generalists and specialists) lay beyond the scope of most studies. Yet if services existed in CHCs’ new geographically defined catchment areas they would surely have had an influence on policy implementation and the work of practitioners. It is for this reason that gaps in information exist regarding the context in which the CHP policy was implemented. Two qualitative studies make a contribution to our understanding of context. Milio2, a public health and nursing academic, explored process from a national perspective (1983b,c,d, 1984, 1986a,b,c, 1986c, 1988a). Milio was a ‘trail-blazer’ making the use of qualitative methods acceptable within an environment dominated by quantitative methods. A second study, conducted by the NSW Community Health Association, newly formed to lobby for CHCs, explored staffing issues to generate debate on proposed funding cuts (NSWCHA 1981). These studies, conducted by researchers with inside knowledge of the CHP policy, CHCs and/or community nursing (as researchers or interviewees), reveal how fiscal and political issues hindered policy implementation nationally and in NSW. Neither study sought to explore implementation at a state or local level. They do illustrate that researchers need to contexualise the processes used to implement a policy and that it is crucial to identify support and/or opposition. Clearly some governments, administrators and politicians supported CHCs as a means to foster interdisciplinary practice, reduce structural barriers between primary and other levels of care and increase a population’s access to primary care while reducing their access to tertiary care (Alford 1975; Ginzberg et al 1971; Hall et al 1975).

2 Milio reported the findings of this study in articles and a monograph. I refer mostly to the articles.

6 The Context of Community Health Centres By the 1960s the literature reflected support for CHCs amongst bureaucrats, professional groups, communities and politicians in Canada (Church 1993; Lomas 1985), United Kingdom (Hall et al 1975 ) and the United States of America (Alford 1975; Ginzberg et al 1971). In almost all cases federal governments promoted CHCs and provided the necessary funding. In Australia the national Hospitals and Health Services Commission funded submissions from state governments and non-government organisations consistent with the CHP policy’s purpose (H&HSC 1973, 1976a,b). A diverse range of projects was funded including CHCs, women’s health centres, and education programs for GPs and community nurses (ACHA 1986; H&HSC 1974, 1976a,b). Most projects were to establish CHCs and/or form multi-disciplinary teams of health professionals. NSW, with almost 50 percent of all projects funded by 1976, established CHCs as multi-disciplinary teams, mostly without doctors, and administered by a Health Commission. The implications of this arrangement, especially for nurses whose responsibilities were limited by legislation, remain unexplored. The findings of evaluations of Queensland CHCs, which operated under similar circumstances, suggest that state governments influenced the range of services CHCs offered and the activities of some professional groups (CDH 1978; Gibson 1980, 1981, 1984; Najman, Burns, Gibson et al 1980; Najman, Jones, Gibson et al 1981; Najman, Gibson, Jones et al 1983). CHC services were used by populations as illustrated by government reports (ADHHSC 1975, 1976a, 1976b, 1977a,b,c; CDH 1977c, 1978, 1979a; H&HSC 1976a) and research (ACHA 1986; Duckett & Ellen 1980; Gibson 1980; Grant & Lapsley 1993; Morey, Williams & Moloney 1980; Najman et al 1980, 1981, 1983; SCHRU 1987, 1988). Evaluations found that CHC services were illness focussed. Whether the services offered were relevant to a population’s needs or reflected employers’ expectations of professional groups was not explored. During the mid-1980s researchers began to consider structural, organisational and political, influences on practitioners. A much cited Review of the Community Health Program conducted by Lennie and Owen (1986a) for a new, federally funded, Australian Community Health Association (ACHA) offers some insights. While finding that practitioners retained an illness ‘case’ orientation the authors argued that federal governments were responsible because they had failed to monitor implementation processes. This tended to ignore the fact that most CHCs (being non-government organisations or organisations administered by a state government), had team leaders or centre managers, some of whom were health professionals. The observations of insiders, CHC practitioners (Crofts 1985, 1986; Jackson, Mitchell & Wright 1989; Saltzberg 1981) and a consultant to some Victorian centres (Wellard 1992) offer alternative explanations. In Victoria few centres had established the structures and processes needed for decision-making, policy development, and clarifying what was meant by preventive services and this fuelled intra-personal, intra- team conflict (Crofts 1984; Saltzberg 1981; Wellard 1992). The findings of these works suggest that the purported illness focus of practitioners might have been associated with their managers’ lack of

7 understanding of the purpose of the CHP policy and the responsibilities of various practitioner groups. By the early 1990s researchers had started to consider the influence of organisation and management on practice.

Structure and Culture The formation of Area Health Boards in NSW was a major structural change which brought CHCs and hospitals together under one administrative arrangement and acted as a catalyst for shifting attention from practitioners to managers and administrators. Bryson, Adamson and Lennie (1992) and Lennie, Copeman, & Sangster (1990) examined managers expectations, leadership styles (Lennie et al 1990), organisational arrangements, public service, non-government or Area Board (Bryson et al 1992). The question was whether the administrative structures within which centres operated influenced the orientation of practitioners. The answer was yes. A non-government or State Public Service structure was found to provide practitioners with greater autonomy and a greater capacity to respond to community need than Area Health Boards (Bryson et al 1992). However a non-government structure, which the Australian Community Health Association favoured, did not guarantee practitioners would develop a community focus as managers could foster an individual client (case) or educational orientation (Bryson et al 1992). These studies raised the possibility that the ethos of practitioners, whether they focussed on individuals or populations, on illness or prevention, case or team work, reflected that of their work environment rather than, as argued earlier, their commitment to CHP policy goals or early professional socialisation (Gibson 1980). This proposition, that work environments influenced the orientation of practitioners, was not new. It was consistent with the findings of studies since the 1960s involving general and psychiatric hospitals (H&HSC 1976; Goffman 1976; Menzies 1970; Milio 1981 p.95-97) and community nursing services (Ginzberg, Balinsky, Ostow 1984; Milio 1970, 1975a) that the structure and culture of professional work environments does matter.

Organisational Environments Australian evaluation studies generally concluded that CHCs ‘failed’ to achieve CHP policy’s goals even though little was known about individual projects or practitioners’ activities over time (Palmer & Short 2000). Why this conclusion was reached is partly explainable by the purpose of these early studies (evaluation), the methodology selected to conduct them (quantitative), and the limited information available concerning the Australian health system. Most evaluations were conducted to answer questions of immediate interest to the organisations commissioning the research. Attention was directed at CHCs but few attempts were made to compare CHCs with other services. When comparisons were made CHCs were found to offer cheaper services which were more preventive in orientation (Duckett & Ellen 1980). Researchers were hindered by the methodology then guiding evaluations and reliance on what became recognised as inadequate data collection tools. One early study was abandoned due to the inadequacy of

8 the tools selected (CDH 1978). Practitioners on the other hand, lacking guidance, relied on their best guesses to identify and address community needs much like the remover of Broad Street Pump3. Sadly information was lacking on the health care system as a whole and how its many parts operated. In the 1980s it was acknowledged that CHCs had contributed to Australia’s health care system (ACHA 1986; Sax 1984; SCHRU 1987). How this contribution was made, who benefited, and what discipline groups added to Australia’s established health care system is still unclear. A problem identified by Palmer and Short (2000) remains, too little is known about the CHP to provide a ‘basis for sound future policy making’ because of ‘an unfortunate lack of information about the details of individual projects’ (p.125). Information about generalist nurses, the largest practitioner group employed at centres in NSW since 1973, is especially limited.

Process and Orientation When evaluation of CHCs began understanding of the processes public hospitals and primary care services used to make fiscal and other decisions remained poor (Palmer 1971; Sax 1972b). Knowledge of services provided outside large general hospitals was limited and has remained so in Australia as internationally (Sax 1972a; Starfield 1992). The CHP policy was written as small local studies began finding that general practitioners were seeing people with complex physical, social and psychological problems (Sax 1972a p.22-24). It was similar for community nurses. Histories of community nursing services offer insights into community nurses’ work in Victoria (Linn 1993; Rosenthal 1974). In this state, as in Canada, the United Kingdom and the United States of America, nurses worked with clients who were sick, isolated and disadvantaged. However, national data on community nurse numbers, their employers, and their work remained poor (Archer 1976; Hurworth 1976; Keleher 2000; St John 1996). The CHP policy raised awareness of community nursing. This was partly through research. Between 1976 and 2000 studies were conducted by professional nursing bodies, employers of community nurses, potential educators, researchers and nurses to fill an information vacuum (Archer 1976; Buckley & Gray 1993; Dunt, Temple-Smith & Johnson 1991; Dowling, Rotem & White 1983; Gilson, Baum, Cooke et al 1991; Hurworth 1976; Keleher 2000; Johnson, Temple-Smith, & Dunt 1987; Katz, Matthews, Pepe & White 1976; McMurray 1991; Round & Sellick 1984; St John 1991,1996; Wadsworth 1980). These studies focussed on community nurses:

• roles and responsibilities • actual and required professional preparation • expertise gained through practice

3In 1855 John Snow, a surgeon, convinced the parish Board of Guardians to remove the handle from a Street Pump in Soho, London, after finding the 93 people who had died of cholera drew water from this well (Porter 1997, p.412).

9 Many of the nurses included in these studies worked for non-government organisations or in child health. Few included GCNs employed at CHCs in South Australia (Gilson et al 1991), Victoria (Round & Sellick 1984; St John 1991, 1996), Queensland (Archer 1976) or NSW (Archer 1976; Dowling et al 1983; Katz et al 1976). One consequence of this focus is that the role of GCNs remains an enigma.

Generalist Community Nurses Nurses have worked in communities since the late 1800s, as private nurses, employees of non- government organisations and, more recently, of hospitals and health centres. The CHP policy created a new generalist nurse category of community nurse. It was surprising to find a deficit in information about this group of nurses. The paucity of relevant nursing literature can partly be attributed to support for nursing research, until recently, being limited to nursing organisations. The International Council of Nursing, established in 1899, and the National League of Nursing in America have supported nursing research. The League gave Yssabella Waters (1909), from the Henry Street (Nurses) Settlement in New York, the support she required to conduct a national study of District Nurses. In Australia, and the United Kingdom (Robinson, Grey & Elkan 1992), support for nursing research has coincided with governments’ efforts to extend nurses’ responsibilities and improve their education. Implementation of the Australian CHP policy encouraged various nursing organisations and universities to research community nurses’ work. In Australia, as internationally, community nurses have traditionally worked with vulnerable, disadvantaged and under-served populations − mothers and babies, school children, elderly and disabled persons, persons in need of nursing following discharge from hospital or to prevent admission, and at risk of contact with or having a notifiable infectious disease (q.v. Dewdney 1972; Gandevia 1978; Sax 1972a). The responsibilities of community nurses have included illness prevention through case finding, monitoring and health education (Stewart et al 1985; Sines 1995; Warring & McLennan 1979; Mahler 1985). It is unclear if these were the types of activities leading evaluators to label practitioners as ‘illness focussed’ mainly because it remains unclear what generalist nurses did or what their work entailed.

Federal and State Issues Despite gaps in information, or maybe due to them, federal government support (political and fiscal) for a CHP policy (and for generalist nurses) has waxed and waned since it was tabled in federal parliament in June 1973 (ACHA 1986; H&HSC 1976; Milio 1983b,c, 1984, 1986a,b, 1986a,b,c, 1988). Federal funding formulas were changed and project funding reduced before the findings of evaluations, which were mostly negative, were reported in the literature. The importance of context, from a methodological perspective, becomes apparent when one considers health care as a predominantly state/territory government responsibility. State health care systems share some common features, and problems. That said, historic differences between states have influenced how community services are offered, how access is gained to such services, and how they are administered. Historical differences influenced how centres were administered in different states (ABS 1976; ACHA 1986; H&HSC 1976; Lennie 1987).

10 Despite these known differences most evaluations, the basis of current knowledge of the work undertaken by health centre teams, were conducted in states where doctors worked at centres as clinicians (ACHA 1986; Lennie et al 1990). These were the states where non-government organisations had a long tradition of providing community nursing services and working with general hospitals and general practitioners (Linn 1993; Rosenthal, 1974; ACHA 1986). In NSW, which had few community nursing services, the situation was more diverse. Evaluations, in general, tended to ignore such contextual issues mainly because their concern lay with the present, with what was happening at a specific centre at that time. It was rare for judgements to be made about the relevance of a centre’s services for a particular population based on its need/s or gaps in services (Najman et al 1979, 1981). The Australian CHP policy literature did not explore whether state governments influenced the direction taken by community health centres or how they were managed. There were some hints that management problems had occurred but no details (Gibson 1981; SCHRU 1987). An inference, however, that can be drawn from the literature (evaluations, first person reports, official records) collectively concerns the organisational culture evolving at centres. Culture becomes embodied in an organisation’s structures, rules, regulations, traditions, policies, procedures, behavioural norms, and in managers’, peers’ and practitioners’ expectations (Castle 1987; Dreitzel 1971; Goffman 1976; Green 1974; Green 1985; Growe 1991; H&HSC 1974; Kinston 1983; Masson 1988, 1989; Menzies 1970; Reverby 1987; Russell 1990; Rosenham 1973; Rosenthal 1974; Street 1992). Practitioners make some choices about the way they practice. However, as Milio (1981 pp. 95-97) has argued, the way in which a work setting, hospital, ambulatory care or solo/group practice operates exerts a far greater influence on practitioners’ practice than their level of professional knowledge. Context matters as an organisation’s policies create opportunities for ‘choice making’ that shapes, without necessarily determining, what services practitioners provide (what they do) and how they provide them (how they do what they do).

Multiple Stakeholders The outcomes of policy implementation according to Degeling and Colebatch (1997 p. 354) ‘are produced by the way participants act in terms of their perceptions, values and their experiences’. Of necessity numerous stakeholders (governments, federal and state, government departments, administrative officers and practitioners) were involved in the processes involved in developing and implementing a national CHP policy. All had to make choices. Given a choice between easily achievable, politically safe options and more difficult ones, most people lean towards the easy option (Milio 1981 p.95). To what extent those who participated in implementing the CHP policy confronted difficult or easy choices is unclear. The Australian literature includes proportionally more studies involving CHCs operating as non-government organisations than administered by state governments. This means that few CHCs located in NSW were included as these centres were administered by state governments as part of a large Public Service bureaucracy (a Health Commission, a Health Department and by 1986 Area Health Services). Under this organisational arrangement individual practitioners’ options for choice-making would have been constrained by the

11 legislative and bureaucratic arrangements under which they worked. The findings of early studies of CHP policy projects indicate the need for an in-depth multi-faceted study to gain an understanding of the implementation process and the activities of practitioners, especially GCNs, in NSW.

Reform Agenda Extensive health care reform is difficult to achieve and rarely undertaken in societies with already established, and politically entrenched, systems (Alford 1975; Roemer 1969, 1971, 1976, 1977). When, as in the United States of America or the United Kingdom, a government seeks to change the status quo by introducing new policies, new models of care, new services, or changed professional responsibilities, political, organisational and fiscal problems of varying magnitude can arise (Alford 1975; Baggott 1994; Klien 1989; Ginzberg et al 1971; Milio 1975, 1981; Sax 1984; Seedhouse & Cribb 1989; Roemer 1969, 1977, 1978; Church 1993). Interest groups opposed to the proposed changes, preferring existing arrangements or for ideological or other reasons, can raise obstacles that hinder new developments (Alford 1975; Ginzberg et al 1971; Church 1993; Sax 1984). Opposition to change has to be overcome if new policies are to be implemented successfully. New structures, like community health centres, are sometimes necessary to achieve change or achieve a new purpose (Apte 1968; Pearse & Crocker 1944). Implementation of the CHP policy and Medibank began in 1973 and 1975 respectively. Both of these contentious policies had their opponents and supporters.

Impetus for this Study The impetus for this current study arose from three sources. Firstly an identified gap in the literature concerning the way the CHP policy was implemented and the activities of practitioners and regional administrators in NSW, all employees of a large government bureaucracy, over time. The activities of generalist nurses, the largest discipline group employed at health centres in this state, were particularly important because a focus on ‘community health workers’ had rendered this group near invisible, and so silent, within the current literature. Secondly the event itself, implementation of a CHP policy, together with the processes involved, was historically, socially and politically important to Australia. In addition to being consistent with international trends it was significant as an attempt to alter the composition of the primary care sector by increasing the number of non-medical professionals, allied health personnel and community nurses and extending their professional responsibilities, when so little was known about this sector of the health system or the activities of community nurses. Finally, personal experience as a GCN with an ongoing interest in community health and community nursing practice challenged me to want to explore implementation of this policy in depth.

12 The Purpose of this Study The aim of this case study was to provide a contexualised account of a significant event, that is how the CHP policy was implemented in one geographic area of NSW, Australia. It was not my aim to measure, evaluate or judge if CHP policy goals were achieved. My purpose was to explore and describe an event of significance, make the choices, actions and decisions of practitioners’, especially GCNs, and regional administrators visible and understandable. As practitioners in NSW were state government employees the perspectives and views of regional administrators were relevant to a local study. The aim of this study was to understand a process and the context in which it occurred. Understanding, as Milio (1991) pointed out, is necessary as policy-relevant information is only obtainable by analysing the real world of policy making to gain an understanding of the processes used. Understanding is crucial for ‘insiders’ and ‘outsiders’ to gain the skills needed to influence formal and informal policy making processes. A narrative providing thick description is offered so that readers can judge for themselves what the CHP policy achieved in one region. I discuss my position as both an insider and outsider in Chapter 4.

Contribution of Thesis This case study takes a socio-historical approach to exploring how and why the CHP policy was developed and implemented. It reveals the actions, dilemmas and choices of practitioners, especially GCNs, and regional administrators. A contribution of this study is the in depth analysis it offers of the context (cultural, demographic, socioeconomic, political, organisational and policy) in which the CHP policy was implemented in one area of NSW. Finally the study findings and conclusions are linked to the contemporary public health and community nursing literature. It contributes to literature on the Australian community health program (CHP), community health centre (CHC), community nursing, nursing and health services research by offering a detailed description of individual CHP projects about which too little is known. It makes some contribution to the health policy literature where, as Milio (1981 p.11) noted, gaps exist for ‘process-orientated analyses’ of policy development, implementation, inter-organisational and social change. Such gaps remain in relation to community health centres and generalist nurses. This study’s major contribution is that it offers new insights into past activities of multidisciplinary CHC teams by making the activities and expectation of GCNs and their government employers visible over time. Description of the particulars of the process enables the story of street level bureaucrats to be told. This is timely as it enables lessons to be learnt from the past.

Structure of the Thesis This chapter contains an introduction and outlines the thesis structure. Chapters 2 and 3 examine literature streams relevant to this study. Theoretical understandings of key processes and concepts underpinning the Australian CHP policy, public health, primary, secondary and tertiary prevention, primary

13 health care (PHC), health promotion, determinants of health and health inequalities, are discussed in Chapter 2 to locate this study in a broader public health and community nursing context. Chapter 3 reviews Australian studies of CHCs relevant to the period of interest to this study which raise organisational and professional issues along with studies conducted overseas which illustrate the various constraints and opportunities, political and fiscal, operating in different contexts. Chapter 4 introduces the methodology used to conduct this study, the selection of data sources, methods to collect and analyse the data, and discusses issues of trustworthiness and ethical concerns. It also described the research process in detail. Chapters 5 to 9 discuss the study findings. Chapter 5 explains the national and international policy contexts and the problems the CHP policy, CHCs and GCNs were expected to address. Chapter 6 explores the unique features of the Hunter Region, its population, and its health system before and during implementation of the CHP policy. It discusses submissions for CHP funding and the locations selected for CHCs, team composition and client characteristics. Chapter 7 focuses on CHC teams. It describes how team members were selected, how they were prepared for practice, and the services they provided. Chapter 8 explores the approach taken by regional administrators when implementing the CHP policy. It discusses NSW government expectations of administrators and highlights the conflict and problems which hindered the implementation process. Local stakeholders’ expectations of CHC teams are also explored. Chapter 9 examines practitioners’ approaches to policy implementation and how teams were formed. Comparisons are made between the approach taken by teams and administrators. The contribution of GCNs is revealed and discussed. Chapter 10 discusses the significance of this study, the findings and conclusions, the limitations of this study and implications for further research.

14 CHAPTER 2 CONCEPTUAL UNDERPINNINGS FOR A STUDY OF A COMMUNITY HEALTH PROGRAM POLICY Theories do not provide answers to problems; people do. But a theory can provide a framework for analysis.….Powerful theories redirect us towards problems and issues we might otherwise have ignored or from which we could have been ideologically or methodologically distracted (Forester 1993, p1-1).

Introduction The purpose of this study is to gain an understanding of how a CHP policy was implemented in one region of NSW between 1974 and 1989. A central aim of this study is to uncover the activities of participants. The CHP policy was a significant policy. Its implementation precipitated structural change in Australia’s health care system through the establishment of CHCs, generalist multi-disciplinary teams, and a new type of community nurse, a generalist. The purpose of this Chapter is to discuss selected literature to assist understanding of the policy making process and the difficulties associated with policy implementation, especially when it involves an innovative policy. Literature was drawn from diverse streams: public policy, organisational theory, health systems, public health, primary health care and nursing. The processes used to select the literature reviewed in this Chapter are discussed in detail in Chapter 4. The works reviewed here provide some insight into the complexities of policy making and policy implementation and the contemporary ideas which gave rise to the CHP policy and the establishment of CHCs. Studies in these areas are discussed in Chapter 3.

Public Policy Policy studies are important, as Birkland (2001 p.24) and Milio (1981, 1991 p11) argue, as they can provide information about processes involved in developing and implementing a policy and inform practitioners. Policy studies can uncover how and why a particular policy was developed and illuminate influences exerted by various groups participating from the stage of problem identification through to policy development and policy implementation. Colebatch (2002 p.8) describes policy making as a way of 'labelling thoughts about the way the world is and how it might be'. It becomes a vehicle for endorsing specific courses of action and communicating ideas to those agencies participating in its implementation. Public policy studies are grounded in the study of politics as policy development, which includes implementation and is affected by relevant state apparatus and legislative processes. Contemporary Australian texts illustrate that governments, federal, state and local, participate in making and implementing policy within limits imposed by their legislative and Constitutional responsibilities (Bridgeman & Davis 2000; Colebatch 2002; Davis et al 1988; Edwards 2001; Gardner 1992,1995; Palmer & Short 1989; Sax 1972a, 1975a, 1984, 1993). Policy making involves numerous 'stakeholders' : governments, government agencies, officials, professionals, non-government organisations and various interest groups all of whom have an interest in the outcome of a specific policy. The CHP policy for

15 example, as I will show later, was of interest to state governments, GPs, and hospitals amongst others because it had implications for federal funding and how practitioners practiced. The policy making process is inherently political. Governments use policy to govern and achieve their political agendas (Birkland 2001; Bridgeman & Davis 2000; Colebatch 2002; Culyer 1980; Davis, Dunn 1994; Davis, Wanna, Warhurst, & Weller 1988; Edwards 2001; Gardner 1992; Hill 1993; Laver 1986; Munger 2000; Nagal 1999, 2002; Sax 1972a, 1984, 1989). Such authors argue that to understand the complexity of policy making, researchers have to ask questions about how and why a policy emerged, who had an interest in the processes involved, and how power was exercised and resources allocated to those groups who were involved or affected. Attention has to be paid to identifying laws, rules, standards and goals that determine what governments can or cannot do and what decisions they can and cannot make in relation to a particular policy. Such matters are of particular importance for Australia as federal and state governments share responsibility for funding and providing health care. Two major perspectives on policy development are evident in the literature, rational or scientific and incremental (Bridgeman et al 2000; Edwards 2001; Davis et al 1998; Hogwood & Gunn 1984; Lindblom 1959). Edwards, an Australian academic with extensive experience as a bureaucrat involved in policy development, argues for a rational approach on the basis that a systematic approach can deliver 'significant benefits of order and process' (2001 p.3). She points out that Policy environments are full of complexities, usually involving a diverse range of players coming from different perspectives and spawning a host of unexpected events. It is therefore very unlikely that circumstances would permit anything approaching classical rationality in the decision-making process. An alternative to rational policy making is incremental policy building whereby existing policies are built upon and extended, in small steps, a situation Edwards argues is appropriate in some instances in the ‘real world’. Bridgeman et al argue that a ‘rational’ process would include identifying: a problem and objectives; values and goals; options; cost benefit options; cost benefit comparisons; and lastly decision-makers choosing an option (2000 p.48). The problem as they point out, however, is that rarely do those involved in making policy have all the information they require to make the best decisions possible. In reality, governments often make ad hoc decisions. It is argued this occurs because problems are hard to define, solutions complex and contested, and compromise is often necessary in a bureaucratic organisational context where official and unofficial ‘actors' exert influence over how particular policies evolve (Bridgeman et al 2000 p.26-27; Davis et al 1988). Governments can conceptualise problems, causes and solutions, in ways which reflect the incumbent’s party-specific position on a particular policy area. This is especially evident in those policy areas which remain contentious like health care. In Australia, as in the United Kingdom and the United States of America, health policy has remained an area fraught with tensions and conflicts driven by different philosophical and political positions concerning how health care should be funded and provided.

16 Australian authors such as Gardner (1992, 1995), Palmer and Short (2000) and Sax (1972a, 1975a, 1984, 1990, 1993) provide insights into the problems facing Australian governments within contemporary society. A central problem remains the division of responsibility between federal and state governments and various departments or agencies. Differences of opinion within governments, amongst public officials, add to the difficulties. While the policy literature refers to ‘the government’ or ‘the state’ this does not suggest that these organisations are perceived as acting as coordinated collaborative bodies aiming to work in unison to achieve a common purpose. This happens, but not as frequently as one might expect. In reality, as numerous studies of Western bureaucracies illustrate, along with a popular BBC television series ‘Yes Minister’ (Lynn & Jay 1986), governments are fragmented and comprised of agencies which at times compete for resources and which may or may not support the political and/or ideological1 agendas of elected politicians or other government agencies (Alaba 1994; Alford 1975; Helco 1974; Helco, Hugh & Wildavsky 1981; Pressman & Wildavsky 1973). This is an important issue in relation to health policy.

Influences on Policy Making The term ‘policy maker’, as Colebatch (2002) has recently argued, is a seductive term that implies policy is made and implemented by a known group of individuals who control all processes and all the resources required. This is rarely so. It was certainly not so in relation to the CHP policy. Authors generally agree that policy problems are socially constructed (cf. Colebatch 2002; Davis et al 1988; Edwards 2001;Dunn 1994). One of the first and most difficult aspects of policy making is getting a problem on the agenda, articulating it so that it becomes an issue requiring attention. This is where bureaucrats play a significant part. Ministers can be heavily involved in identifying and articulating problems but they are reliant, of necessity, on key bureaucrats. Edwards (2001), for example, observes that bureaucrats ‘will try to influence the policy agendas of their ministers according to their own priorities’ (p.5). Taking these comments on board, this study of policy implementation has to answer several questions about the Australian CHP policy. Who made it and why? What was the problem it was intended to address? Which departments (officials) did it affect? Who had the potential to exert influence on the CHP policy and its implementation? These are all questions related to context and process. Edwards (2001) modified a framework developed by Bridgman and Davis (2000) to develop what she describes as a 'policy building framework' that she found useful in practice. This framework involves six steps: identify issues; analyse policy; undertake consultation; move towards decision; implement and evaluate (p.4). It shows that within government departments especially interested stakeholders have numerous opportunities to exert influence on a policy from its formulation as a problem to implementation.

1Ideology is a highly articulated world view or organizing schema. Dominant world views, being embedded in societal and organizational structures, are reinforced by daily practices and policy choices (Kincheloe & McLaren 2004 p.303).

17 The most difficult and undervalued part of the policy process starts after policy decisions are made and implementation commences.

Policy Implementation As Gardner and Barraclough (1992) observe, policy development and implementation are political activities that involve competing interests and demands (p.7). How a policy is implemented is critical to what it does or does not achieve. This is so, as the policy literature makes clear, because it is in this phase that participants can make fundamental changes by reinterpreting the purpose of the policy. As I have already pointed out the CHP policy had implications for numerous stakeholders with varied and competing interests − general hospitals, specialist services, community based services, GPs, community nurses employed by non-government and other organisations and departments of public health. Political and economic factors influence implementation processes and the eventual outcome of a policy (Gardner et al 1992 p.23), especially when state governments are involved in implementing federal policies as is revealed by research conducted in America (Alford 1975; Bullough & Rosen 1992; Ginsberg et al 1971; Leavitt & Numbers 1997; Morrison 2000; Porter 1999; Rosenberg 1987, 1992), Australia (Dewdney 1972; Edwards 2001), Britain (Baggott 1994; Culyer 1980; Levitt & Wall 1976, 1994; Ham 1992; Seedhouse 1994) and Canada (Rachlis & Kushner 1994; Sutherland & Felton 1990). In Australia state governments influence how federal health policies are implemented as they are responsible for providing health care although their central organisational and decentralised decision-making structures vary (Dewdney 1972; Gardner 1995; Sax 1972a, 1975b, 1993). Difficulties can arise if federal and state governments disagree on policy directions. However, as Gardner et al (1992 p.23) observed, where federal and state governments share policy goals implementation of a particular policy can be vigorously pursued. This is an important observation with regard to this study for as Palmer and Short (2000) have argued, state governments either embraced or opposed the CHP policy. What ACHA (1986) and Milio (1983b,c, 1986a, 1988a) reveal is the vigour with which the NSW state government implemented this policy, at least initially, compared with other state governments. They do not explain why this occurred. They do highlight and explain the effect of diminished federal government support on CHP policy funding for almost a decade from 1975 until 1984 when a new Labor government was elected. Political will is important. Politics are played out at many levels and most importantly in bureaucracies. The importance of bureaucratic support is raised by Hill (1993), amongst others, when he points out that implementation can be relatively unproblematic if bureaucracies remain 'subservient to their political masters' (p.213). If bureaucracies, or departments within one, are opposed to a specific policy implementation it can be problematic. In the case of the CHP policy Milio (1983a, 1986a) found that federal and state bureaucrats' understanding of this policy diverged. For some it was an opportunity to do something new and for others

18 a way of keeping people out of hospitals. The interpretation imposed on the CHP policy by NSW state governments has not been explicated. Even if all governments involved agree on a policy’s purpose and the relevant bureaucracies are subservient and dutiful, perfect implementation is unobtainable mainly because it is impossible to control the complex array of circumstances involved in such a process (Etzioni 1976; Hood 1976; Hogwood & Gunn 1993; Pressman & Wildavsky 1973). Hogwood and Gunn (1993 p.221-223) illustrate the near impossibility of any organisation achieving ‘perfect implementation’ by identifying ten preconditions required for this feat: • external circumstances do not impose crippling constraints, physical or political • adequate time and resources are available to change attitudes or behaviour • all resources are available (eg. money to purchase qualified professionals or time to train them). • policy is underpinned by valid theory of cause and effect • relationships between cause and effect are direct with few intervening links • process relies on few dependency relationships with other authorities or groups • program objectives are understood and agreed to by all involved • tasks are specified in a correct sequence • communication and coordination are perfect • those in authority have perfect compliance from all participants, no resistance, conflicts of interest, status disputes or compartmentalisation. In Australia, as in other complex democratic societies, public policies such as the CHP policy tend to be implemented by diverse large, highly bureaucratic, and small, less bureaucratic organisations, and such perfect conditions will rarely if ever arise. Such conditions did not arise for those seeking to implement the CHP policy at a federal level as Milio (1983b,c, 1984b) describes. However, as Chapter 3 will illustrate, the conditions under which this policy was implemented at a state, regional or local level have not been adequately explored by Australian researchers. Yet, as overseas studies have revealed, when governments have tried to implement policies directed at establishing CHCs, as the CHP policy did, they have encountered problems mainly because such policies can be considered innovative in that they propose an alternative to what is already occurring. According to Hogwood and Gunn, resistance can be overcome but only where participants understand the complexity generated by 'environmental, political, and organizational factors' (1993 p.223). Case studies conducted in America, Britain and Canada suggest that with regard to CHCs such resistance was rarely overcome (Alford 1975; Church 1993; Ginzberg et al 197; Hall et al 1975; Lomas 1985). With regard to Australia the work undertaken by Milio found that those seeking to implement the CHP policy at a national level had an extremely complex set of circumstances to understand. Of necessity this process would have included participants from diverse professional backgrounds. It would have involved, for example, federal, state and in NSW, regional bureaucrats. At the coal face, so to speak, it would have involved

19 organisations with long histories in an area − hospitals, non-government organisations − as well as a diverse array of health professionals − doctors, nurses, psychologists, social workers, and others − and in some states non-health professionals. All would have had their own views and expectations of this policy, of CHC practitioners, and the purpose of the health care system. As Edwards (2001) amongst others points out, at a state level the Minister responsible for a policy area decides how to handle this process, how to deal with potential opposition. There are various ways in which opposition can be addressed including by establishing interdepartmental committees at critical points in the implementation process. The quality of advice provided by advisers at such times is critical and has implications for the outcome. As the following Chapters will illustrate governments at all levels established such committees as well as consulting with key stakeholder groups. These actions appear to have done little to reduce opposition to this policy or foster a shared sense of purpose. State governments, as Weber (1946) demonstrated, are bureaucratic in that they rely on rule, regulation, documentation, experts, officials, hierarchical systems of management, and downward delegation of authority (Weber 1946). In such organisations officials operate within a chain of command. Senior officials delegate the authority those below them require to carry out their responsibilities. Those 'at the bottom' are constrained, like those above them, by their role, authority, power, and control over resources that can either facilitate or hinder their capacity for independent decision making. This does not mean, however, that they lack influence. Fragmentation, created by divided responsibilities, makes cooperation essential; it is necessary to form links, horizontal and vertical, to facilitate action or remove barriers to action. The administrative structure of government departments ensures that vertical and horizontal dimensions of influence are exerted on policy processes especially during implementation (Colebatch 2002). Within bureaucracies it is generally agreed that communication and authority run vertically from those at the top to those at the bottom, to those at the 'coal face' whose job it is to interact with the public. The need to forge links and relationships with officers outside of this vertical authority structure is evident by what is known about how the CHP policy was implemented. This policy was developed and implemented at a national level by a new federal government via a new H&HSC which delegated responsibility for the process to state governments and other organisations interested in establishing projects consistent with its purpose (H&HSC 1973, 1975a, 1976a,b). The Department of Treasury provided the funds required for this initiative. Newly appointed H&HSC commissioners would have had to form relationships with officers in Treasury, including personal and organisational links, to facilitate this event. By all accounts many in the federal public service who had served under a conservative government for twenty-three years found the reformist nature of the Whitlam government difficult to deal with (Alaba 1994 p.69). There was opposition to many policies. The federal government brought in advisers from outside the public service to overcome some problems (Freudenburg 1977). At a state level, especially in NSW which implemented the largest CHP, the officials involved in this process would have had to establish relationships with contemporaries in various departments in order to act. To gain an

20 understanding of this policy and how it was implemented requires, as Colebatch (2002) has argued, identifying who was involved, how they got there and what they did along vertical and horizontal dimensions. Three federal governments, numerous politicians and incumbents of key positions (eg. H&HSC Commissioners, departmental heads, medical and nursing experts, public hospital boards) participated in implementing the CHP policy. For this reason the allegiances and perspectives of key players over time are relevant to this study as their opportunities to exert influence would likely have differed. However, as has been mentioned earlier, those who interacted with the public, those at the coal face were not without influence. Lipsky (1976, 1979) and Prottas (1978), have long argued that professionals and/or officials have the capacity to influence policy from the ‘bottom’ up. In the 1970s Lipskey (1976, 1979) coined the term ‘street level’ bureaucrats to encompass officials (teachers, police) who were employed for their expertise and to whom authority was delegated to implement policies locally, on the ground. This study concerns a policy which was in many ways implemented by ‘street level’ bureaucrats, that is the health and non-health professionals employed at CHCs by non-government and government organisations. Thus their backgrounds, educational preparation, professional ethos, experience and understanding of concepts such as health, illness, people and society, are also relevant. So too is the administrative context in which they worked. Most early studies of the CHP policy and CHCs, as the next Chapter illustrates, focussed on the activities of this group. However, as the preceding discussion has illustrated, the context in which they worked, administrative and political, also needs to be understood. Lipsky (1976, 1979) and Prottas (1978), argue that it is important how street level bureaucrats are informed about a policy and the clarity with which goals or objectives are explained. Where a policy’s goals or objectives are incompatible with those of the professionals involved in policy making processes they can develop their own objectives, compounding the difficulties inherent in policy implementation. They also point out that poor communication from ‘headquarters’ down and outwards can contribute to a poor understanding of policy objectives which can be altered, expanded, and displaced even when understood. As Chapter 3 illustrates, early researchers found practitioners at CHCs expressing commitment to the goals of the CHP policy although they were not achieved. This raises interesting questions about contextual issues. Elmore (1993) suggests that policies can be understood by the means used to implement them and observes that some policies fail because they are poor policies and others fail because they are poorly implemented. Hogwood and Gunn (1993 p.221) argue that some policies are ‘bad’ and that they required better analysis of relevant issues and options before implementation by testing the underlying hypotheses or learning from the experience of other countries. Elmore (1993) argues poor implementation can arise from the administrative processes used to translate policy into action. Knowledge about public organisations is thus critical. To understand how implementation shapes policies it is necessary to understand how organisations work and how organisational cultures evolve. The significance of organisational behaviour and culture, how it influences street level bureaucrats’ and senior officers’ ability

21 to translate new concepts into action, is raised by studies of the efforts of various organisations seeking to establish CHCs in America, Britain and Canada (Alford 1975; Church 1993; Hall 1973; Hall, Land, Parker, & Webb,1975; Ginzberg et al 1971; Kensig 1992; Lomas 1985; Rosen 1971). One problem associated with implementation, as Kahn (1969) argued, is that the originators of a policy are rarely responsible for its implementation. The responsibility falls to administrators who interpret a policy from the perspective, the culture, of their organisation. This is important for this study because while street level bureaucrats participated in translating the CHP policy into action all were employees of bureaucratic organisations. This is significant for, as Alford argued after studying various American health services, the attributes of organisations and individuals are pervasive and continuing but they 'cannot account for historically specific characteristics of social institutions' (1975, p.18). Alford argues against use of theories which seek to explain how organisations operate by referring to individual psychology, status and power, organisational failure or what he refers to as ‘unenlightened leadership’ because they ignore structural influences. He proposes that health care institutions are best understood by exploring ongoing struggles between three groups: controllers of major health resources, ‘professional monopolists’; those challenging their power, ‘corporate rationalists’; and communities seeking access to better care via ‘equal health advocates’. Citing Mechanic, a medical sociologist, Alford argues a struggle between structural interests arises within health care systems as interest groups: ... tend to view priorities from their own particular perspective and interests, and it is enormously difficult to achieve a consensus. Groups are usually reluctant to yield rights and privileges that they have already exercised, and will resist significant restructuring unless it appears that there is something in it for them (1975, p.9). This perspective is relevant to this study of Australia's CHP policy, implementation of which altered how the health sector was structured by promoting expansion of community based services and extension of nurses' and allied health professionals' responsibilities.

Organisations, Structure and Culture The organisational literature focuses on how organisations are structured, administered and managed. The organisation of general hospitals is relevant here. In Western societies most are organised hierarchically and stratified along professional lines. Traditionally they have been less bureaucratic than, for example, a federal or state public service, a situation leading many authors to comment that little is known about the processes and procedures used by these organisations (q.v. Palmer 1971). Hospitals are hierarchically structured, however at the unit level practices vary. How various units are managed has implications for staff and patients. Most authors classify styles of management as authoritarian, democratic and laissez-faire. As early as the 1940s connections were being made between the organisational structures, management practices and employees' work practices in health services with health outcomes for patients. Two studies are relevant here, that of Main (1989) and of Menzies (1970). The report by Main (1989), written in 1946, reveals differences in the morale and mental health of British soldiers in different

22 battalions and different British Army hospitals. Main argued that culture was decisive for human relations and that … the ways people in the structure relate to each other is decisive for whether the people in the structure treat each other’s roles with distance or warmth, enmity, or friendliness, respect or contempt, concern or coldness (1989 p. 141). Culture, not structure, decided whether staff and patients of different ranks truly respected and expressed interest in each other's work and listened to one another’s ideas as ‘personal equals’ when discussing doubts, resistances and enlisting and evoking others’ talents and participation in various tasks. Within organisations, culture influences whether delegation of power and responsibility are adequate and if people trust each other or watch each other suspiciously. Folk-ways, the informal ways in which people relate to each other were decisive and these, according to Main, were influenced by the way organisational heads related to each other. Their attitudes were reflected in relations with their immediate sub-heads and how they then related to their staff and their staff to their juniors. These observations arose from Main’s efforts to establish a therapeutic community, a mode of treatment in vogue from the 1950s, based on a culture of honesty, inquiry, and understanding within personal, group and community systems. Main argued it was essential for heads of community organisations to ‘practise true personal respect and professional concern for one another and for their immediate subordinates’ (p.141). Menzies' (1970) observations of nurses' working conditions in a general hospital raise similar issues to Main. The authoritarian culture of a general hospital affected how nurses worked with one another, with patients and their self-concept. She argued that this culture left nurses anxious and that to survive it they became ‘schizoid’ to work or they left.

Health and Health Policy As the preceding discussion illustrates, health care systems are comprised of organisations which are complex, organised hierarchically, and the culture of which influences how people work with one another and with patients. Until recent times conceptions of health have relied more on medical than social science interpretations. How health is understood influences the strategies selected to improve individual, family and population health and the criteria for judging effectiveness (Milio 1988 p.xv). Implementing a new health policy is a complex activity which involves stakeholders whose view of the ‘problem’ needing solving is influenced by their experience, by the dominant ideas, beliefs, and understandings of their roles, and expected behaviour, gained in the health system as administrators or practitioners. It is within this environment that they also gain an understanding of ‘health’ and what is meant by ‘health care’. In Australia, as in most Western societies over time, distinct disciplines and services have evolved to treat bodies, minds and environmental hazards. Historical studies illustrate a trend of moving from generalist to specialist with areas of specialisation shrinking as more is learnt about a field. Psychiatry offers a useful example. Shorter (1997) in his History of Psychiatry shows how asylums were established in Europe from 1403 and psychiatry in the late 1800s. Until that time family doctors cared for people with ‘nervous

23 disorders’ (p.22). Tensions have always existed in this discipline between neuroscience, brain chemistry, anatomy and medication, and a psycho-social view that attributed symptoms to social and personal stresses (p.26). Tensions over cause are evident in other specialities as is illustrated by the development of discrete bodies of knowledge and the evolution of ‘profession’ specific languages that define how ‘health problems’ or ‘health issues’ are identified, described, and problematised (q.v. Lewis 1988, 2003; Meleis 1997; Porter 1997; Porter 1999; Shorter 1997; Swanson & Nies 1997; Wicks 1999). Medical anthropologists have long argued that ‘health’ and ‘illness' are dynamic, culturally based concepts (Helman 1984; Kleinman 1980; Mechanic 1972, 1982,1983a,b). Western and non-Western views of health vary. In Western societies health and health care were viewed from a biomedical perspective for most of the 20th century (Foucault, 1973). Grounded in dualism, this perspective portrays mind and body as separate entities leading to what Underwood and Owen (1986) call a mechanistic, clockwork view of health focussed on body parts (eg. heart, legs, brain). Non-Western societies have retained a more holistic view (Kleinman 1980; Helman 1984; Eisenberg & Kleinman 1981). As Helman (1984 p.69) explains health for many non-Western societies arises from a ‘balanced relationship' between nature, 'the supernatural world' and individuals. The aim of treatment is to restore balance (Eisenberg & Kleinman 1981; Helman 1984; Kleinman 1980; Mechanic 1983). In the West there is some acceptance that culture influences health practices, norms, mores, beliefs, protocol, systems of control, and so contributes to a population's health or ill health. The influence of culture has long been recognised by American nurses such as Milio (1970, 1975) and Leininger (1970), amongst others, who have made a case for providing culturally relevant care. Researchers seeking to explain why people fail to make effective use of existing health services, when cost is not an issue, have also pointed to the importance of culture. Walters (1980), for example, who studied use of the British national health service, found that services needed to be geographically accessible, affordable, available at suitable times, and culturally relevant (Walters 1980). Studies of CHCs conducted since the 1940s, and mentioned earlier, have raised similar issues as has the World Health Organisation (WHO 1978). In 1948 WHO included in its first constitution a definition of health as ‘a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity’ (WHO 1958). This definition was politically and conceptually important as it framed ‘health’ as a relational rather than an absolute state, which had implications for national and international health policies. This shift in emphasis from disease to well-being followed World War II. It occurred as governments and humanitarian organisations continued to address the ‘health’ needs of populations exposed to years of material, physical and emotional depravation, loss, grief and, for some, horrendous experiences as refugees or prisoners of war. Physical illnesses were more readily identifiable and treatable than emotional illnesses which could remain hidden. Wars, like disasters, have provided opportunities for researchers to learn more about environmental influence on people's health and how individuals, families and communities respond to adverse situations. In some instances this has led researchers to develop new models for conceptualising influences on health and changes in practice.

The Scope and Practice of Public Health Implementation of a new CHP policy of the nature described meant that health care providers were required to consider the wider community as a whole rather than just individuals presenting for care. Issues of public health needed to be addressed alongside clinical care. The public health literature identifies two central differences in focus and purpose for this sector of a health care system. Public health is focussed on populations and its purpose is to prevent and control rather than treat. During the 19th and 20th centuries governments enacted legislation which reduced the incidence of preventable illness by changing environments (q.v. Beaglehole & Bonita 1997; Lewis 2003; Milio 1981, 1984; Porter 1994). Significant gains were made as deaths from infectious diseases declined (Porter 1994; Rosen 1993; Sax 1972a; Wallace 1998; Winslow 1958). Porter (1994) argues these gains did not reflect a ‘triumphant’ or 'linear’ march forward as changing views and tensions concerning the scope of public health and which strategies were appropriate have impeded progress. The purpose of public health is generally agreed to be about reducing illness and promoting health (Ashton & Seymour, 1988; Baum 1998; Beaglehole & Bonita 1997; Gardner 1992; Lewis 2003; Milio 1970; 1971; 1975a,b, 1976a,b, 1981, 1985, 2000; Sax 1972a, 1984). Few would dispute the intent of Winslow (1920) who as President of the American Public Health Association, defined public health as; ... the science and the art of preventing disease, prolonging life, and promoting physical health and efficiency through organised community effort for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health (1920, p.30). This definition is important, illustrating the centrality of doctors and nurses to public health and the need for ‘social machinery’ to maintain health. This is significant for this study of the CHP policy. What histories of public health illustrate is that doctors and nurses traditionally worked with individuals, with specific population groups, while non-health professionals proposed solutions to problems and monitored environmental compliance with legislative requirements (Brainard 1985; Fowler 1986; Goldstein 1983; Potter 1999; Sax 1972a; Taylor 1979a,b; Wyatt, 1962; Winslow 1920, 1938, 1943, 1984). Doctors’ and nurses’ place within public health is central to tensions that have emerged between a narrow medical perspective and a broader perspective focussed on social and economic causes of ill health. What ‘social machinery’ and which strategies are appropriate? What is the scope of public health practice? Which disciplines should be involved and in what capacity? Beaglehole and Bonita (1997 p.145) argue the problem stems partly from public health policy, practice and research being driven by purpose rather than theoretical frameworks or an agreed body of knowledge. They argue this has contributed to public health being marginalised within Western societies where politicians and bureaucrats from the 1960s have focused on medical care and trying to reform health sectors. Such activity has been evident in America (q.v. Alford 1975; Roemer 1969, 1971, 1976, 1977) and in Australia (Dax 1961; Lewis 2003, Sax 1972a,

25 1984). Great emphasis has also been placed on managing health services as a plethora of health services publications and rise of management courses illustrate (q.v. Cuthbert et al 1992; Lawson 1968, 1970). Government involvement in public health has meant that the political agenda of incumbent governments and the dominant views of what ‘health’ means and how to maintain it have influenced policy and public health practitioners’ scope of practice (Baum 1998; Baum, Fry & Lennie 1992, Porter 1994; Sax 1972a, 1975a,b).

Environments, Populations or Individuals Government policy is influenced by dominant understandings, theories of causation, our so-called best guesses, until research supports or falsifies earlier findings. From the late 1800s public health literature has shifted its focus away from environments towards individuals (Ashton & Seymour, 1988; Beaglehole & Bonita 1997; Baum 1998; Holman 1992; Sax 1972a). As germ theory and immunity were better understood and antibiotics became commonplace, practitioners began focusing on detecting and preventing infectious diseases via immunization and quarantine. As communicable diseases declined concern shifted to what were called diseases of ‘affluence’ and an emphasis on changing people's lifestyles in an attempt to reduce these conditions. Some public health advocates opposed the shift in emphasis from environments to individuals which occurred early in the 20th century. Winslow (1920), for example, a doctor, argued both foci were required to prevent illness and promote health. His vision was ahead of his time. He predicted a ‘new public health’ would arise characterised by greater collaboration between various public health professions. From his perspective the boundary between private medicine and public health was artificial because diagnosis was necessary before education became possible. Coordination between public health practitioners (doctors, nurses, bacteriologists, epidemiologists, engineers, statisticians, social workers, health inspectors, administrators) and other services was essential (1920 p. 30). He considered mental health a public health issue and supported public health nurses working to establish a Mental Health Association and a Public Health Nursing Section of the American Public Health Association (1938). Like other early public health advocates, many of whom were nurses2 (eg. Jossens & Ferjancsik, 1996; Swanson & Nies 1997), Winslow viewed the scope of public health practice from a broad social perspective despite lacking the standards of evidence expected today. Like many early advocates of public health internationally he argued for an increase in public health nurses (1920, 1938) and appears to have based his proposals on observation of people’s circumstances. During the 1920s Australian public health doctors also argued that more public health nurses were required and the Australasian Medical Congress of 1927 passed resolutions to this effect (Keleher 2000).

2 Lillian Wald and Mary Brewster, both trained nurses, established a district nursing service in New York. The house on Henry Street, as it was known, became the Visiting Nurses Association of New York City.

Determinants of Health and Illness The CHP policy was concerned with improving the health of total populations. It reflected a more contemporary understanding of ‘health’ being affected by peoples’ social, environmental and physical circumstances. Despite the biomedical emphasis that has dominated health care since the early 20th century the idea that social environments contribute to physical and mental health was not unknown. For example in 1897 Durkheim (1952), a sociologist, linked suicide rates to people's social situation, to the presence or absence of what he termed ‘social fabric’. He found people who had established strong social bonds were less vulnerable to self-destructive behaviour (p.209). He was not alone. Social critics such as Booth (1970), Booth (1942) Dickens (1945), Eliot (1992), Hugo (1862), early public health advocates like Rosen (1993) Winslow (1920, 1938, 1984), and even insurance companies (Hamiliton 1988), have made connections between poverty, poor living and working conditions, illness, early death and social problems such as crime, based on observation, deduction and induction since the early 19th Century. Life insurance companies, for example, responded to their analysis by employing nurses to help people change their personal circumstances (Hamilton 1988). By the early 1940s psychiatrists had begun theorising about how traumatic and unexpected situations adversely effected the long term mental and physical health of some individuals, families and population (Lindemann 1944; Main 1989). The idea of resilience was raised. Lindemann (1965, p.271) argued people's responses were influenced by their ‘repertoire of coping mechanisms and emotional defences,’ that is, how they interacted with and interpreted their world. By the mid-1950s social scientists had begun to explore the impact of child rearing practices, family dynamics and control on people's sense of self and their health. Bowlby (1969) raised questions about the impact of long term hospitalisation on children. Women’s and civil rights activists began to identify the implications of gender and race for particular population groups (The Boston Womens Collective 1976) and how health professionals responded to them. By the 1960s people’s personal environments, how they interacted with others, were accepted as having a significant influence on their health. Social milieu and group therapy were promoted with some inpatient psychiatric units organised as therapeutic environments (Carson & Arnold 1996; Lewis 1988; Maddison, Day & Leabeater 1963; Shorter 1997). Researchers argued hospital environments affected individual and group behaviour, patients and staff, patients' expectations of their future and staff interpretations of patients’ behaviour (Goffman 1976; Green 1985; Rosenhan 1973). Hospital culture influenced people’s behaviour. Importantly, rigid authoritarian cultures were found to have a negative affect on the mental health of nurses (Menzies 1970) and patients (Main 1989). In Primary Care, authoritarian attitudes were seen to disable rather than to assist (Broom 1991, 1989; The Boston Womens Collective 1976). The culture of work and treatment environments, it was argued, could have negative effects on individuals and groups over and above their specific personal, mental health, problems (Illich, Zola, McKnight, Caplan, & Shaiken, 1977).

27 By the 1970s there was acceptance in some research circles that influences on people's health were multi-factorial and complex and that some populations had poorer health than others due to their particular circumstances. This is the argument advanced by Milio (1975) in ‘Health Care for Outcastes’. Based on a meta analysis of the findings of numerous studies conducted in the United States of America, she argued non-white populations, especially women, were more likely to be poor and have poor health than other populations. In her later works she continued to explore relationships between people's circumstances and their health and government action. Her position, expressed succinctly in 1981, was that governments had a responsibility to develop and implement policy which made it easier for people to make healthier choices. Milio argued that while the personal and economic cost of illness was high for individuals the cost of preventable illness was also high for governments who had the capacity, via policy initiatives, to reduce the cost for all (1981, 1983a). By the 1970s Dubos (1959), Illich (1975, 1976) and McKeown (1979) had advanced their arguments that health gains achieved from the early 20th century were an outcome of public health initiatives (improvements in nutrition, better housing and hygiene, reduced exposure to infection and smaller families) rather than medical treatment or immunization. From their perspective modern medicine contributed to, rather than solved, some contemporary health problems: ‘iatrogenic’, doctor induced, illnesses were real (Illich 1976; Illich et al 1977). Even the WHO questioned use of increasingly complex medical technology and an emphasis on treatment at any cost. Preventing preventable conditions received little attention despite social and environmental determinants of health being identified. From the 1980s, literature on determinants of health burgeoned as researchers found variations between different socio-economic groups. In Great Britain a divide was found between the health of populations of higher and lower socioeconomic status (Evans, Barer & Marmor 1992; Townsend & Davidson 1982; Townsend, Phillimore & Beattie 1988; Whitehead 1988). Higher death and illness rates from all causes were found, with rates for coronary heart disease being especially high for adult men in lower socio-economic groups. Australian researchers were also finding Aboriginal and Torres Straight Islanders health to be strikingly poor (McMichael 1985; National Health Strategy 1991b, 1992c; Simons, Simons, Magnus, & Bennett 1986). Increasingly complex epidemiological analysis provided support for the theories advanced by public health practitioners (eg. community or public health nurses) and social scientists a decade earlier.

Theoretical Perspectives on Prevention My concern was to understand how the CHP policy was implemented over time in one area of Australia. However, because this study concerns a health policy it is necessary to understand the various theories and models that have evolved to explain why people remain healthy or become ill as dominant views influence policy development. Decades before social epidemiology began identifying ‘paths’ leading from social circumstances to ill health practitioners and social scientists had theorised, offered their best

28 guesses, on the processes and interactions leading to ill health. Caplan (1964), a community psychiatrist, who built upon the work of Lindemann (1944), developed one of the earliest models conceptualising primary, secondary and tertiary prevention for mental health. Prevention is central to public health activity (Brainard 1985; Fowler 1986; Goldstein 1983; Taylor 1979a,b; Wyatt, 1962). Developed in the 1940s and early 1960s these models are important because they resonate with the findings of new research. Lindemann’s (1944) seminal work on grief raised awareness amongst mental health professionals of the potentially negative impact of grief on some individuals and families following sudden or truamatic events. Lindemann (1944), having worked with survivors or families of victims of a night club fire in New York, identified aspects of normal grief: (1) somatic distress, (2) preoccupation with the deceased, (3) guilt, (4) hostile reactions and (5) loss of patterns of conduct, which he differentiated from morbid grief. He argued that people with obsessive personalities were more likely to develop agitated depression, a morbid grief response and proposed ‘proper psychiatric’ management of grief might prevent ‘prolonged and serious alterations’ in their social adjustment (p.147). He hypothesised that offering timely intervention, support and opportunity to talk, might prevent problems arising or lessen their severity. Caplan (1964), a community psychiatrist, built on Lindemann’s work to identify three levels of prevention. Primary, to prevent problems/diseases arising through monitoring and controlling environmental hazards, creating safe environments, pro-active outreach and personal health education. Secondary, to reduce the severity of problems by early detection and early treatment. Tertiary, to assist those with existing problems maintain their health through rehabilitation and habilitation. For Caplan primary prevention of mental health problems included: ... lowering the rate of new cases of mental disorder in a population over a certain period by counteracting harmful circumstances before they have had a chance to produce illness. It does not seek to prevent a specific person from becoming sick. Instead, it seeks to reduce the risk for a whole population, so that, although some may become ill, their number will be reduced (Caplan 1964, p.26). It involved supporting positive influences on health and assisting people adapt so: ... harmful pressures will be reduced in intensity, that people will be helped to find healthy ways of dealing with them, and that their capacity to deal with future difficulties will be increased. This approach is based on the assumption that many mental disorders result from maladaption and maladjustment and that, by altering the balance of forces, a healthy adaption and adjustment is possible (Caplan 1964, p.28). For Caplan, working preventively with populations, families, or individuals required professionals to understand the ‘vulnerability or the resistance of persons exposed’ to assist them to choose the most appropriate response (Caplan 1964, p.27). A preventive approach thus included assisting people to find healthier ways of solving or reducing their problems by offering them a little 'extra' support (Caplan 1964 p.30). Milio (1970, 1975a) also focused on prevention but sought to help people change what she referred to as ‘health-damaging’ social, environmental, economic and personal circumstances with the aim of helping them adopt ‘health-generating’ ones. Health professionals therefore had be able to identify:

29 ... health allowing, health-depriving social and physical realities, in particular the socioeconomic and ecological environments of social groups as they exist in communities (Milio 1975a, p.294). Milio emphasised change, Caplan emphasised adaption, maybe because of the populations with whom they worked as well as the historical context. Caplan, a psychiatrist, worked with people experiencing situations they could not change, the loss of a relative, a diagnosis of schizophrenia. Acceptance was a way forward. Milio worked with marginalised, disadvantaged African-American and Hispanic communities some of whose circumstances could be changed by learning new behavioural, social and political skills. Where circumstances were unchangeable, however, Milio argued health professionals should try and repair the damage done without creating new problems ( Milio 1975a p.295-298 ). Caplan (1964) and Milio (1975a,1981) conceptualised a preventive approach as connecting individual and collective perspectives. Caplan valued working with individuals ‘to make an individual diagnosis’ and ‘form a picture of the situation of the other members of his group or class’ to develop community wide strategies to prevent problems within communities (1964, p.26). A preventive approach meant using different strategies for different purposes to achieve different outcomes. Milio (1981, p.3) argued a population’s prospects for health were determined by public policy, by decisions shaping communities, workplaces, homes and schools. Public policies, in her view, could influence some circumstances by creating environments that made it easier to make healthy choices. She argued the obligation of public policy: ...if it is to serve the health interests of the public, does not extend to assuring every individual the attainment of personally defined "health". In a democratic society that seeks at least internal equanimity, if not humaneness and social justice, the responsibility of government is to establish environments that make possible an attainable level of health for the total population. This responsibility includes the assurance of environmental circumstances that do not impose more risks to health of some segments of the population than for others, for such inequality of risk would be to doom some groups of people ! regardless of their choice ! to a reduction in opportunities to develop their capacities (Milio 1981, p.5). A nation state having a responsibility to develop policies with the potential to promote health as the net gain or cost of a choice, to practitioners and consumers, would influence, if not necessarily determine, the choices made (1981, p.97). The preventive view advocated by Milio (1970, 1981) and Caplan (1964) was rarely evident in Australia in 1973 when the CHP policy was written. General hospitals and clinics continued to focus on diseases and nurses’ attempts to understand patients’ perspectives, it was argued, were often thwarted by hierarchical organisational cultures (Dreitzel 1971; Growe 1991; Green 1974; H&HSC 1974; Menzies 1970; HCNSW 1977a,b,c,d,e,f; Reverby 1987). Understanding of determinants of health and ill-health had increased but a preventive approach was rarely evident in Australia’s health care system. Milio, a public health researcher with experience as a visiting nurse, developed a model of causation to guide policy development and trans-disciplinary practice from 1970 (Milio 1970, 1975a, 1975b, 1976a, 1976b, 1979, 1981, 1983a, 1986d, 1988b, 1988c, 1991). She argued that ‘mutual-causal interconnections’ between individual or populations’ environmental circumstances created health or ill-

30 health (1981 p.27). She theorised interconnections between socioeconomic conditions (biophysical, workplace, home), personal behaviour patterns (habits, coping practices) and physiological responses (risk conditions, damaging responses) and people's health. Family, education and employment were conceptualised as mediated, or health promoting, while other actions and responses to circumstances were health damaging with effects accumulating over time. Milio emphasised the effects on individuals and communities but argued that national and international policy impacted on the health of individuals, families, communities and nations (1981, 1984a, 2000). Others have advanced similar models, however Milio articulated her ideas much earlier than other public health researchers as well as conducting meta- analyses of vast bodies of research drawn from different disciplines. Like Lindemann (1944) and Caplan (1964), Milio had observed that people's personal capacity to deal with situations varied. Like others, for example Seligman (1975) who developed models of learned helplessness and optimism, and Antonovsky (1979), who developed a salutogenic model, she sought to explain how people's interactions with their world affected their health, physical and emotional. These models, and the work of others mentioned earlier, accept that past experiences influence how people view and interact with their world, how they respond to new situations, and their physical and mental health (Antonovsky 1979, 1987; Kiely 1973; Lindemann 1944, 1974; Main 1989; Seligman 1979). At the basis of their models is a view that people learn ways of being and so can relearn new ways of being. They also shared the view that as interactions between aspects of a society outside of the control of individuals affected population health, multifaceted interventions were required to promote health and/or reduce the incidence of disorder or disease. A multifaceted approach was conceptualised as involving: providing people with ready access to relevant personal health services; taking a health rather than illness focus; and governments being capable of developing policies to promote health, and having the political will to do so (Baduraet al 1991; Caplin 1964; Milio 1981; WHO 1978, 1983). By 1990, beyond the scope of this study, there was one major problem remaining, this being that a core requisite for making healthy public policy a political reality is ‘learning how to do it’ (Badura et al 1991 p. 6). Identifying influences on health, demonstrating processes, is not enough, we need to know how best to develop and implement healthy public policy. As early as the 1970s the World Health Organisation provided some guidance in this regard in the formulation of a declaration.

Primary Health Care Much contemporary understanding of prevention stems from the WHO’s Alma Ata Declaration (WHO 1978) which called for action on determinants of health and provided international impetus for growing Primary Health Care (PHC) which it defined as

31 …..essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination (1978 p.16). Nurses' input was viewed as central to a PHC philosophy as Mahler when Director General of WHO illustrated with his observation that If the millions of nurses in a thousand different places articulated the same ideas and convictions about primary health care, and came together as one force, then they could act as a powerhouse for change (1985 p.22). The Alma Ata Declaration (WHO 1978) was important to Australia and it provided impetus for the development of models and theories of health promotion over the next three decades. For people with health problems to benefit from health care they require access. Access to services remained a problem especially for socially disadvantaged populations whose health is generally poorer than that of socially advantaged populations. Governments, internationally, have sought to establish CHCs, a new model of health care delivery, as a means to increase access to health care in − Australia (Andrew 1971; Champion De Crespigny 1972; Gordon 1972, 1979; Saint 1971; Sax 1972a; Webster 1971) − Canada (Report of the CHC Project to the Conference for Health Ministers 1972; Sutherland & Fulton 1990) − the United Kingdom (Hall et al 1975; Tate 1973) and − the United States of America (Roemer 1969; Report of the Community Health Centre Project 1972; Rosen 1971).

In Summary Policy implementation is a contentious and complex process especially when a new policy seeks to change how a health care system is organised and health care services are delivered. Changing how primary care services are organised has implications for how practitioners practise. One important reason for changing the organisation of primary care related to changed understandings of health and illness: specifically, the way people use health care services and relations between illness and a population's, family's or individual's socio-economic circumstances and cultural practices. Health services cannot resolve the cause of such problems but they could address or allay the results of illness and aim to prevent preventable illness. Health problems create distress. Making relevant services accessible can reduce distress for individuals and, in some instances, reduce further preventable problems arising.

32 CHAPTER 3 OVERVIEW OF THE COMMUNITY HEALTH CENTRE AND COMMUNITY NURSING LITERATURE Few people will ever derive more enjoyment from good health or suffer more distress from bad than will the individual health-holder whose life it is. (Reisman 1993 p.5).

Introduction The last Chapter provided a review of literature relevant to a study concerning how the Australian CHP policy was implemented in a bureaucratic context in NSW. This Chapter reviews literature concerned with community health centres (CHCs) and generalist community nursing practice. It begins with a review of overseas literature reporting on innovative projects, social experiments, as they provide some insights into directions being undertaken in other English speaking countries by 1973 when the CHP policy was written. A review of relevant Australian literature concerned with CHCs and community nurses’ work follows. This review is limited to the period of concern to this study. The methods used to identify the literature included here are discussed in more detail in Chapter 4.

Innovative Projects which Met People’s Needs Implementation of the CHP policy commenced in Australia in 1973. By that time health centres were operating in other English speaking countries, such as the United Kingdom, Canada and United States of America. Philanthropists (Pearse & Crocker 1943; Silver 1963), researchers (Beloff & Korper 1972), governments (Alford 1975; Ginzberg et al 1971; Hall et al 1975; Lewis 2003; Rosen 1971) and communities (Church 1993; Lomas 1985) had established centres. In some European and Asian countries centres were an institutionalised feature of their health care systems (Einevik-Backstrand & Borgquist 1995; Kohn 1983). The process of establishing CHCs in English speaking countries appears to have been slower and more difficult partly due to opposition from medical organisations (Alford 1975; Hall et al 1975; Lewis 2003 p.102-107). The Peckham Centre in South East London was the first centre established in the United Kingdom and it operated between 1933 and 1947. As Pearse and Crocker (1943) explain, the centre offered local families from diverse socio-economic backgrounds access to medical, non-medical, social and leisure services for a small fee. The centre promoted independence, its guiding philosophy being that healthy individuals prefer ‘freedom of independent action' (Pearse & Crocker 1943, p.74). Professionals were encouraged to view themselves as resources families could use to reach and sustain ‘their own maximum capacity for health' (p. 78). The report of this social experiment shows that this centre, like others seeking to replicate it, sought to assist people to remain healthy. Member families were screened and their progress monitored over time. Many had disorders or diseases (32%), masked by well-being (59%), few (>10%) were healthy. The

33 combination of medical, non-medical and social services offered improved people's health over time (judged on objective criteria) and altered their patterns of service use. Member families’ use of non- medical preventive services increased as their use of medical services declined. This change in patterns of service usage was attributed to routine cross-disciplinary referrals, doctor to nurse and other staff for education and health checks. Pearse and Crocker concluded that the practice of ‘health’ and ‘medicine’ differed. The centre had long term effects for some. Stallibrass (1989) conducted a retrospective analysis to uncover what this centre had helped people learn about health. She found clients and staff remembered the centre fondly and saw it as having had an enormous influence on their lives. One practitioner recalled that this centre taught her that people resented instruction, that teachers could frighten and that ‘impatience, even when called helpfulness rather than compulsion, strangles creativity’ (1989 p.x). During the 1960s other experimental centres were established in America based on this model. A project in New York achieved similar findings over five years. Silver (1963) found that the health of families improved, their use of non-medical services increased and that of medical services declined. Similar findings were gained by Beloff and Korper (1972), from the Family Health Care Program, Yale University, School of Medicine which established a centre to test the hypothesis that: …. the organizational structure and operational philosophy of a health delivery system can significantly alter the pattern of behaviour related to the health of its patient population (p.359). This project began as health planners were arguing a successful health delivery system had to cater for social, emotional and biological health and emphasise ‘prevention, health maintenance, and outreach efforts’ (p.359). They found that over thirty months the health of ‘poor’ families improved and patterns of service use changed with use of ‘nurse counselling, psychosocial guidance, employment assistance, health education, marriage counselling, and rehabilitation’ increasing while their use of ‘physician services for illness care’ decreased (p.359). Beloff and Korper attributed their findings to families being provided with opportunities to build relationships with practitioners who understood their needs. They concluded offering disadvantaged families services to address ‘acute episodic illness may not be a primary need’ and that it might be better to improve their ‘health behaviour and functioning’ by facilitating ‘continuing positive experiences with a comprehensive health care system’ to enable them to ‘cope’ with their ‘social and emotional problems' (1972, p.359). Families benefited from these experimental centres which co-located medical and non-medical providers. The doctors here valued non-medical input. Practitioners’ responsibilities were clearly defined and doctors were expected to refer families to nurses and allied health practitioners for non-medical preventive care. It was similar at other centres. Some insight into the thinking of the doctors involved can be deduced from Silver (1963) who, citing Fox, argued …..our Greater Medical Profession will run better if we go as far as is reasonably possible towards granting full professional status to every kind of trained person in it (p.59). If we ignore the implicit paternalism (which reflects the era) this statement suggests that for Silver, and other doctors involved in these experiments, non-medical professionals were essential for a ‘health’ care, as opposed to medical, team. Teamwork was important. It enabled doctors to focus on prevention, and

34 increased the ability of family members to seek appropriate assistance and cope with their current circumstances. These centres provided medical care but practitioners used opportunities as they arose to provide relevant additional services, services that Caplan (1964) would classify as secondary prevention. Additionally practitioners built relationships, they created positive experiences and in doing so could be seen as helping people develop skills they could use in other areas of their lives. The idea that practitioners need to build relationships with individuals and communities if they are to provide relevant services is central to the work of Milio (1970) reported in ‘9226 Kercheval, the storefront that did not burn’. Milio discusses how and why she initiated a mothers’ and babies’ project in a poor black (sic) neighbourhood in Detroit, America. Impetus came from her realisation that a traditional home visiting service would be of little benefit to local women. Milio chose to use participatory community development strategies, with employer permission but little institutional support, to establish a new service run by the community. She reveals the commitment, time and energy invested by a lone practitioner (p.55). Milio explains her situation poignantly reflecting that …I was ready to stop the struggle. I was tired, I was hurt, in body and soul. And what made the weight heavier was that I knew the truth of what was told me: if I stopped even to rest there would be no one on the professional side to carry on (1970, p.127). This report highlights the personal commitment required by ‘lone rangers’, that is individual practitioners who decide to set up a new project without administrative or institutional support. It also reflects, like the reports of experimental CHCs, that practitioners need to be committed to these projects, and the communities they serve (Pearse & Crocker 1943; Silver 1963; Beloff & Korper 1972). Milio explains that to succeed she had to relate to individuals, families and communities as a person, not a professional (1970, p.130). Communities need to feel a sense of ownership. Milio succeeded here as the building which housed this community project survived race riots in the 1960s when surrounding buildings were gutted by fire − hence the title. Personal as well as professional commitment was foundational to the success of these projects.

Community Activism The findings of experimental and community projects discussed above indicate communities will use new services if they are relevant and, if they are accessible and provided by practitioners who understand them, they might learn to use preventive services. Practitioners sought to foster participation in centre activities. This would have been a rather novel idea as traditionally governments, professionals and non- government organisations have established services they think are required. Until the Alma Ata Declaration (WHO 1978) highlighted community participation this term was generally confined to the community development literature (eg. Alinsky 1962; Friere 1973) and rarely if ever mentioned in relation to Western health services. Communities were viewed as passive recipients of care. It was, and remains, uncommon to read about a population taking collective action to establish a health service.

35 This is what makes reports of two communities in Ontario, Canada taking collective action to establish CHCs interesting. Lomas (1985) and Church (1993) report on two projects, undertaken in the 1980s and driven by a perceived need for medical care. Local doctors opposed both initiatives for professional and ideological reasons. Lomas (1985) explored how industrial workers in Sault Ste Marie, an isolated industrial town in Ontario, mobilised a community to establish a workers’ health centre modelled on those operating in the USA in the 1950s. Even without government support these communities overcame medical opposition to gain a centre. Lomas concluded health centres were an important part of Canada’s health care system by the 1980s and that they provided a focal point for struggles between mainstream service providers and communities. Church (1993) explored how groups established health centres in Ontario to find progress impeded by structural and political barriers despite some stakeholder support. In this situation health department officials supported the establishment of a CHC while private doctors opposed it despite an obvious need. Church concluded that establishing health centres required the forming of alliances between local activists and health administrators.

Governments Driving Change It is interesting that governments rather than health professionals have driven reforms in health care in the face of opposition from some professional groups. Three studies illustrate this point. Ginzberg et al (1971), Alford (1975) and Hall et al (1975) each conducted in depth case studies which show bureaucrat’s attempts to reform health systems have met with opposition. Ginzberg et al (1971) and Alford (1975) focus on New York City where officials tried for forty years to establish neighbourhood health centres and regionalise hospitals. Ginzberg et al (1971) sought to identify barriers to reform, ‘forces leading to change and those which stop and retard change’ to understand why so few recommendations (to improve the city's health care system) had been implemented (p.8). Planners wanted to broaden ‘poor peoples’ access to medical care and rationalise ‘hydra-headed’ hospital structures (p.207). In an attempt to resolve their problems (resources, patterns of care, planning) planners made submission for federal health centre funding (Office of Economic Opportunity). Seven centres were funded to offer comprehensive services. They differed from the experimental centres discussed earlier as practitioners worked in teams, provided educational opportunities for local residents, engaged in community development and undertook research and evaluation. New operational reforms were introduced: uniform records; family registration; flexible appointment systems; and greater use of allied health professionals. According to Ginzberg et al (1971) the plan to locate centres where the population’s access to medical care was limited ‘collapsed even before all of the building blocks were in place’ as federal and state legislators ‘looked at the financial cost’ and ‘beat a hasty retreat’ (p. 207). Hospitals were regionalised in one area, the Bronx, due to a unique mix of circumstances, fiscal considerations, attitudes and institutional interests (p.170). Four preconditions for regionalisation were identified: ‘institutional interest, strong professional leadership, funds for new developments, and the absence of entrenched political and

36 professional opposition to change’ (p.7). Ginzberg et al concluded that pluralism offered potential for reform but limited government power to achieve it because governments had to rely on other groups for support. Second he observed that political leadership and administrative stability were required to reform a health care system and governments had to understand the long term financing prospects of new services before implementation began. Alford (1975) also studied CHCs in New York. His aim was to test a hypothesis that advertisements of crises in the health system were used as political weapons by interest groups, in and outside of government, to divert resources from one program to another. Structural interest groups, medical professionals and health service administrators, were a principal barrier to reform. Commission of Inquiry reports conducted between 1950 to 1970 posed the same solutions to the same problems. These reports identified CHCs as a means to resolve a lack of outpatient and ambulatory care facilities. Progress was slow. Half the centres proposed in 1965 had been approved for funding by 1971 (Alford 1975 p.107). Most submissions for funding were made by hospital administrators, few of whom understood their purpose, considered how to coordinate new and existing services, or assessed local needs, seeing only funding opportunities to develop centres under their auspices. Alford found development hindered by funding cut-backs, rising costs, scarcity of professionals and insufficient staff (centrally) to plan ambulatory care. Professional monopolists and corporate rationalizers competed for control of ‘the sources of profit’ (p.217). The latter, fuelled by a vision of an ideal health system of primary health centres in every neighbourhood, struggled with governments whose commitment to CHCs was limited because they considered them peripheral. Alford argued that struggles between professional monopolists and corporate rationalizers left CHCs precarious and starved of funds. Funding for new policies was essential but only became secure when a policy was institutionalised. Hall et al (1975) conducted six case studies, one on health centres, to ‘formulate middle range propositions about how and in what particular circumstances certain issues attain predominance over others and become the source of new policy’ in the United Kingdom (1975 p.5). They found fluctuating fiscal and political support, factors outside health care and political factors facilitated or hindered implementation of a health centre policy over time. Restrictions on expenditure were critical while government willingness to establish centres facilitated policy implementation (p.300). They argue that policy enactment is as much an article of faith as a statement of intent. Schemes labelled ‘experimental’ were vulnerable to fiscal stringency; program future was affected by varied interpretations of success or failure; and GP support was required to establish CHCs which the British Medical Association (BMA) opposed (pp.308-310). Hall et al concluded health centres were an example of an evolutionary policy emerging from the decisions of groups, local and central, professional and administrative (p.298). The studies discussed so far illustrate that structural constraints hinder policy implementation. Government support (economic and political) has been shown to be crucial. Studies reveal that cost hindered the development of CHCs which many officials considered peripheral to hospitals and private medical practice. By 1973 a forty year experiment tested in New York illustrated that CHCs were effective

37 for clients and facilitated interdisciplinary practice but that implementation of such a policy was difficult because of opposition by GPs and some health department officials. The warnings were there.

Australian Studies Governments develop and implement policies to resolve problems of concern (Alford 1975; Ginzberg et al 1971; Hall et al 1975; Kahn 1969). Evidence from overseas suggests CHCs were a ‘good’ policy but that structural and political impediments made implementation difficult to achieve. The difficulties associated with implementation and benefits for clients are rarely addressed within the Australian literature as this review illustrates. Nine evaluations were conducted in Australia between 1979 and 1988. As Figure 3.1 shows most were conducted in the early 1980s. Most focussed on CHCs in one state. Only one national study was conducted.

Figure 3.1. Evaluations Conducted In Australia Between 1979 and 1986. State Date Author Purpose Methods Findings National 1986 ACHA Problems, Interviews, evaluation A body of CHC strategies and reports, visits to 21 CHCs services and Commonwealth differences involvement between states Queensland 1979 Najman Do CHCs Quasi-experimental 3 Hospital admission 1980 et al improve the phase. 2 CHCs and 5 rates declined or 1981 health of total communities slowed for elderly 1983 communities persons 1980 Gibson Case study, Phase 2 of above. 8 CHP policy did not 1983 goal CHCs, dairies, 129 semi take the form 1984 achievement structured interviews intended evaluation 1980 Raymer Did a CHC 1 CHC, structured Practitioners knew increase access interviews with 71 local of the CHC but did to services service providers not refer Victoria 1987 Blacker Use of Telephone interviews Administrative et al Evaluation with representatives of processes were 49 CHCs lacking NSW 1980 Duckett Compared the 50 centres, 270 CHC services and Ellen type and cost of practitioners, diaries cheaper, more CHC and other educative and services preventive 1980 Mant Allocation of Geographic SES analysis More funds to CHP funding areas of health scarcity 1980 Morey et Clients of Glebe Retrospective study (6 GP referrals to al CHC years) of charts CHCs increased

South 1987 SCHRU Evaluation, Pilot 5 CHCs’ records, semi- CHCs more Australia 1988 study structured interviews, preventively diaries, 54 practitioners orientated than and 28 administrators other services

38 Failing to Achieve the CHP Policy’s Goals Hall et al (1975) argued that a program’s future is affected by evaluations. This is not surprising. Evaluation is a contentious process. Political factors can intrude on the findings and influence decision- making as to a project or policy’s worth. Debate revolves around what to evaluate, how to evaluate it and when. Evaluation of the CHP policy began, as Najman et al (1979) observed, when there was no evidence of failure but when its future was under question for political reasons. Evaluations started after the election of a new conservative federal Coalition Government, one opposed to this policy and other initiatives of the previous Labor Government, and within two years of CHCs being established. Most studies of the CHP policy were conducted to establish if policy goals had been or were being achieved by CHCs (Boyce 1980; Duckett & Ellen 1980; Gibson 1980, 1981, 1984; Najman et al 1979, 1980, 1981, 1983; Raymer 1980; SCHRU 1987, 1988). Many of these studies were government funded and conducted by stakeholders, for example community health or public health practitioners or researchers, whose interest in CHCs was more than academic. The most commonly cited and thus influential study provides a useful starting point.

A National Study Conducted in 1986 for the Australian Community Health Association (ACHA), towards the end of the time frame of concern to this study, this review provides insights into issues relevant to this current study. It was federally funded and conducted by two project officers, Allen Owen and Ian Lennie, who took 20 weeks to identify problems, strategies to resolve them, and recommend on continuing Commonwealth involvement in implementing the CHP policy using ‘Health for All’ and ‘Primary Health Care’ as a framework. Data were collected from stakeholder interviews, Community Health Evaluation and Standards System (CHESS) evaluations of centres in Queensland and Victoria, and visits to 21 centres1 they concluded it had not developed as intended. In all states they found a ‘body of community health services, with some degree of coherence’ which ‘appeared to have an established position within the overall mix of health services’. There was also ‘a surprising degree of similarity in service content, and in the approach of community health workers’ (ACHA 1986). Nationally this review found …. a degree of conservatism that was not in accord with the intentions of the original Program. That program was envisaged as shifting priorities in health from expensive, specialist, curative services to community-focussed primary care services with an emphasis on primary prevention and community participation. Some of this work was certainly being done, but the core of community health was an illness focussed, residual service providing mainly tertiary and some secondary prevention (ACHA 1986 Summary ). This review reveals huge differences in program size and administrative and funding arrangements between NSW and other states. In NSW CHCs (276) operated under regional administration. There was evidence of advertising, community participation, evaluation, coordination, liaison and staff development. There was a dedicated community health budget but no salaried doctors or local budgets and the eleven

1 Visits were made to 7 CHCs in the Northern Territory (90% of CHCs here), 5 in NSW (2%), 4 in Western Australia (30%), 2 in Victoria (3%), 1 in Tasmania (17%) and 2 Aboriginal Health Centres).

39 health regions operated with considerable autonomy which ACHA predicted would increase when area health authorities were established in October 1986 (1986a, p.64). The impression was of ‘stretched services’ responding to caseloads rather than planning guidelines (1986a, p.66). Fewer CHCs operated in states other than NSW. Queensland had 54 centres, operating separately from infant health and mental health, focussing on providing primary medical care and domiciliary nursing (ACHA 1986 pp.21-22). Central administration meant teams had little freedom. Heath education, liaison and staff development occurred however advertising was prohibited, some sub-teams were unidisciplinary (all nurses) and there was no budget. In Victoria 62 centres, administered by boards, emphasised prevention and community participation but little planning or coordination was evident and some centres charged fees (p.37-41). In South Australia 31 centres, administered mainly by boards, focussed more on primary prevention and health promotion than family work, however there was greater community participation and some coordination between services. Other states, ACT (11), NT (8), Tasmania (6), WA (14), had few CHCs. This review illustrates CHCs operated under varied administrative arrangements and these appear to have affected how CHC team members practised. Evaluations conducted prior to this review shed more light on differences between CHCs in various states. The situation in NSW was different and so discussed separately.

NSW CHCs more Preventively Orientated than other Services Evaluations conducted in NSW five years prior to the National Review reveal a rosier picture. Areas of health service scarcity gained more CHP funding during 1973 and 1974 according to Mant (1980). CHCs offered a comprehensive range of accessible services to populations with known needs. The services offered were more preventively orientated than those offered by GPs or hospital outreach (Duckett et al 1980; Mant 1980; Morey, Williams & Maloney 1980). In NSW, where doctors worked as centre managers, GP referrals to allied health professionals and nurses increased, suggesting that referral patterns changed. Morey et al (1980) conducted a six year retrospective study of Glebe CHC clients − mental health, social work, nursing, physiotherapy, occupational therapy, speech therapy, dietetics and counselling services, self-help groups, day centres − to find more were referred by doctors (50%) than hospitals (20%), non-government agencies or individuals (15%). A third of clients (13,251 of 37,735) were referred to or seen by nurses, often for physical problems. Self-referrals were mostly for psycho-social problems (p.56). Clients reported the assistance provided helped them resolve or cope with their problem/s. This in-depth study suggests increasing use being made of CHCs by other service providers. Duckett and Ellen (1980) compared the type and cost of services offered by 50 different types of health centres (baby 30, CHCs 6, child 4, mental 3, rehabilitation 2, geriatric 2, community information, occupational, Aboriginal), hospital outreach and GP services in inner Sydney. They found health centre practitioners reached the populations they were intended to reach: women, the very young and poor, and persons from ethnic backgrounds or with existing illnesses or disabilities. These services were cheaper, more educative and more orientated to prevention, however, despite nurses being more preventively

40 orientated than other practitioners, all were found to be orientated ‘disappointingly, strongly towards more curative areas of the service such as illness and disability management’ (p.205). It seems that health centres in inner Sydney offered services that were cheaper to provide and more preventively orientated than those offered by traditional providers, hospitals and GPs, however according to Duckett et al (1980) they were still not preventive enough. This theme was also evident in evaluations conducted in South Australia and Victoria. The Southern Community Health Research Unit (SCHRU) in Metropolitan Adelaide (1985, 1987) conducted a pilot study in 1985 a year before the national review was undertaken. This study involved 54 practitioners and 28 administrators from five teams of varying size (6-22) and composition and working under different organisational structures in different locations (p.54-56). The findings reflect those of earlier studies conducted in NSW. Nurses were more committed to prevention (p.68-69) and also, like social workers, to team and group work (p.115). This finding was attributed to nurses having had greater formal education in primary health care. The study concluded that health centres were more preventively orientated than other health services and argued that it was appropriate for teams to provide treatment services ‘delivered within a preventive framework’ (p. 137-13). The recommendations made in Figure 3.2 suggest CHC teams experienced tensions that had yet to be addressed. These proposals suggest that teams suffered from structural problems: team members disagreed on the purpose of CHCs; managers held a bio-medical view; and administrative structures were inadequate.

Figure 3.2. Proposals made by SCHRU following a Pilot Study in 1985.

• team work be increased to increase preventive activity • managers adopt a social health perspective • practitioners use a full range of strategies to provide services • health education officers be located at all health centres • workshops be held to discuss community health ideology • strategies be developed to deal with conflict, • strategies be developed to address individual and social influences on health • communities be involved in goal setting • data be collected on centre activities • teams be provided with training in evaluation and research (p.139-152)

A repeat study in 1987, conducted with different CHCs found indications of preventive activity increasing and team composition changing with more social workers, senior staff, a doubling of ‘other health workers’ and fewer nurses. More time was spent on preparation, follow-up, administration and management, suggesting time spent in the field or with clients had declined (p.26). Nurses remained more committed to teamwork (p.28). Different disciplines were found to spend more or less time with clients.

41 This was attributed in one team to ‘differing service delivery styles of the professions’ and a ‘particular interpretation of community health policies’ by a component of another (p.35). That more time was spent on preventive work was taken to indicate a ‘more consistent implementation of policy’ starting to ‘over-ride professional differences’ (p.36). It seems that various disciplines interpreted their responsibilities and the purpose of CHCs from different perspectives.

Determining Focus and Administrative Processes Studies conducted in South Australia raise issues about structure and agency, how CHCs were administered, the processes used, and the freedom of individual practitioners, actors, to interpret their responsibilities in relation to their team. Practitioners’ responsibilities were not defined as they were at the centres discussed earlier (q.v. Pearse & Crocker 1943; Silver 1963). A fertile ground for conflict existed. Studies conducted in Victoria suggest intra-team, inter-disciplinary problems were commonplace. Blacker and McLennan (1987) interviewed representatives of 49 (out of 62) centres employing 1 to 40 members to find that few assessed need (<10%), monitored client outcomes, held case conferences, or invited feedback. They had objectives, goals or targets but determined quality by quantification rather than client satisfaction or outcomes. Managers were ambivalent about, and resistant to, evaluation. As a consultant to several CHCs in Victoria Wellard (1992) had ample opportunity to observe how CHCs were administered and managed, what structures, processes and policies were established. Wellard found teams’ ability to plan, set goals and communicate to be hindered by a lack of decision- making processes. Alliances formed along discipline lines. Differences in basic beliefs, values, philosophies, a lack of respect for non-professional managers, and close proximity of team members fuelled interpersonal conflicts. He proposed that the establishment of regional offices might resolve such problems or prevent them arising. The earliest evaluations, commenced within two years of implementation of the CHP policy, were conducted in Queensland. Najman et al (1979, 1980, 1981, 1983) conducted a complex evaluation to examine if the presence of CHCs improved the health of total populations. Five communities, two with CHCs, were involved in a longitudinal (3 year), three phase, quasi-experimental study. Inala CHC, a hospital-based medical teaching centre with 40 professionals, served a population that included a high proportion of immigrants, unemployed, single or divorced women, living in rented premises. Ipswich CHC, with 15 non-medical professionals, served an older population living in a self-contained city (1981 p.12). Practitioners were supportive of CHP policy goals (operationalised as: identifying community needs; providing treatment and therapy; liaison and coordination, education and prevention), they treated and maintained people with health problems but did little primary prevention (1980 p.27-28). While many of Inala’s medical clients had chronic and degenerative conditions, speech problems, psycho-social disorders, or mental retardation (sic) doctors retained a ‘therapeutic model of consultation’ (1983 p.489). They made few cross-disciplinary referrals for preventive services. Stillbirth, neonatal mortality and ex- nuptial birth rates remained unchanged, however hospital admissions for frail elderly persons declined at

42 Inala and slowed for Ipswich; a finding attributed to community nurses’ work. Phase two involved examining the appropriateness of the ‘goal attainment’ model of evaluation. In phase two of this study Gibson (1980) examined 129 team members’ activities at eight CHCs. She found that while practitioners supported the CHP policy’s goals they spent most of their time working with clients. This led Gibson to question the assumption underlying a goal achievement model of evaluation, that is that program goals informed practice. Gibson concluded the CHP policy had failed to take the form the government intended (p.245-246) and proposed five explanations for this outcome: grandiose or vague program goals; bureaucratic red tape; bureaucratic inexperience; demands by others; situational influences; and practitioner fallibility. She rejected explanations related to goals and administration as it was ‘impossible to tell to what extent bureaucratic and political limitations have prevented centre staff from engaging in certain activities’ (p.247). However, Gibson argued that new programs which depended on ‘a level of bureaucratic competence not normally found in Government departments’ were ‘likely to fail’ as they depended on ‘fallible bureaucracies for administrative support’ (p.249). Gibson concluded that situational influences, demands by others and fallibility led practitioners to retain pre-existing patterns of practice ‘irrespective of new Program settings’ and contributed to non-achievement of the CHP policy’s goals (p.250). Questioning ‘the sustainability of the goal achievement model of evaluation research’ and the concept of ‘real goals’ (p.260) Gibson argued that pragmatic incremental changes in practice were likely missed (p.268). The obvious appears not to be stated: doctors did not change their practice. Unlike those employed at centres established overseas (discussed earlier in this Chapter) the doctors working at Inala CHC chose not to refer clients to their non-medical team members for preventive services. A similar situation appears to have arisen at Ipswich CHC. Raymer (1980) conducted a study to evaluate if a new CHC had increased people’s access to services. This study was conducted as a new social work school was being established. Raymer found local ‘caretakers’, including doctors (24), pharmacists (15) and school guidance counsellors (6), made few referrals to social workers although they referred to nurses. Lack of knowledge and a disinclination to work with social workers or welfare services were found to hinder referrals. Doctors who were interested in counselling their clients were less inclined to refer. Implying that bureaucratic constraints operated, Raymer proposed the CHC advertise, contact other services and professional groups and distribute pamphlets (p.44). She proposed that the image of the centre had to be changed so local providers, familiar with nursing services, were aware of the other services the CHC could offer apart from nursing. The Australian studies discussed thus far suggest that: CHC practitioners worked in different organisational contexts; managers’ and practitioners’ interpretation of the purpose of the CHP policy varied; planning and monitoring at a CHC level were hindered by lack of structure; personal attitudes, professional education and professional experience influenced the practice orientation which evolved amongst practitioners; and some practitioners developed a preventive orientation (ACHA 1986; Boyce 1980; Duckett & Ellen 1980; Gibson 1980, 1981, 1984; Najman et al 1979, 1980, 1983; Raymer 1980; SCHRU 1987, 1988). There are indications that organisational environments played a part in how

43 practitioners worked. Studies concerning community nurses and social workers provide additional insights into the services they provided and sources of intra-team conflict.

Community Nursing and Social Work The CHP policy, which made funding available to employ community nurses, provided the impetus for numerous studies of community nursing from the mid 1970s to the late 1980s (Figure 3.3). By 1973

Figure 3.3. Studies of Community Nursing Conducted Between 1976 and 1991 State Date Author Purpose Included Findings National 1976 Archer Exploratory Survey of 79 RNs in Rivalry hindered access 7 settings. NSW 1976 Katz, Could nurses Interviews with 162 Nurses’ roles were Matthews, provide primary RNs in 3 settings, changing Pepe & care and 224 GPs and 58 White improve MCH&CH doctors. continuity of Observation of 24 care. nurses 1983 Dowling, Nurses’ Unstructured Practice of bush, Rotem & understanding Interviews with 58 maternal and infant and White of PHC nurses working in CHC nurses closely hospital and paralleled PHC community. Victoria 1976 Hurworth Workloads Survey of 50 CHCs, Access, coordination and 18 bush nursing continuity of care and day hospitals hindered by structural problems 1980 Wadsworth How child health Action research Fragmentation and nurses could involving 600 overlap of nursing work together working with services children and families 1984 Round & Role ambiguity Interviews with 65 Managers and doctors Sellick team members at had limited 10 CHcs understanding of nurses’ responsibilities 1989 Temple- Educational Survey 825 RNs in Nurses worked in Smith, needs of non- 11 settings communities out of Johnson & hospital nurses interest or to gain Dunt autonomy 1991 Dunt, The work of Survey of 338 RNs Core and diverse Temple- non-hospital in 11 settings activities occurred within Smith & nurses and between settings Johnson South 1991 Gilson Nurses work in Survey of 78 RNs in Client population affects Australia 1991 multidisciplinary 5 multidiciplinary nurses’ work and teams and self teamwork recorded diaries governments had some idea of the number of registered nurses employed in maternal and child health and bush nursing services but not those working in private and non-government district nursing services

44 (ABS 1974, NSWYB 1975). In America in 1937 Winslow had proposed a ratio of one public health nurse to 2000 people (Winslow 1993). At the time he argued there were serious deficiencies, in ‘quantity and quality, in the nursing service provided to the American people’ (p.58-59). In Australia lack of consensus as to the appropriate responsibilities of community nurses had made it difficult to determine how many were needed. In Victoria Hurworth (1976) conducted a workload study but observed it was unknown how many community nurses were required. It was also unclear, except for maternal and child health, what nurses did, what education they received or required. As Figure 3.3 shows, nine studies were conducted between 1975 and 1991. As this table illustrates the earliest studies were conducted nationally and in NSW, most (5) were conducted in Victoria, the state with most non-government district nursing services, and fewest in South Australia. My interest concerns their findings relating to nurses working at CHCs. Archer (1976), an American scholar, under the auspices of the Royal College of Nursing Australia and assisted by local experts compared nurses' (79) practice across seven settings (5 communicable diseases, 8 mental health, 20 domiciliary, 22 general community, 11 occupational health, 24 maternal and child, and 10 school medical) to find that the clients of nurses were mostly women being assisted with child rearing, chronic health problems, accessing services and understanding medical and nursing instructions or suggestions. Clients (363) expressed feelings of being listened to, having their questions answered, and were generally satisfied with the physical care or support given as it met their needs and situation. Nurses felt hindered by: isolation, travelling, lack of managerial support; lack of acceptance by medical and nursing colleagues; managers’ and doctors’ limited awareness of health promotion; unsupportive local governments; and apathy in communities. Compared with other settings those working at CHCs spent more time with clients (50%) and, like maternal and child health nurses, teaching (p.154). Whether nurses increased access, coordination and continuity of care is unclear as Archer concluded that inter-organisational rivalry had to decline and nurses had to reach a shared understanding of purpose. Archer also proposed establishing generalist pre-service education, comprehensive generalist nursing services and ongoing work based education. Hurworth (1976) studied community and other nurses’ work as part of a Victorian workforce planning study. She included 50 health centres, 18 bush nursing centres and day hospitals and found, like Archer, that nurses' activities varied as did the populations they worked with. Those at health and bush centres worked on-call, outside office hours, and with other professionals. Bush nurses worked with clients who were isolated, transient, mobile, spread over large areas and most of whom had pre-existing health problems. At CHCs nurses worked with stable populations, communities and schools and provided health education and preventive services. Hurworth found structural problems, use of idiosyncratic methods to allocate work, and boundaries between district and CHC nurses hindering people’s access to services, service coordination and continuity of care. She concluded that registered nurses’ responsibilities required clarification and proposed that managers develop job descriptions and establish professional development/ in-service programs for teams.

45 Katz et al (1976) conducted their study in NSW to establish whether community nurses might be used to provide primary care to reduce care costs and improve continuity of care for chronically ill, aged or less affluent populations. The study involved maternal and child health (128) district and domiciliary (25) and bush nurses (9), GPs (224) and Bureau of Maternal and Child Health medical officers (58) and observed 24 nurses in three settings (district, pathology and GP practice) over 80 days. Nurses’ responsibilities and clients’ problems were found to have changed with doctors increasingly referring to nurses. Medical officers with maternal and child health services, unaware that change was occurring, viewed planning, initiating care and providing support and treatment as non-nursing activities (p.49). Nurses were found to provide preventive, treatment, and follow-up services and coordinated services but their responsibilities increased or decreased depending on the presence or absence of other professionals (pp.73-75). Katz et al proposed increasing nurses’ responsibilities by creating three types of nurse: one for GP practices; two to liaise between hospitals and primary care to increase access and coordination; and a third for multiple purposes (p.82). They concluded nurses' responsibilities could include routine time-demanding medical tasks to improve the use of health teams. Nurses' responsibilities were varied and their scope contested. The fragmentation of community nursing services contributed to this problem. Wadsworth (1979) coordinated a study sponsored by the Royal Australian Nursing Federation (RANF) (Victorian Branch), funded by the Felton Bequest, involving an Interim Committee for the Child Health/Care Coordinating Group, representatives of interest groups (community, infant, mental health, midwives, paediatric), and informal groups concerned with child and family nursing. It involved 600 nurses. Infant welfare nurses (327) were over represented (p.9). The purpose of this study was to ‘bring nurses together’ to develop ‘clearer understandings about what the best roles are for nurses within the various streams of nursing’ and how they might work ‘together as a total child nursing system in the community’ (p.80). It found nurses ‘fearful of criticising organisational structures which impinged on nursing practice and clearly affected the quality of nursing care‘ as they considered it disloyal to their employers (p.10). Structural issues were central to problems of fragmentation and overlap arising from 44 streams of nurses, employed by different organisations, working with families and children (p. 14). Some had role statements identifying ‘team work’,’ health education’, ‘family support’, ’liaison’, ‘prevention’; ‘screening’ and ‘total care’ as nursing roles; other did not (p.17). Conflict and role confusion were the norm (p. 28) with infant welfare and CHC nurses most affected. Employers wanted infant welfare nurses to focus on families. CHC administrators and management committees saw CHC nurses' roles as health maintenance and rehabilitation where nurses saw their roles as ‘developmental, community-orientated health promotion and illness prevention’ (p.30). Nurses were frustrated that others defined their roles for them (p.33). Fragmentation and overlap associated with structural problems hindered people’s access to care. Families in crisis or with multiple problems were most vulnerable as it was difficult to identify who to contact leading, at times, to loss of trust in and refusal of services (p.43-46). Time and effort were wasted and inefficient use made of resources. Nurses observed areas with adequate services gained more

46 services due to federal funding2 (p.45). Wadsworth (1980) found poor planning, lack of consultation and ad hoc development along with inadequate understanding of nurses’ roles and services by health professionals compounded these problems (p.53-56). Wadsworth also found that while nurses identified social structural factors as causes of fragmentation and overlap they posed personal solutions such as improving communication and holding face-to-face meetings to resolve them (p.59). Her solution was structural; clarify nurses’ roles; change nursing education (p.62); establish broad focussed regional nursing services (p.63), and facilitate nurses’ involvement in policy development and decision making (p. 65). Policy, she argued, was required to specify the kinds of nurses required and the structural relationships between them; the ratio of specialist and generalist nurses; and coordination of different streams at central and local levels (p.68). Wadsworth proposed generalists focus on age-specific groups with a primary coordination role at a local level (p.69) and that infant welfare and school nursing services be consolidated to achieve a more comprehensive child health service (p.70). For a ‘strong, resilient, enthusiastic profession, nurses need to become more active, organising, arguing, initiating, concerned, aroused, interested, writers-of-punchy reports‘ (p.73). Wadsworth proposed nurses draw on ‘the as-yet-untapped reservoir of support and lobbying power: the consumers (p.73). The findings of this study reveal that poor planning and poor communication, partly due to bureaucrats lacking an understanding of their varied roles and the needs of various population groups, affected the quality of the service nurses provided. Nurses were concerned about the quality of the services they provided but some nurses and service managers did not understand that access, coordination and continuity of care were important for clients. Collaboration, cooperation and preventive care were not high on the agendas of organisations many of which remained unaware of evolving new perspectives. This theme of changing roles was also raised by Dowling, Rotem and White (1983) who studied registered nurses’ understanding of Primary Health Care (PHC) (p.1). Unstructured interviews with nurses, practitioners (26), administrators (13), educators (10), students (9) in hospital and community settings, found a few specialised nurses, most in community settings, familiar with PHC concepts (p.2). Some confused it with primary care or first contact or total patient care while more understood it as a preventive approach (p.3-4). Few understood PHC as an integrative approach to service delivery which involved preventative, maintenance, curative and rehabilitative aspects (p.4) or mentioned community participation (p.5). Community nurses identified self-help, self-determination or self-reliance as important aspects of this approach (p. 5). Nurses familiar with PHC principles claimed the latter were not evident in the NSW health system (p.6). Nursing education limited nurses’ ability to take a preventive approach (p.8). Community nurses identified ‘discontinuity’ of funding and staff as barriers to their engaging in health promotion (p.10). Community nurses’ roles were poorly defined (p.12) and their education and preparation inadequate (p.22). Despite

2 CHP funding was available to non-government organisations in Victoria. No central planning occurred.

47 their not necessarily understanding PHC, bush, maternal and infant, and CHC nurses’ practice was found to more closely parallel PHC principles (p.22). Dowling et al concluded nurses were ready to ‘provide PHC’ and contribute to Health for All (HFA), statements their profession bodies had endorsed, but that their educational preparation for practice had to change (p.23). Studies of community nurses' work indicate that environmental factors, employers' and other professional groups' expectations, the purpose of a service, its geographic location, and client characteristics influenced what nurses did and how they did it (Archer 1976; Hurworth 1976; Dowling et al 1983; Wadsworth 1980). They also suggest that professional groups have little understanding of other groups' responsibilities or their own profession working in different areas (Wadsworth 1980). This has implications for the work of CHC teams. A study conducted by Boyce (1980) illustrates why. Boyce began with a theoretical proposition that role ambiguity existed in CHC teams. She conducted structured interviews with 172 team members at 15 CHCs in Brisbane as a new social work school started clinical placements at CHCs. Boyce illustrates that social workers’ perceptions of their responsibilities differed from those of other disciplines. Non-social workers expected social workers to provide direct services to people in need of social, emotional and financial support, liaise with other agencies, engage in education, advocacy, research and provide preventive services. Coordinating, consultation, and mediation, centre management, assessing clients for domiciliary nursing or working with clients experiencing psychological problems were not viewed as the responsibilities of social workers by non-social workers. Perhaps more importantly, other disciplines viewed traditional social worker responsibilities, client advocacy and ensuring continuity of care, as their responsibility. Boyce concluded ‘role ambiguity’ hindered team work in CHCs and observed that ‘collaboration appears to be an outgrowth of working together rather than a point of departure’ (p.86). Round and Sellick (1984) found managers' and medical team members' understanding of allied health and nurses' responsibilities limited. Having modified the questionnaire developed by Boyce to reflect nurses' responsibilities they interviewed 65 key team-members (16 doctors, 16 social workers, 10 team managers and 23 community nurses) at ten CHCs in Victoria. Nurses and social workers were found to be in greater agreement about nurses' roles than other groups. Doctors saw making independent clinical decisions, encouraging patient self-determination, liaison, working with community groups, coordinating care and referring, as non-nursing work. Managers and doctors considered arranging care for people in need of placement and assessing them for domiciliary care as nursing work. Significant differences were found between nurses’ and doctors’ attitudes to care provision. Nurses valued involving clients in their own care more than doctors, a finding Round and Sellick attributed to nurses liaising with non-medical disciplines and their post basic-education. Managers and doctors considered working with clients more important than research, liaison and working with communities. Only social workers and community nurses considered promoting client self-determination and interpreting the functions of CHCs to communities as important activities. The findings of this study indicate that non-medical professionals’ responsibilities varied and that some doctors and managers remained entrenched in an hierarchical

48 biomedical model of care as other disciplines developed a community focussed teamwork model. Importantly for community nurses their responsibilities remained contested ground. Two other studies require brief mention. Temple-Smith, Johnson and Dunt (1989) and Dunt, Temple- Smith and Johnson (1991) explored the educational needs and work of non-hospital nurses by surveying 825 nurses in 11 practice settings (CHCs, maternal and child health, school medical, hospital-based domiciliary, community based domiciliary, occupational health, medical clinics, public health, psychiatric community, educational institutions and pathology). The first part of this two phase study found most community nurses were women with hospital experience who chose non-institutional work out of interest or to gain autonomy or involvement with patients. They concluded that community nurses in Victoria lacked a strong professional orientation. Dunt et al (1991) compared nurses' (338) characteristics to find that most (70%) community nurses worked in six settings (medical clinics, district visiting, maternal and child health, occupational health, CHCs, hospital-based district nursing services). They had job descriptions or statements of conditions, they could control or reschedule their work, take time-in-lieu, although few received pay for overtime or a formal orientation and none were responsible for coordinating or supervising other professionals. The study found core and diverse activities occurring within and between settings. At CHCs nurses provided health teaching, assessed people’s health status and need for direct care (maintaining activities of living, technical care and counselling) and assisted them maintain safe environments. Nurses with district and visiting services (hospital, community based) assessed, provided direct care and rehabilitation. Only maternal and child and occupational health nurses conducted routine screening. A significant finding of this study was that Victoria had 281 job titles for community nurses suggesting an increase in specialisation and shrinking areas of responsibility. Community nurses' work was diverse, as Gilson (1991) assisted by a project team including Fran Baum, Director of SCHRU, found when studying 78 nurses working in five multidisciplinary teams in metropolitan Adelaide (CHC, women’s health centre, Child Adolescent and Mental Health Services, Southern Domiciliary Care, Southern Assessment Review Team and Allied Services). Using surveys and self-reported daily diaries Gilson found nurses understood and adhered to PHC concepts and principles and spent more time than other discipline groups on preventive activities, preparation and follow-up of clients but less on teamwork, personal and professional development. Differences were found between teams. Women’s health nurses allocated more time to preventive activities than nurses with the Review and Allied Services team who allocated more time to clients and community work. Teamwork was found to be associated with the client population and to occur more often when clients had complex problems requiring treatment. Nurses responded to client needs, worked outside business hours and at times suitable to clients and participated in policy making, advisory groups, and coordinated health promotion and community development activities. Few held management qualifications and those in management positions encountered difficulties. Gilson, who found ‘hints of differences’ in the activities of nurses ‘working in different agencies’, concluded that more research was required.

49 These studies suggest that nurses’ activities vary and are influenced by geographic location, problems of client populations, managers’ expectations, and the presence or absence of other professional groups. Community nurses, including maternal and child health nurses, educated their clients and worked with communities and other organisations and professional groups in ways consistent with the PHC principles. Victoria, more than other states, appears to have more community nurses working with doctors and non- medical managers who were opposed to their working autonomously and with communities. The findings of these studies of community nursing and social workers and evaluations of the CHP policy suggest that community nurses were more orientated towards preventive, team and community work than other professional groups. Nurses also considered promoting client autonomy to be important. The findings of the Australian studies discussed thus far suggest centre managers might have limited nurses’ activities due to a lack of understanding of their roles, and that the CHP policy offered nurses an opportunity to work closely with non-medical disciplines, other organisations, community groups and communities.

Teamwork, Conflict, and Service Development There is a wealth of literature concerned with teamwork. I have limited this review to the works of authors focusing on community care and community mental health centres as this literature provides insights into problems identified by the time researchers began evaluating the Australian CHP policy. Parsloe (1981), who wrote about teamwork in social services, has argued that for effective teamwork to occur team members need to agree on a team’s purpose and members’ responsibilities. The demonstration centre projects established from the 1940s to the 1960s saw teamwork as essential and specified expectations for each professional group (Pearse & Crocker 1943, Silver 1963). Social workers working in social services were also aware of the importance of teamwork (Stevenson 1981; Payne 1982). Tradition and clear procedures aid this process. Difficulties tend to arise when different disciplines become involved in establishing new innovative projects such as community mental health centres. Rubin, Plovnick, and Fry (1975) developed a workbook to assist new mental health teams clarify their purpose, members’ responsibilities and decision-making processes (Rubin, Fry, & Plovnick 1975). Baker-Schulberg also developed a scale to measure commitment to a community ideology (1967). Australian researchers used these works to assess teamwork when evaluating CHCs (eg. SCHRU 1987). Evaluations of the CHP policy suggest CHC practitioners, those to whom responsibility for implementing the CHP policy was delegated, were effectively left to their own devices (ACHA 1986a; Boyce 1980; Bryson et al 1992; Duckett & Ellen 1980; Gibson 1980; Lennie et al 1990; Najman et al 1983; SCHRU 1985, 1987). This, as Furler and Howard (1982) argued, resulted in intra-team conflict arising at centres in Victoria, South Australia and Queensland. Team composition was found to be important with professional hierarchies, more rigid definitions of responsibilities, interdisciplinary rivalry, service segmentation and a decline in client power being associated with the inclusion of doctors. Intra-team conflict directed attention away from the task of clarifying team purpose and establishing the structures and process required to facilitate negotiation within teams.

50 Saltzberg (1981) and Crofts (1986) offer an insiders’ perspective of the experience of working at CHCs in Victoria where conflict arose. They argue team members’ philosophical positions, how they interpreted the purpose of CHCs, varied. According to Saltzberg (1981) problems of conflict between doctors and nurses at a CHC located on a public housing estate brewed over six years. The centre, the ‘brainchild’ of a local GP, was administered by a board and offered primary medical and primary care. Team members became involved in community development projects aimed at redressing social problems, social isolation and fragmentation of services, which brought people together as a means to build trust in a community then ‘wary’ of professionals. Nurses’ and doctors’ views varied. Doctors saw nurses spending too little time on routine clinical work and too much time on preventive services, health education and outreach and community work. Nurses saw doctors running clinics in ways that precluded them from teaching and counselling clients and thus offering the type of primary care appropriate for CHCs. Saltzberg (1981) saw doctors failing to understand that a community development approach meant issues were fuzzy, projects long term, outcomes difficult to define and responsibilities blurred. Structural issues fuelled problems. Doctors, contracted by state governments, were autonomous, they did not have to collaborate or attend meetings. The Board could not ‘force doctors’ to do what CHCs were ‘set up to do’ (p. 23). She concluded that doctors seeking to work at CHCs should understand what they were required to do and consider if they were ‘new’ doctors and willing to account to a community and work with a team, or ‘old’ doctors in ‘a new attire’. Gender and class politics fuelled disagreement. Saltzberg described male doctors as behaving like ‘transplanted hospital consultants’ who believed that they as ‘talented, highly qualified workers should be left in peace to pursue their own interests − but given every help to do so’ (p. 23). She concluded that conflict arose over services and responsibilities but structural problems, lack of leadership, contributed. Crofts (1986), a doctor at Collingwood CHC, had similar concerns as conflict arose between team members, centre board members and hospital executives. For Crofts health centres were ‘a field of frustration, perpetual hope, and occasional creation’ where tensions arose between competing curative- preventive and professional-community orientations as teams tried to answer a question about ‘do we do what they want, or what we know they need?’ Decision-making was: ... complicated because despite the assumption that professionals are conservative, the case is often that what we know they need is often more far-sighted and radical than what they think they need. Or so the argument goes (p.9). The board of management, local Austalian Labor Party politics, and team members’ responses to day-today demands were seen as inhibiting preventive work. Crofts argued he was now unable to ...imagine practice without a pharmacist, physiotherapist, social worker or community nurse in close proximity, who can be a colleague because we are employed in the same way (p.10). Working at a CHC influenced practice. Crofts observed team members, influenced by other members, moving away from ‘individually-orientated, supportive roles to educative preventive roles’ (p.10) and providing antenatal, developmental, parenting education and becoming involved with residents of local public housing estates.

51 Conflict arose between team members, CHCs and hospitals, over ‘rhetoric about curative and preventive orientations’. Workers, orientated to individual therapies by training, are described as castigating themselves for failing to ‘move effectively into the preventive domain’ (p.11). Leadership was affected as discussion ‘degenerated into the kind of political exchange’ that serves ‘sectional interests’ (p.11). Crofts concluded that failure to prevent problems arising within teams meant that the ‘linking of health with dignity, with the power to make decisions about one's own life, control over one's own destiny’ made only the ‘vaguest roads into C.H.C. practice’ (p.11). Participation and collaborative decision-making failed as ‘dominant groups continue to control what is now becoming the empire of community health’ leaving ‘the powerless’, clients and local communities, ‘without power’ (p 11). For Saltzberg (1981) and Crofts (1984) intra-team conflict arose from differing ideological and philosophical positions, inadequate organisational structures and a lack of resources. Practitioners also had difficulty finding and understanding preventive and curative approaches. Jackson, Mitchell and Wright (1989), health education officers at Fitzroy CHC in Victoria, developed a model for practice to integrate both behavioural and environmental strategies to work with a population including a high proportion of immigrants, unemployed persons, income beneficiaries, people living in rented accommodation and some double income families. Their aim was to fill gaps in ‘a fragmented system’ of services (p.188). They conceptualised community development and casework as preventive strategies to help people resolve problems and develop personal skills. Community participation and personal services were viewed as complementary rather than dichotomous strategies. By conceptualising case work as developmental work along a continuum which included community participation they connected personal and community issues. Their model acknowledges that for people to participate effectively they need personal skills and case work is a strategy for achieving this outcome. Their work makes clear that some practitioners developed a preventive teamwork orientation that enabled them to work collaboratively with other disciplines, organisations, populations and communities. Some managers and practitioners retained a bio-medical practice orientation. In 1989 I conducted a small study in the Hunter Region. Semi-structured interviews were conducted with 16 team managers and practitioners employed at CHCs offering school medical, baby health, mental health and home nursing and health education services (Schulz 1988, 1992a). Like Crofts (1984) and Saltzberg (1981) this study identified differences in values, ideologies and professional boundaries. It found teams working in a context of fiscal austerity, funding cuts and administrative change that left managers, mostly allied health professionals and doctors, and practitioners, mainly nurses, feeling powerless. Service development was also limited and nurses' responsibilities were limited, at some CHCs, to home nursing (p.104-105). Conclusions drawn were that CHC teams in NSW had evolved as a support for the acute care system a situation I initially attributed to practitioners providing the types of services they felt comfortable providing. This analysis was revised (Schulz 1992a). I later argued that by the 1980s managers, team leaders and senior nurses influenced practitioner activities, especially those of GCNs.

52 What this study, and others (ACHA 1989c; Gibson 1980; Najman et al 1983; SCHRU 1987), failed to explore was whether managers, team leaders and senior nurses reacted to the expectations of state governments and regional administrators. Like Duckett et al (1980), Crofts (1984, Jackson (1985), and SCHRU (1985, 1987, 1988) I concurred it was appropriate for CHC teams to provide primary care providing they used an educative framework that was sensitive to cultural differences, community needs and a population’s pattern of health service usage. Nurses working with individuals with chronic illnesses should assist them ‘develop skills which will enable them to take responsibility for themselves, and to utilise when required the assistance of health professionals’ (1992b p.255). What I, like others, failed to consider was whether the social and administrative context in which implementation of the CHP policy began had implications for practitioners and administrators. Interactions between practitioners, clients, and communities were viewed as potential opportunities for promoting health. This is the position taken by Caplan (1964), Crofts (1984), Jackson, Mitchell and Wright (1989) and Milio (1981). What this early study demonstrated, however, was the need for a larger study. Studies suggest that community nurses adopted an educative framework using contact with clients as opportunities to teach, and that they were more committed to preventive work than other disciplines and nurses working in hospitals (Archer 1976; Duckett et al 1980; Hurworth 1976; Round & Sellick 1984 Saltzberg 1981; SCHRU 1987). SCHRU (1987, 1988) attributed this development to nurses’ post basic education. Round and Sellick (1984) attributed it to nurses’ exposure to allied health professionals. Duckett et al (1980) found nurses working at baby health centres, having completed post-registration education programs conducted by the Department of Health, took a similar approach. Studies indicate that some CHC practitioners retained a medical approach. This has been attributed to different interpretations of the CHP policy (SCHRU 1988), retention of traditional modes of practice (Gibson 1980) and hierarchical relationships associated with the inclusion of doctors in CHCs (Furler & Howard 1982). More recent evidence suggests team managers were influential. Despite the literature suggesting structural and cultural issues affected practitioners' practice it was 1990 before researchers turned their attention to these matters. Lennie, Copeman and Sangster (1990) explored the effect of integrating doctors into CHC teams (9) in three states. They surveyed managers and held focus groups with doctors (>2), non-medical team members (>4) and board representatives to conclude doctors did not affect the orientation of established CHCs. The nine CHCs were compared on numerous criteria (location, other medical practices, type of medical service provided, team size, community or client orientation, work satisfaction and teamwork, financial form, shared goals /ethos, education/ experience, management and community). This study found the organisational structure of CHCs and their management processes affected the orientation of team members. The teams that developed a community orientation shared two characteristics − formal mechanisms attributing responsibility to individuals and opportunities to develop a community focus because managers did not emphasise teaching or direct care. Effective CHC managers were found to be leaders who established systems and procedures that enabled a team to develop a shared vision, a chosen direction, by:

53 ... understanding community health principles, community needs, the particular competence of each member of staff, the teamwork process and the scope of primary health care (Lennie et al 1990, p.115). Lennie et al concluded primary medical care could be integrated into CHC teams but noted more research was needed to explore relationships between effective management and a shared team ethos to devise ‘measures to strengthen’ this relationship and improve service outcomes (p.115). CHC teams managed by boards were more likely to have a community orientation but this structure did not guarantee this orientation would evolve. Lennie et al's work supports the findings of Saltzberg (1981), Crofts (1984), SCHRU (1987), Round and Sellick (1984), Schulz (1992a,b) and Wellard (1992) discussed earlier. It is clear that CHCs in different states operated under different administrative arrangements from 1973. Those in NSW operated under a regional administrative structure until 1986 at which time Area Health Boards were established. This structural change prompted Bryson, Adamson and Lennie (1992) to examine whether administrative structures affected a CHC team’s ability to respond to community needs and maintain a community orientation. Seventeen CHCs operating under area boards, public service or independent boards were compared. Managers, team and board members were interviewed and the three administrative forms were conceptualised as ideal types along a protection-deregulation continuum. Bryson et al (1992) found the public service structure operating in Queensland protected CHC teams from the demands of other parts of the health system. Autonomous boards, as in South Australia and Victoria, where found to protect teams from demands from a public service and acute health care system thus enabling teams to respond to local needs and involve communities in decision-making. The Area Health Boards operating in NSW were found to create a deregulated environment that placed CHCs in competition with ‘powerful’ hospitals and changed the ability of regions to respond to community needs. The least satisfactory aspect of CHC services, under all administrative forms, was continuity of care which they attributed to a hospital versus CHC attitude. Autonomous boards were considered the most desirable form. A conclusion drawn by this study was that the ‘corporate context’ influenced a CHC team's ability to respond to community needs. A logical extension of this conclusion is that the administrative context in which implementation of the CHP policy commenced in NSW enabled CHC teams to respond to community needs. If this is so it raises questions about the findings and conclusions of earlier studies including the national review cited earlier. The conclusions of these studies, inter alia, indicate that the objectives of the CHP policy were not achieved as a major objective of the CHP, as Najman et al (1981) pointed out, was that health centres develop and provide relevant services to defined communities. Studies reveal that CHC teams and community nurses worked under different administrative and management arrangements, and in different contexts, over time. State and national studies illustrate that CHCs operated in a difficult and changing administrative context during which understanding of prevention changed. These differences need to be explicated. The Queensland state government added federal CHP policy funded practitioners to existing geriatric services (Boyce 1980; Gibson 1980; Raymer 1980). In NSW

54 CHCs were established by a regional administration and maternal and child, community psychiatric and district nursing services were integrated with newly appointed CHP funded practitioners (Duckett et al 1980; H&HSC 1976a; HCNSW 1973). In South Australia and Victoria community groups and doctors sought and obtained CHP funding to establish CHCs as part of a medical practice (ACHA 1986a,b; H&HSC 1976). H&HSC Commissioners expected the organisations implementing the CHP policy to establish structures and procedures which would enable its objectives to be achieved. The findings and conclusions of studies discussed in this review suggest this did not always occur. CHCs in Victoria and South Australia were identified as lacking policies and procedures to facilitate teamwork, goal setting, planning and evaluation into the 1990s (Blacker & McLennan 1987; Round & Sellick 1984; SCHRU 1987; Wellard 1992). As the H&HSC (1973) predicted, lack of policy, procedures, guidelines and clear responsibilities led to conflict over professional responsibilities, values, remuneration, status and employment conditions. Most problems arose in Victoria where managers were mostly from non-professional backgrounds and CHCs operated in isolation from long established district and bush nursing services and some practitioners (GPs) worked on a fee-for-service basis and others on wages. Conflict also arose in Queensland where a central government bureaucracy administered centres and in NSW where this responsibility was taken by regional offices of a Health Commission. Scant attention was paid to the demographic or administrative contexts in which CHC teams worked until the late 1980s. Little mention is made of non-government, not-for-profit, private for-profit or state government organisations that controlled the distribution and type of non-medical health and welfare services offered apart from acute hospitals for decades before 1973. It was 1990 before the administrative and management context of CHCs was found to influence how practitioners practised (Bryson et al 1992). At this time managers' expectations were found to establish the parameters within which CHC practitioners worked. The few studies which focussed on implementation found the political and administrative context in which teams worked imposed constraints on practitioners' activities. One national study addressed these issues. As referred to in the previous Chapter, Milio (1988), an American public health and nursing academic, explored the national context in which the CHP policy was implemented. She interviewed nearly all (150) involved in developing and implementing the CHP policy nationally, visited CHCs (7) in NSW, Victoria and South Australia, met with staff (12), and analysed newspapers (1983b,c, 1984, 1985, 1986a,b,c, 1988). Milio found the views of governments, employees and pressure groups about the purpose of the CHP policy varied. ALP leaders saw CHCs as a means to assist people to cope. State governments and CHC teams saw them as a way to prevent ‘faulty lifestyles’ (by screening, counselling, mass media education). This, she pointed out, ignored the fact that people’s opportunities to use information effectively varied and that some problems were associated with a lack of opportunity and control over their lives. Milio found rare instances of CHC teams trying to promote health by changing people’s options. Milio was critical of the divide between public and community health as she saw the CHP policy as a bridge to link individual and collective perspectives, a means to change a community's circumstances,

55 prevent risks from acute and chronic problems and initiate or support collective action (1983b p.189-190). She argued for the establishment of a broad-based national community health organisation to conduct bi- annual conferences, publish proceedings, reports and discussion papers, critiques of government policy; research and establish a data base to ‘create a balancing of the influence of organised medicine on the mass media and in policy making areas’ (1983b p.191). This proposal led to the Australian Community Health Association being funded and founded in 1984. Milio found that economic and political support for the CHP policy had fluctuated over time. Federal funding had declined under the Fraser Liberal and Country Party Coalition. During 1977-1978 she estimated funding declined 8% in real terms and that by 1980-1981 it had declined to 45% below the 1976-1977 level (1984 p.25). She attributed an increase in 1977 to a pre-budget submission by the Australian Council of Community Services and Doctors Reform Society (DRS), the ‘save the community health campaign’ in NSW and opinion polls demonstrating people wanted more social welfare and health programs. Interest in and influence on the CHP policy fluctuated. The Australian Hospitals Association (AHA) viewed this policy as a tertiary prevention program rather than a strategy to facilitate organisational or structural change. The AHA actively fostered hospital interest in this policy and offered community health outreach awards by the 1980s. The AMA and Doctors Reform Society interest in and influence on the CHP policy declined as they became preoccupied with Medicare and an escalating doctors’ dispute (1986a). As state government bureaucracies’ fiscal responsibility for hospitals increased so did their influence and that of the H&HSC declined. Decline in federal funding offered state governments three options − ending the CHP, re-allocating monies from other programs or funding their CHP policy projects from new sources. Milio argues pragmatic governments like that in NSW rationalised services, shifted costs to the Commonwealth and used CHP policy funds to accelerate deinstitutionalisation (1986a, p.53). States were able to shift their priorities when hospital and CHP policy funding were incorporated without strings or monitoring (Milio 1986b p.53). According to Milio the media generated little public debate during the 1970s and 1980s as they consulted officials and professionals rather than those community and/or consumer groups who held a social view of health (1986b). During 1984/1985, following the election of a federal ALP government, CHP funding was increased as part of a ‘Rebuilding the Community Health Program’ and Health for All Strategy. The Minister for Health, Neil Blewett, funded the Australian Community Health Association to establish a national Secretariat ($107,524), conduct a comparative national study ($68,290) and a national conference ($10,000). Milio argued state governments shaped federal policy: their powers in relation to federal concerns, ‘exercised, implied or latent, lay in the support or damage it could do the policy makers' interests’ (1986b p.57). Public, policy makers’, and media priorities changed over time as federal and state governments responded to: ... the reality of changing conditions and of the perceptions of those changes mainly by groups who are organized to influence policy makers' views of "reality". The direction, humaneness, and healthfulness

56 of societal changes to the extent that they can be guided depend on whether new and old things are seen by policy makers in new or old ways (1988 p.3). Milio concluded that users of CHC services found them effective and rated them highly but failed to support them. She suggested a national policy would be …..most likely to develop with firm national leadership and support that is both prodded and supported in turn by organised health advocates and an informed press and public’ (1988 p.297). So how were the states affected? The problems besetting NSW by 1981 can be discerned from the NSW Community Health Association’s Inaugural Statement and Information Kit endorsed by an interim committee three months prior to the official formation of this association. It reveals that fiscal and structural constraints hindered growth of CHP projects from 1973 (NSWCHA 1981). Furler and Howard (1982) described this document as a manifesto whose purpose was to foster debate amongst ‘Association members and others about the nature and priorities and necessary improvements in community health’ (NSWCHA 1981 p.1). Based on official statistics the authors, all insiders, expose the strategies used by the Public Service Board and Treasury to limit CHP policy project growth. From 1974 to 1976 this was achieved by imposing staff ceilings to limit CHP employee numbers (to 1,927). In 1977 zero growth was achieved by channelling CHP policy funds via psychiatric and public hospitals. From 1978 to 1980 attempts were made to retrench 400 employees. March 1979 to March 1980 saw 70 positions lost, a decline from 2,337 to 2,267 staff. These cuts were partly in response to federal funding cuts. Employees of CHCs took action. In September 1978 and between September 1979 and July 1980, following the fourth federal cut to the CHP policy funding in six years, they orchestrated a public campaign to ‘save community health’ (p.12). A Community Health Association was formed in 1981, and this statement became part of this campaign. CHC teams are described as linking physical, medical and environmental levels of care for those populations the NSW Health Commission saw as being in need of services: mothers and babies, aged, handicapped and disabled persons, ethnic minorities, women, aborigines, poor, rural dwellers and the ‘worried well’ (p.22-34). It also reveals population to staff ratios below Commission recommendations for allied health, ethnic health workers, health education officers and community nurses, which, it argued, constrained service development. The authors argued CHC teams contributed to primary prevention by using health education strategies and running groups for ‘the worried well’, they made their greatest contribution to secondary prevention (p.39). This Statement argues for using broad social and economic indicators standardised for age, sex, size, and death rates, good predictors of differences in death and illness rates, to estimate staff needs. They describe hospital admission rates as invalid measures of sickness, ill-health and need, and note hospital and private medical services are inaccessible or inappropriate for some populations. The low penetration rates (2.5%) of some CHC teams are compared with hospitals (7-10%), but they note client registrations slowed from 1978 to 1980 when positions were lost or frozen. Lack of community awareness of CHC services is attributed to the small (under $10,000) advertising budget in 1977/1978. An argument is offered for CHP policy expenditure increasing from 4% to 15% of total hospital expenditure by redirecting savings achieved from rationalising hospital expenditure.

57 Support for doctors working at CHCs is evident, however hospital management of CHCs is dismissed as the ... issues are too complex and under-explored, and the current balance of power too loaded in favour of large-scale hospital institutions, for one monolithic structure to be imposed. In the short-to-medium term it favours a pluralist approach, with several pilot models of co-ordination at the State, regional and local level being developed and monitored. Underlying the objective in all models of improved coordination must be sensitivity to the distinctive philosophy and method of operation of community health services and a willingness to preserve these (p.69). This Statement, which established the NSW CHA as a lobby group, illustrates that the NSW state government, via Treasury and the Public Service Board, had limited growth and that there were tensions between hospitals and CHC teams. The CHA viewed the CHP policy as a means to develop a more balanced health system. It provides an analysis of the state context, as was its intent. It offers no insights into how regions and individual CHC teams experienced or responded to cuts in this state context or how the political and fiscal problems raised affected them. Australian studies focussed on practitioners without considering the context in which they worked or the effect on practitioners. Overseas studies focused on CHCs and outcomes for clients or constraints and opportunities encountered by those establishing CHCs. These studies reveal that clients benefited from CHCs and that opposition to CHCs and fluctuating fiscal and political support hindered development. Studies of the Australian CHP made little if any reference to contexts overseas.

Gaps in the Australian CHP Policy Literature This literature review has illustrated that the largest and most influential Australian studies were conducted to measure if CHC teams had achieved the objectives of the CHP (ACHA 1986; Duckett & Ellen 1980; Gibson 1980; Najman et al 1983; SCHRU 1986, 1987). Community nurses were studied to establish what they did, whether they could provide other services, and their level of and/or need for further education. Collectively these studies reveal little about the context in which the CHP policy was implemented. They tell us little about the processes practitioners and administrators used to establish CHC services locally. Nor do they inform us about whether they had support or were faced with structural or political opposition at a local level. They do not inform us of the types of services practitioners established or the needs of the populations with whom they worked or how working at a CHC influenced their practice orientation. It remains unclear if practitioners provided services they felt comfortable providing (Schulz, 1988, 1992a, 1992b) or services in response to the expressed or identified needs of communities and population groups (Crofts 1984; NSWCHA 1981; SCHRU 1987). Milio argues implementation may be different in every community: All parts of the community health service mosaic do not necessarily fit in all communities. What is needed for every community is enough of the right "pieces" to effect a picture of community health relevant to its circumstances as judged by the informed participation of its members and indices of health (1988 p.3).

58 The current literature reveals that CHC teams operated in different geographic, cultural and administrative contexts. Studies of community nurses’ work suggest environments influenced how they practised (Archer 1976, Hurworth 1976, Katz et al 1976, Temple-Smith et al 1989, Dunt et al 1991). Initially more CHC team members were nurses yet nurses receive little specific mention in the Australian CHP literature. When nurses are mentioned researchers note their impact on population groups, the aged, and their approach to practice, preventive and collaborative. Nurses reduced or slowed hospital admission rates for frail elderly populations (Najman et al 1983). They remained more orientated towards preventive practice and teamwork (Duckett et al 1980; SCHRU 1987, 1988; Round & Sellick 1984). The latter led to conflict between nurses, managers, and doctors at some centres as the nursing literature illustrates (Archer 1976; Round & Sellick 1984; Saltzberg 1981). As Milio pointed out little is known about CHC team activities (1988). Furthermore, little is known about the NSW context where regional administrators and practitioners implemented the CHP and state governments monitored this process. It remains unclear if administrators and practitioners worked with other organisations and communities, and if so how. The other gap concerns the intentions of administrators and practitioners. Fiscal constraints are known to have affected the CHP nationally and at state level (NSWCHA 1981; Milio 1988) yet the impact on regions and specific teams is unknown. In the absence of an understanding of the regional, local, political and administrative context in which administrators and practitioners implemented the CHP, the conclusion that CHC teams failed to achieve the objectives of the CHP has to be questioned, at least for NSW. Studies of the CHP and community nurses were conducted to answer questions of concern to federal and state governments (ACHA 1986; Duckett et al 1980; Gibson 1980; Hurworth 1976; Najman et al 1983; SCHRU 1987) and nursing organisations (Archer 1976; Wadsworth 1980). They wanted to establish if practitioners had achieved the goals or objectives of the CHP policy. The 1986 Review of the CHP, for instance, was undertaken to: identify progress and shortcomings of the CHP policy and services; to assess the relationship between policy and practice; describe distinctive community health goals and strategies; identify components of CHP yet to be attained and obstacles to implementation; and propose strategies to overcome the obstacles identified (ACHA 1986, p.3). This review found deficiencies in administration, evaluation, monitoring, service content, organization and policy and recommended continued involvement by the Commonwealth and increasing funding to resolve problems. Other studies examined the activities and orientations of teams and practitioners; few explored state policies and or change over time (ACHA 1986; NCWCHA 1981). Studies of community nursing were more exploratory as they were conducted to ascertain what community nurses did, and what their responsibilities were, in different settings (Archer 1976; Hurworth 1976; Dowling et al 1983; Dunt et al 1991; Katz et al 1976; Round et al 1984; Temple-Smith et al 1989; Wadsworth 1980).

59 The Orientation of Practitioners by the Late 1980s By the mid 1980s there was less diversity apparent amongst CHP projects (CDH 1979c) and greater similarity in services and approach amongst CHC teams (ACHA 1989c). Nurses at CHCs worked differently to those employed by other services, engaging in different activities, developing a different orientation and working with different populations (Archer 1976; Dunt et al 1991; Gilson et al 1991; Hurworth 1980; Katz et al 1976; Round et al 1984; Temple-Smith et al 1989; Wadsworth 1980). So although the CHP was implemented in different states under different organisational arrangements, by the 1980s CHC, and within them community nurses, were working in ways that were more similar than different (ACHA 1989c; H&HSC 1976; Wellard 1992; Bryson et al 1992; Lennie et al 1990; SCHRU 1987). The orientation and activities of different discipline groups varied (Duckett et al 1980; Gibson 1980; Lennie et al 1990; SCHRU 1987). Nurses employed by different services practised differently (Dunt et al 1991; Gilson et al 1991; Hurworth 1980; Johnson et al 1987; Katz et al 1976; Round et al 1984; Temple-Smith et al 1989). These studies fail to explore the context in which practitioners and administrators worked over time. Analysis of contemporary Australian CHP literature reveals that few longitudinal (Najman et al 1979, 1983), historical (Milio 1988a) or retrospective (Morey et al 1980) studies were conducted. Concern with practitioners’ activities led earlier researchers to succumb to what Dunkerly (1988 p.83) describes as the ‘temptation’ of ‘micro analysis’, they focussed on ‘the present without reference to the past’ yet history is significant. Federal support for a CHP policy fluctuated over time, priorities changed in response to influences exerted by stakeholders, professional and consumer groups and state governments (Milio 1983b, 1984a, 1988a). Some state governments reacted to reductions in federal funding by reducing CHP staff numbers (NSWCHA 1981). In NSW expectations of GPs and GCNs changed over time (Dowling et al 1983; Gilson et al 1991; H&HSC 1976a; Katz et al 1976; Morey et al 1980; SCHRU 1987, 1988; CDH 1979c). District nurses responsibilities were affected by the implementation of the CHP and introduction of GCNs (Archer 1976; Dowling et al 1983; Hurworth 1976). CHCs encountered difficulties planning, setting goals and evaluating partly because they lacked infrastructure and also because team leaders' responsibilities were often unclear (Blacker et al 1983; Wellard 1992). Various disciplines had different understandings of the CHP policy, its purpose and their responsibilities (Hurworth 1976; Blacker et al 1983; Milio 1988a; SCHRU 1987; Wellard 1992). Community nurses' orientation differed, being more preventative than other disciplines (Duckett et al 1980; Gilson et al 1991; SCHRU 1987), a situation some attributed to their greater post basic education (SCHRU 1987). In NSW generalist and maternal and child health nurses had limited understanding of primary health care but their practice reflected these concepts (Dowling et al 1983; Katz et al 1976). They took an educative, preventive approach to their work with clients and involved clients in their own care. By 1989, little was known of the day-to-day work of CHP practitioners and administrators, the processes used to set goals, plan, make decisions and resolve conflict, their responses to funding and policy changes, or how they established services, negotiated and communicated with state governments,

60 other organisations, communities or clients. There was agreement that practitioners spent more time working with people with existing illnesses rather than preventing illness (ACHA 1989a; Duckett et al 1983; Gibson 1980). Their major contribution was therefore to secondary rather than primary prevention (NSWCHA 1981). Yet the actions, intentions and motivation of practitioners and administrators are incomprehensible unless the context in which they worked is understood. Overseas studies, even those conducted using experimental designs (Beloff et al 1972; Pearse & Crocker 1943; Silver 1963), illustrate that researchers collected, analysed and reported their findings using techniques which enabled them to explore and explain the context in which projects operated and outcomes for clients and staff (Church 1993; Hall et al 1975; Lomas 1985; Milio 1970).

In Summary The national CHP policy was implemented to increase the Australian population’s access to a broader range of primary care services, increase coordination between health and welfare services, promote health and reduce use of inpatient hospital services. This review of the salient overseas and Australian literature demonstrates that a gap exists in the community health literature regarding the socio-economic, geographic, political, historical and organisational context in which the CHP was implemented, the service content offered to a geographically defined population, the relevance of services in relation to existing services and identified and expressed community needs, and the approach taken by administrators and practitioners, together with the processes they used to establish and provide services, how they worked with other organisations and professional groups, communities and clients over time. It further demonstrates that the researchers who evaluated the CHP and the work of community health practitioners during the early 1970s, mostly funded by the federal government to answer questions of immediate importance, had to rely on inadequate tools. Over time the focus of researchers changed as did their theoretical perspective. Between 1973 and the mid 1980s theoretical understandings of health, determinants of health, and difficulties associated with policy implementation have burgeoned. The gaps in understanding as demonstrated in the literature provided the impetus for this study.

61 CHAPTER 4 THE METHOD OF INQUIRY The qualitative researcher is not an objective, authoritative, politically neutral observer standing outside and above the text ... The qualitative researcher is ‘historically positioned and locally situated … (Bruner, 1993, p1).

Introduction The Australian CHP policy was a significant policy that, like Medibank, has had a major impact on how the Australian health care system has evolved since 1973. As I demonstrated in Chapter 3, limited attention has been paid to exploring if and how political and/or fiscal issues influenced how this policy was implemented. Most studies have tended to evaluate whether practitioners were achieving the goals of this policy at the level of individual CHCs. Generally they found that policy goals were not being met. It is because these studies focussed on program outcomes rather than process that so little is known about the historical, social, political and organisational context in which the CHP policy was implemented at a state or regional level. Little is known about the daily reality of practitioners, what they did, what their employers expected of them, or the needs of the communities in which they worked. This is the result of their activities being evaluated against goal statements conceptualised as ideal types. Importantly, most practitioners were nurses yet their involvement has been submerged in a literature focusing on ‘community health workers’ rather than specific discipline groups. So far studies of the CHP policy and CHCs do little to help us understand what CHC practitioners did, how they did it and under what circumstances.

Purpose of This Study This study seeks to make a contribution to filling this gap in understanding, by exploring how CHP policy was implemented and its historical, cultural, social, economic and organisational context. The overarching question this study sought to answer was: How was the community health program (CHP) policy implemented, in what context did this event occur, what processes were used and why, and how did generalist community nurses participate? This question evolved as part of the research process as I reviewed the literature and was refined during the early phase of data collection fuelled by questions concerning context, process and outcomes. In seeking to understand how Australia’s CHP policy was implemented, my intent differed from previous studies, discussed in Chapter 3, most of which were conducted to evaluate if CHP policy goals had been achieved. The ‘goals’ against which researchers measured behaviour were often developed by the researchers themselves, sometimes in conjunction with state and federal bureaucrats whose views concerning the purpose of the policy varied as Milio (1984, 1986a) has shown. The conventional scientific paradigm used led researchers to take a ‘top-down’ approach using study designs that emphasised measurement of behaviour and goal achievement (Guba & Lincoln 1994 p. 30-37; Swanson & Chapman 1994 pp.66-68). Many were atheoretical in the sense that few made any attempt to link their findings to

62 contemporary social science theories or models. There was one exception. Najman et al (1979, 1981) linked the findings of their study to literature concerning socio-economic status, health status and a population’s use of preventive health services. Most of the studies conducted between the 1970s and early 1990s made use of a quantitative research approach. The use of structured designs and predetermined frameworks in this manner (ACHA 1986a; Gibson 1980, 1981, 1984; Najman et al 1981,1983) tended to direct attention towards predetermined foci, such as goal achievement and outcomes, and away from what was actually happening.

The Research Approach My purpose was not to evaluate if the goals of this program had been achieved but to understand what those involved had done and why. I was concerned with process, action and intent. After reviewing the approaches, study designs, data sources and methods used by earlier studies, I selected a qualitative case study as my preferred research approach, using naturalistic methods to collect and analyse the data. This, in my view, was the most appropriate way to answer my research question. I wanted to avoid the situation described by Furler (1979) where earlier Australian researchers were required to dismantle 'a complex social phenomenon ... an innovative programme' to ‘reframe it’ for investigation to such an extent that reconstructing the ‘whole’ became impossible. This research approach would enable me to understand a past event within the political and pragmatic context in which it occurred, and to report my findings from an holistic perspective. Epistemologically this study was firmly grounded in a critical, interpretive and constructive approach rather than a positivistic one since it was seeking to understand a course of action over time and the motivation and intent of participants during this period. The stance adopted was chosen as it was grounded in the view that knowledge of reality is socially constructed and that the purpose of research of this nature is to create interpretive understanding of the phenomena of interest.

A Qualitative Case Study Qualitative studies, historical studies and case studies represent overlapping research standpoints (Morse, 1994; Morse & Field 1995; Ragin, 1987; Stake 1995, 2000; Yin 1989,1994). Case studies focus on real, bounded, usually complex events (Stake 1995). I chose to study a particular phenomenon (a study of a case), to explore what happened over time and within a context (from a historical perspective), using data collection techniques selected to capture the information I was seeking (primarily qualitative techniques). My purpose was to understand all aspects in which the CHP policy was implemented, from the perspectives of all involved. As is more common in case study research, the approach I wanted to use would be flexible, the design would not be predetermined but rather evolving as further information and understanding would be sought to better address the research question posed.

63 Case studies by other researchers have been used to explore, describe or explain a phenomenon or event, falsify or develop theories and/or to test propositions or hypotheses derived from earlier studies against new data (Diesing 1970; Dunkerley 1988; Haralambos & Holborn 1991; Stake 1995, 2000; Yin 1994). Studies concerning ‘what’ questions tend to be exploratory, while those addressing ‘how’ and ‘why’ questions will more likely to lead to explanations that identify operational links traceable over time (Yin 1994 p.6). A single study can serve one or more purposes. The flexibility of the qualitative case study approach made it ideal for studying implementation as a study design can be deliberately changed during the research process without hindering the integrity of the study (Diesing 1970; Dunkerley 1988; Haralambos & Holborn 1991; Ragin & Becker, 1992; Stake 1995, 2003; Yin 1994). Two studies involving the CHP policy and CHCs have taken this approach, as reviewed in Chapter 3. Milio (1988) used this approach to explore how the CHP policy was implemented nationally. Gibson (1980) conducted a case study as part of a large quasi-experimental study. Overseas studies of CHCs have tended to favour a qualitative approach (Alford 1975; Church 1993; Ginzberg 1971; Hall et al 1975; Lomas 1985; Milio 1970; Pearse & Crocker 1943; Silver 1963).

Strengths of Case Studies One of the strengths of qualitative case studies is that they facilitate understanding of an event and, written as a narrative, uncover new insights. Analytical critique enables a study’s findings to be linked to an existing body of literature or to particular theories or explanatory models (Stake 1995, 2000; Yin 1993, 1994). Comprehensive reports can offer opportunities for ‘propositional’ or ‘experiential’ learning (Stake 2000 p. 242). A detailed study report enables readers to decide if the case is similar to their own and what learnings they can take from it (Diesing 1972). Rigour and trustworthiness can be enhanced by writing detailed reports which include thick description1 and present multiple perspectives (Denzin & Lincoln 2000; McWilliam 1996; McWilliam, Brown, Carmichael & Lehman, 1994; Silverman 1985, 1989, 2000; Stake 1995; Yin 1994). Detailed studies are archivally useful as they allow a study’s findings and conclusions to be reconsidered at a later date. Another strength of a case study approach for this research is that it could facilitate exploration of context and enables important circumstances and ‘episodes of nuance’ or ‘sequentiality of happenings’ to be identified and made explicit (Stake 1995, xii). Exploring the actions, motives and intentions of those involved enables them to be identified and explained (Von Wright cited in Stake 1995 p.37). A case study approach enables the complexity and particularity of the chosen case to be detailed, a valuable aspect for research seeking to explain how a policy was implemented by participants over time (Diesing 1972; Ragin & Becker, 1992; Stake 1995).

1 Thick description provides detailed, indepth, description of an event, activity or behaviour. By providing a background, a context, an interpretation of relationships, readers can follow a researchers reasoning and draw their own conclusion (q.v.. Denzin & Lincoln 2004; Geertz 1973; Morese & Field 1995; Muecke 1994). 64 The Study Design and Research Questions This study sought to answer ‘what’, ‘how’ and ‘why’ questions about a relatively contemporary event (Compact Oxford Dictionary 2002 p.377; Yin 1994 p.139). Consistent with the qualitative case study approach selected, the design of this study evolved and was influenced by the work of various case study researchers (Diesing 1970; Hakim 1987; Stake 1995, 2000; Yin 1993, 1994). The decision to conduct a case study was not a methodological choice but rather, as Stake (1994) has proposed, ‘a choice of an object to be studied’ to best address the research question posed (p.236). In this instance, purpose determined form. In Stake’s terminology this study was an intrinsic study since it was conducted because of my interest in this unique event (Stake 1995, 2000). My purpose was to capture the particularity, and complexity of this 'case' and the context in which it occurred, in order to make it understandable in its own right. Holistic studies need the imposition of boundaries broad enough to enable all important interrelationships between the case and its historical context to be studied comprehensively while also providing completeness of detail (Diesing 1972 p.277). I needed, as Hakim (1987) has argued, a design that would enable me to provide ‘a rounded picture of a situation or event from the perspectives of all persons involved’ from data collected ‘using a variety of methods’ (p.9). I also needed boundaries that would enable me to explore the ‘historical background and wider contemporary context of the main event’ in order to gain a full understanding of the case and its uniqueness (Diesing 1970 p.277). Uniqueness, as Stake (1994) amongst others has argued, can be ‘pervasive’ and include, as it did for this study, the nature of the case, its historical background, its physical setting, its context, its relationship with other cases and the informants involved with it (p.238). The study had to be designed to maximise opportunities to explore the particular and access multiple perspectives. Taking Stake’s (1994) suggestion I decided to view ‘the case’ as a complex entity consisting of a ‘concatenation’ of domains from which I could sample (Stake 1994). That is, I identified foci for data collection and analysis. The reason for this is explained by Yin (1994) who takes a more structured approach to case study design than Stake or Diesing. Yin argues that in most studies it is possible to identify what he refers to as ‘logical’ units of analysis embedded in the case. Identifying ‘units’ or ‘domains’ serves to focus data collection and analysis. This is not, however, the same as identifying variables. The boundaries imposed on this study, including a time frame from 1974 to 1989, evolved like the ‘case’ as part of the research process as the literature was reviewed, terms defined, and as domains/units were identified to focus data collection and analysis. The major question this study sought to answer, which evolved as part of the research process, and stated at the beginning of this Chapter, was How was the community health program (CHP) policy implemented, in what context did this event occur, what processes were used and why, and how did generalist community nurses participate?

Before this overall question was formed, twenty-three questions had emerged from my early review of the Australian CHP policy literature, in particular from the studies discussed in Chapter 3, and early data

65 collection phase during which policy documents were being read, regarding context, process and outcomes. The following became sub-questions for specific investigation:

Context, national, state, regional, administrative and professional • What was the social, political and economic, environmental and health service context in which the CHP was implemented? • What influenced practitioners and administrators to take a particular approach to implementing the CHP? • Were the constraints experienced by administrators and practitioners peculiar to the specific region studied? • Did different teams, different professional groups, experience different constraints? • Why did community nurses like working outside of hospitals?

Processes, regional, team, administrative, coordination, practice • How did regional administrators implement the CHP in a region and influence service development by generalist teams? • How did community nurses and individual practitioners, in particular community health nurses plan, develop and provide services for clients, population groups and communities? • Were the services CHC teams provided the same as those provided by hospital outreach programs? • Did CHC teams and practitioners from different backgrounds take a similar approach to service development and provision? • Did CHC teams and practitioners have opportunities to develop a community orientation? • Did practitioners from different discipline backgrounds work together? • Did CHC practitioners work with practitioners from other services?

Outcomes, for populations, local communities, local health services and practitioners • What services did generalist CHC teams provide individuals, groups, and communities? • Did CHC teams offer similar service content? • Were the services CHC teams and practitioners provided relevant to communities and populations? • Did practitioners develop a preventive approach? • Were the services provided by CHC teams consistent with the original intent of the CHP? • Was the CHP policy implemented in a manner consistent with the intent of its designers? • Were traditional community-based non-medical health services, maternal and child health and district nursing services, integrated with CHP projects or did they continue to operate separately? • Did collegial relationships evolve between CHC practitioners, general practitioners (GPs), non- government district nursing services, and hospitals? • Did regional administrators and CHC practitioners achieve the objectives intended by the architects of the CHP? • Did specific contextual political, administrative and professional impediments hinder what was achieved in the local region? • Did the services CHC practitioners provide change over time?

Definition of Terms and Data Sources The terms used in any study have to be defined so their meaning is understood. The term event is used to refer to something that happened, an incident, an occurrence of something significant (Compact Oxford Dictionary , p.377; Yin 1994, p.139). In this case the term implementation is used to refer to process and action and concerns the means used by participants to translate policy into action (Pressman & Wildavsky

66 1973). As a term, context is only meaningful historically in that it provides ‘a background’ against which participants' actions can be ‘contrasted and paired’ in the ‘foreground’ (Scharfstein 1989 p.1). For this study ‘context’ refers to a composite of historical circumstances, policy directions, place, locality, social milieu and ambience and includes:

• National and state health policies and health care systems • A population's socioeconomic, cultural and political circumstances, demography, morbidity and mortality rates, access to, and patterns of use of, established health services; • Administrative structures and the processes used at a state, regional and team level to implement the CHP policy; • The professional backgrounds, experiences and responsibilities of administrators, managers and practitioners and their understanding of its purpose; • Relationships between CHP administrators, CHC practitioners, CHC managers, and local organisations.

From these definitions of implementation and context, and the questions that emerged from the early phase of an ongoing literature review and analysis of policy documents I was able to identify six domains/units within the ‘case’ on which to focus data collection and analysis. These were:

• National and state health policies • A defined geographic region, population, and its historical circumstances • CHCs, location, services provided, demography of client and health needs • CHC teams, their composition, culture, administrative processes and resources • CHC practitioners, qualifications, services provided and their approach • Regional administrators, their backgrounds and their approach to implementation

Selecting the State and the Region In designing the study, decisions had to be made about what to include and exclude. Since I designed the study as a qualitative case study, purposeful selection rather than representative sampling was appropriate. The state, region, CHCs, teams, practitioners and administrators were selected for theoretical and pragmatic reasons. NSW was selected as governments here had established more CHCs under the auspices of the Australian CHP policy than any other state through a newly established Health Commission and regional administrative structure. Significant differences between health care systems in this and other states were also influential. In NSW domiciliary, maternal and infant, and community mental health nursing were mostly located in the public rather than non-government sector. By the 1980s, studies of CHP policy and CHCs had mostly been conducted in CHCs established as non-government organisations outside of NSW. The size and diversity of the state of NSW necessitated that I select a smaller geographic area to conduct a detailed study taking account of contextual issues. The Hunter Region was selected for a variety of reasons. First, it was one of the largest and earliest health regions established in NSW. Non-

67 metropolitan, urban and rural areas lay within its boundaries. Metropolitan CHCs had dominated earlier studies. Second, none of the CHCs in this region had been included in the study conducted by the ACHA in 1986. Some had been included in a small study conducted by Belcher (1990) and some practitioners had been included in another, similarly small study which I had conducted (Schulz 1988). Third, implementation of this policy began as the University of Newcastle gained permission to establish a new medical school. The new medical program attracted medical academics and medical specialists to the Hunter Region from metropolitan areas and focused attention on the state of the regions’ health services. Finally, pragmatically, the region was geographically and professionally accessible to me.

Selecting Community Health Centres, Practitioners and Teams As case studies require intensive data collection they are time consuming and often costly to conduct (Deising 1972; Dunkerley 1988; Haralambos & Holborn 1991; Stake 1995; Yin 1994). I limited this study for theoretical and pragmatic reasons. Four CHCs were purposefully selected for data collection. Earlier studies included CHCs in different states, operating under different management structures, some uni- and some multi-disciplinary, and mostly located in metropolitan areas. To reflect the regional context, the CHCs I selected, were Maitland (Lower Hunter), Wallsend (Newcastle West), Toronto (Westlakes) and Windale (Eastlakes). Two were located in mixed urban/rural areas and two others in urban areas. By 1989 all were operating as main CHCs although two had begun as sub-centres. All had been administered by the Regional Office until 1986 and thereafter by newly established Area Health Boards. They had a geographically defined catchment area and a multidisciplinary practitioner mix. Three had begun with a medical centre manager. Differences between these CHCs, selected to reflect the mixed urban/rural regional context, were limited to location, catchment area size, and demography of the populations served. Thus, unlike earlier studies, the CHCs included in this study had more similarities than differences. For pragmatic reasons I excluded CHCs located more than an hour’s drive from Newcastle City as I knew from local knowledge that these centres had oscillated in and out of the Hunter Health Region for a decade. Further, being part of the NSW Public Service, each was likely to hold a similar array of documents. Case studies are also bounded by time. I elected to limit this study to the period starting February 1974, a year before Regional Office administrators began implementing the CHP policy, in the expectation that preparation for policy implementation would have begun prior to CHCs being established. December 1989 was selected as the end point because that was when the Area Health Board announced it would dismantle generalist CHC teams in the Local Government Areas (LGAs) of Greater Newcastle, Newcastle and Lake Macquarie to establish specialist teams including a primary care nursing team. Further, an earthquake in December 1989 caused widespread damage to local hospitals forcing bed closures and the early commissioning of a new regional general hospital.

68 Selecting Practitioners and Administrators As the purpose of this study was to provide a multi-faceted account of the event of interest and the context in which it occurred I needed to include participants in this event as primary sources. Those selected for interview had to reflect the regional context, the multidisciplinary nature of CHC teams and the medical/non-medical mix of regional administrators. Five criteria were identified for selecting interviewees:

• Participation in implementation of the CHP policy between 1974 and 1989 • Current or previous involvement in a CHC • Likelihood of reflecting the composition of generalist teams • Experience in hospital outreach and/or one or more CHC teams • Administrators having a range of medical and non-medical backgrounds.

My Stance as Researcher As the sole researcher in this study, I not only determined the research design and collected the data, I also used my personal experience and my own perceptions and assumptions to guide the study’s progress. Interpretation of the data was through my eyes and I determined the meanings ensuing. From this researcher perspective I was taking an outsider viewpoint, looking in. However, I was deeply involved in the implementation of the CHP policy in the region I chose to study and thus, in a sense, was at the same time an insider (Minichiello et al 1990, p.216). I had lived and worked at hospitals, CHCs and educational facilities in this region for over two decades. I had taught nursing at the Regional School of Nursing and been a foundation member of the Department and then Faculty of Nursing at the University of Newcastle. From the mid 1980s I had sat on selection committees for various CHC teams and assisted community nurses to develop criteria for newly created positions of clinical nurse specialist and clinical nurse consultant. In the early 1990s I had held the positions of Clinical Director and Assistant Dean. I had been responsible for organising and assessing clinical placements for all nursing students and had participated in writing nursing curricula. As an educator of nurses, a frequent visitor to health services across the region, I was an insider in that I was familiar with the culture of health services in this region and accepted by local nurses and regional administrators. This was a bonus in a region where outsiders are often viewed with suspicion. However, I was also in a situation straddling an insider/outsider role, as my position placed me apart from the politics of the health care system. As a teacher, at times employer, of many nurses in the region I had listened to their concerns, shared confidences, benefited from their input into course development and acted as a referee on numerous occasions. As chair of the Hunter Branch of the NSW Community Health Association, practitioners knew me as a supporter of the CHP policy, CHCs, multidisciplinary teams and generalist nurses and a critic of unidisciplinary services. My position was thus unique as it provided me with insights into the health care system and ability to gain information and assistance as needed, but from a position outside the CHP.

69 The recent literature on insider-outsider roles raises questions about the way researchers interpret and present their findings. Also highlighted are the complexities inherent in these roles for researchers who study their ‘own kind’ (Kanuha 2000; Merriam, Johnson- Bailey, Lee, Kee et al 2001; Sherif 2001). This is what I and other CHC researchers (eg. ACHA 1986a; Fry & King 1986; Lennie 1980; 1987; Lennie et al 1990; Owen 1987, 1997) chose to do. There were risks associated with being an insider. First the risk of bias. It was possible that my views about the purpose of the CHP policy and my experience as a practitioner might lead me to see the past through ‘rose coloured glasses’, or select interviewees who shared my views, and finally that loyalty might create blind spots. Being an outsider also presented risks. As an academic, there was a risk that interviewees might say what they thought I wanted to hear, that loyalty to the system might lead to cautious responses, or that they would see me as unaware of changes. The benefits of being an insider, in my view, stood to be greater, namely ease of access, the likelihood of interviewees being open, awareness of political issues, and past problems which meant I had an idea of ‘where the bodies were buried’. Being an outsider also had benefits. Since working at a CHC I studied health systems and community nursing in other countries, I was not beholden to current administrators or practitioners, and I had the freedom to look critically and without fear at the past. As a native, albeit one returning to a different reality to that which I had left, my knowledge was positioned, my perspectives partial and subjective all of which had implications for how the data were collected and the lens through which I interpreted them (Kanuha 2000). Given that representing the ‘truth’ is a complex process I hoped that my position as an insider/outsider, who shared many of the cultural values and norms of participants, would enable me to offer what Sherif (2001 p. 438) refers to as ‘new angles of vision and depths of understanding’.

Data Sources Yin (1989, p.78), identified six data sources as most appropriate for case studies: documents, archival records, interviews, observation, participant observation and artefacts. Four sources were selected as most appropriate for this case study: 1) documents and 2) archival records from relevant organisations and 3) in-depth semi-structured interviews with individuals who participated in formulating and implementing the CHP policy within the chosen region and 4) my personal observations from my insider- outsider position.

Documents and Archival Records One of the benefits of documents is that these primary and secondary sources are generally accessible and this makes re-checking easier and reduces reliance on the memories of individuals (Kellehear 1993). Federal and state government documents and archival records − yearbooks, annual reports, reports to or for ministers, state and regional reports produced by or for a NSW Health Commission or Department of Health − were identified as significant sources of data for this study.

70 To gain a more rounded perspective than that offered by official documents, alternative sources are required. I selected CHC team records, newspaper reports, trade union records, archives, local historical and social studies, council reports and hospital reports as appropriate alternative sources for this study. Local, rather than national, newspapers were selected as being more likely to report contentious local issues and local protagonist and stakeholder views. The NSW Nurses Association’s (NSWNA) archives were identified as another relevant source as most CHC practitioners were generalist nurses and union archives were more likely to reflect nurses’ perspectives. I also knew from personal experience that industrial problems during the early 1970s had led the NSW Health Commission to establish Joint Consultative Committees involving association representatives and local community nurses. The Australian Bureau of Statistics census reports, statistical data bases including Health Wiz (1994) and A Social Atlas (Glover & Woollacott, 1992), and regional reports were also identified as relevant sources of demographic, morbidity and mortality data regarding the Hunter population. Thus the documentary sources identified as relevant for this study were those which would enable me to access data concerning the national CHP policy, NSW policy developments, the regional context, and the activities and perspectives of practitioners and administrators in the Hunter Region.

Interviews Interviews were an essential primary source for this study. As my purpose was to gain access to participants’ perspectives and also factual information about their work history and qualifications I decided a semi-structured format was most suitable (Diesing 1972; Dunkerley 1988; Gibson 1980; Hakim 1987; Hughes 1981; Milio 1983b, 1988a; Minichiello et al 1990; Yin 1989, 1994). During the literature review I examined the scales, schedules and protocols used for earlier studies. As the themes encapsulated in the protocols used by Lennie et al (1990) were relevant to this study these were used to develop an interview guide consisting of twenty seven (27) themes written as open ended questions (Appendix 4.1). I considered this a means to retain the strength of in-depth interviewing while ensuring data were collected on all aspects of the ‘case’. Interviews were conducted to gain access to each interviewee’s perceptions of an event and its context rather than ‘the truth’ or some objective reality. As Denzin and Lincoln (1994, p.2) point out, objective reality cannot be captured, however, I needed to capture the multiple realities of interviewees as influenced by the positions they held, their experiences and the time of their involvement. Factual information was also required about each interviewee’s professional qualifications and experience. For example, I expected the experiences of practitioners employed in 1975 to differ from those appointed in 1981. Multiple perspectives were required to enable data to be cross-checked and to reduce the potential for interviewee and interviewer bias. My insider-outsider status had to be considered, as explained earlier. The quality of interview data is dependent on relationships formed between the interviewer and interviewees and a researcher's ability to understand and explore the subject matter. I expected my experience and knowledge of CHCs and the health care system to assist me to ask questions about practices an outsider might interpret as typical

71 (Minichiello et al 1990, p.216-218) or misinterpret (Diesing 1970). I also decided, like earlier researchers (Gibson 1980; SCHRU 1987), to audio-tape and transcribe all interviews to increase reliability. While non- use of audio-taping might enhance assurances of confidentiality and anonymity and possibly increase an interviewee’s willingness to be open, data reliability can be reduced without this aid. I addressed this problem by using a broad enough range of interviewees and documentary sources to enable me to maximise my exposure to multiple perspectives so I could gain a well-rounded account of the event. As I had been a colleague, peer, employer/employee of some interviewees I had to consider the possibility of interviewer bias. I expected my choice of a non-directive conversational approach to interviewing to reduce the possibility of interviewer bias associated with my insider status, except to confirm facts.

Participant Observation The fourth data source was my personal notes collected as a field log and as memos reflecting on data collection through the other means as described above. Field notes are a vital source of raw data for qualitative researchers (Morse & Field 1996, p.91; Hughes 1981 p.36). Rigorously kept notes provide a record of activity, responses to situations/interviews, new ideas, and they point to relationships within the data. Okely (1994 p. 23- 24) distinguishes between methodological, theoretical and personal notes. My field notes were predominantly methodological − verbatim reports of documents; interpretations of reports and minutes of meetings; notes taken during interviews; questions I needed to ask; people I might interview and theoretical − different ways of looking at the data. Personal comments concerned what I saw and heard. I recorded everything, chronologically (Morse & Field 1996; Hughes 1981). These raw data enabled me to ‘elaborate on inference’ as part of the interpretive process (Hughes 1981 p.39). I was also able to draw on my own reflections of working as a GCN at a CHC for almost a decade.

Conducting the Study Identifying Literature Sources Four methods were used to identify the literature discussed in earlier chapters. I conducted key word searches using electronic data bases: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Expanded Academic Index (EAI), Med-line, Wilson and library catalogues. Terms used were; ‘community health program’, ‘community health centre’, ‘community health nurse’, ‘community nurse’ ‘community medicine’, ‘community health workers’, 'community social worker’, ‘community psychologist’, ‘district nurse’, ‘domiciliary nurse’, ‘health education’, ‘hospital outreach’, ‘public health nurse’, ‘prevention’, ‘teamwork’ and later ‘social capital’, ‘capacity building’ and ‘salutogenesis’. The bibliographies of articles and of key journals, including Community Health Studies, Health Promotion Journal of Australia, Medical Journal of Australia, Australian Hospitals, and Hansard were also searched to identify new sources. These methods were fruitful but problematic. Key words elicited little relevant Australian literature initially and only a few Australian government reports. Studies conducted overseas were difficult to access. I used

72 various means including my insider status to access interlibrary loans, personal collections of interviewees, newspapers archives, and collections at the Australian National Library in Canberra; the Kings Fund Centre Library, The Health Visitors Association Library and The Royal College of Nursing Library, in London; and the NSW Nurses Association’s Archives in Sydney.

Gaining Access In mid 1990 I approached senior administrative officers in the Lower Hunter Area, Newcastle and Lake Macquarie and Mental Health Services requesting permission to access three CHCs to examine documents and records and interview practitioners. Permission was granted quickly (Appendix 4.2). In early 1991 I advised these officers that data collection would have to be delayed due to my work commitments. I commenced in July 1991. In late 1991 I contacted the Acting Director of the Primary Care and Nursing Team, by telephone, seeking permission to access records at Windale (Eastlakes) and Toronto (Westlakes). By this time I realised that the Newcastle centre I had initially identified as a source of data was in the process of being refurbished due to earthquake damage. I decided to include another two centres more likely to hold early records and which were experiencing less disruption. Data were collected from official records at four centres from mid 1991 until November 1994. Interviews were conducted concurrently from mid 1991 but continued until February 1996 (Appendix 4.3). Access to each CHC was negotiated with each centre’s managers. I planned to collect data at CHCs for half a day a week for six to eight weeks. As this time-frame proved totally inadequate I sought permission, again by telephone, for an extension of time. This was granted. Gaining access to CHC records to begin data collection by reading and analysing them was physically difficult and time consuming. The problem was space and how records were indexed. At one CHC the manager gave me a permanent spot in the photocopying room. This made copying records (with permission) easier and located me in a public position which facilitated informal contact with practitioners. At two other CHCs I was given whichever desk was vacant when I arrived. At one centre my access was restricted to mornings, when most nurses were out of the centre, due to a severe lack of space. Access was further hindered by records, some of which were archives, being stored in cardboard boxes on the top shelves awaiting a new filing system. A numerical system was used to file records. Finding some mis-filed I made a systematic search of all available records, a huge task. Unexpected events hindered progress. I ceased accessing one CHC to move to another, fearful of missing an opportunity to access the few records remaining from 1974 to 1977, after being told they were to be transferred to a store. I had missed gaining access to archives at a warehouse when it closed, before I discovered its existence, and records were relocated, so I was told, to a city dump. Archives stored at Wallsend District Hospital were accessed although this created an ethical problem for me. I had trained at this hospital, which closed in 1991, generating a public outcry. Local residents picketed for over 12 months to prevent resources being removed. The Community Health Administration complex there had archives

73 that I managed to borrow and return without incident. I felt awkward and disloyal but very pleased the picketers ignored me.

The Data Collection Process Data collected from records were recorded in notebooks noting the date, venue, file number and document type (report, minutes, correspondence). I photocopied some reports and records, with the manager’s permission, for later analysis. Analysing documents at CHCs was at times difficult. While I found gaps in the records of individual CHCs, use of multiple sources, sites and methods reduced potential problems. I treated documents and records as texts which I read for meaning (Scott 1990). To assist me to understand the circumstances under which authors wrote, I developed a chronology of significant federal, state, regional and team events and an annotated bibliography of official reports leading up to and following the writing of a national and NSW CHP policy. This provided a grid of historical events, facts, policy changes, occupants of key positions, changes in administrators, organisational structures, political and social context against which to interpret the data collected from documents and interviews. This grid also provided me with a guide for identifying potential interviewees. Documents were treated sceptically, for reasons discussed later, checked for accuracy, authenticity and significance by identifying specific features, comparing dates and establishing the author’s position (Scott 1990). Factual data, dates, events and names, were checked for accuracy and authenticity (Diesing 1972, Scott 1992, Yin 1994). Documents are written for specific purposes so the views expressed in them need to be verified and possible biases or motives considered (Scott 1990, p.59). The historical grid and annotated bibliography created a background against which regional and team records could be interpreted to identify trends, patterns, similarities and differences, continuities and discontinuities and conflicts. By late 1993 documentary sources and newspaper reports provided evidence that conflict had occurred in the region from 1975. In 1994 I sought permission to access the NSW Nurses Association Archives. These contained the minutes of the Community Health Nurses Hunter Branch of the Association, correspondence between the Association and regional administrators and local community nurses and the attending union organiser’s notes on Joint Consultative Committee meetings. The Association’s location in Sydney and its closure during lunch breaks hindered access and imposed time limits. As the archives were catalogued broadly all records referring to the Hunter Region were searched to find those relevant to community health. At the Regional Reference Library I conducted a systematic search of the daily index of the Newcastle Herald, a regional newspaper, using key words and estimated dates to identify reports concerning local history, the CHP policy, CHCs, local health and welfare services and population health. I searched for reports on regional administrators, CHCs, reorganisations, and regional health issues. I also obtained sources from the archives of the NSW Nurses Association and National Reference Library. The NSWNA archives contained records, correspondence detailing conflict arising between community nurses and regional administration and minutes of nurses branch meetings. These sources were analysed to identify 74 protagonists and conflicts. As records were stored in boxes, but not indexed, I had to read all available material. The Reference Library provided me with access to difficult-to-obtain reports and the H&HSCs newsletters concerning the CHP policy’s development and implementation. During my time at CHCs I overheard practitioners discussing issues, seeking assistance from colleagues and other agencies in person and via the telephone, and arranging services. I witnessed distress, anger, and excitement over clients and administrative matters. Observations, such as 'off the record' comments during interviews, were treated as confidential, as background information rather than data, for ethical reasons. These observations were used to form questions for exploration during interviews to increase my understanding of context. Three methods were used to identify and contact possible interviewees. First, people holding, or who had held, key administrative positions were contacted, at work, by telephone, to explain the study and request an interview. This was expedient and direct. None who were local refused, but I experienced some difficulty locating potential interviewees who had left the region. Second, to overcome this problem I used a technique called snowballing. When some interviewees suggested I speak with another person who had held a particular position or because they been involved in a particular aspect of the event of interest I accepted. Most were administrative officers. I explained who had referred me and why. Again none refused to talk with me. Third, I contacted potential interviewees at CHCs. The purpose of the study was explained to practitioners at meetings, either by the centre manager or by me. Once this had occurred I asked those meeting my inclusion criteria if they would like to speak with me. Most were aware of the study when I made this request. Once they agreed to be interviewed a mutually convenient time and place were arranged. Written consent was not sought as the agreement to undertake the research did not specify such action. Since participation was voluntary, I accepted the timely arrival of the interviewee at an agreed venue as consent. Most (70%) interviewees were nurses (Appendix 4.3). The interviews were conducted at CHCs (50), my office (5), interviewees' homes (6) or offices (4), coffee shops (2), and by telephone (6). I conducted some in other areas of NSW (4) and in Canberra (2 sessions) and Brisbane (1). Interviews lasted between one and three hours with four running over two sessions. Telephone interviews were shorter, fifteen to forty minutes. I began each interview by asking participants how they became involved with the CHP and what they had done. I facilitated continuation of the interview by asking questions to clarify or probe as needed. A few required sufficient prompting to make a conversational approach difficult. The interview guide was useful at such times. Most interviews (59) were audio recorded. A tape recorder was placed on a table between the interviewee and myself. Before activating the tape I explained the study purpose and the confidential nature of the interview and their right to request that the tape be stopped at any time. Few asked for the tape to be switched off. 'Off the record' comments were not considered data, mainly as these comments were highly sensitive and the interviewee had asked me to stop the tape before making them. To quote them would breach an agreement. Such comments did however influence directions taken in later interviews and document analysis. I took care to ensure potential interviewees felt free to decline

75 or to change their mind. Three practitioners had to reschedule appointments because of clients, two others cancelled appointments for other appointments and then 'forgot' the next interview. I made no attempt to recontact the latter as I took their forgetting as an indication they did not want to participate.

Creating a Data Base To increase the rigour of the study and the dependability of the findings I created an extensive data base: a chronology of significant national, state and regional events; an annotated bibliography; field note books, interview transcripts; newspaper reports, photocopies of records, reports and documents, charts, tables and figures; to enable congruence to be checked across all sources for each unit of analysis (Diesing 1970; Stake 1994, 1995, 2000; Yin 1984). I started a chronology of significant events to provide an historical policy background against which to analyse data collected from all sources (Appendix 4.4). This chronology identified: changes in federal and state governments; organisational and administrative changes (eg. changes in health minister, heads of health departments, regional directors); reports leading to policy decisions relevant to the CHP policy and CHCs; reports on professional education, medical and nursing; changes in regional health care services. I attempted to read all available, relevant, federal, state and regional reports concerning the CHP policy and its implementation in the Hunter region. As each report was read I wrote a brief description noting date, author, purpose and recommendations. This document enabled me to track recommendations and proposals related to the national CHP policy through various reports to identify continuities and discontinuities in direction and intent over time. Using a chronological format, with separate sections for federal, state and regional reports, meant this document added further depth to the chronology events. Interviews were recorded, transcribed verbatim and printed to provide a hard copy that could be read and analysed in relation to other documentary sources. I also maintained the tapes so that I could listen to them as I read. An index was created as each interview was transcribed providing ready access to interviewees' comments about, for example, ‘teamwork’ or ‘conflict’ or ‘community’. Interview transcripts were categorised according to position (administrative, CHC manager, practitioner), discipline (nursing, allied health), length of employment at a CHC and or hospitals outreach service, professional experience prior to beginning work at a CHC and level of education. I took notes during interviews. This included thoughts occurring during the interviews and comments made by the interviewee. Comparisons could thus be made between practitioners' experiences, the length of time spent at CHCs, prior professional experiences and their recollections of the event of interest. Data collected from interviews, federal, state and regional documents, team records and reports, newspapers and NSW Nurses Association archives were recorded in notebooks. Each entry began with the data, venue, and, if relevant, the file number of the documents being read. Detailed notes were made. Some records were reported in their entirety. Other entries contained a brief analysis of a record sometimes with one or more quotes. I photocopied large documents with permission. These notebooks provided a further documentary source for analysis.

76 Data Analysis Chronological, content, and thematic analysis were conducted on data collected from all sources. Chronological analysis was undertaken to identify ‘historical facts’, the sequence of relevant incidents, occurrences, and decisions at multiple levels − national, state, regional and CHCs − and to gain an understanding of processes and who was involved (Denzin & Lincoln 2000; Morse & Field 1996). Documents, records, interview transcripts and field notes were analysed for content to identify topics arising. Indexes were created for each interview transcript (eg. communication, conflict, planning). Thematic analysis was undertaken to identify common threads across all data sources ((Morse & Field 1996 p. 114-115; Ryan & Bernard 2000 p.780-781). The grid of significant historical events, mentioned earlier, provided an historical backdrop against which the experiences and perceptions of practitioners and administrators were analysed. The secondary questions, discussed earlier, which evolved during the research process along with the interview guide provided a basis for beginning thematic analysis, constructing themes against which I interrogated the data. Further unanticipated themes arose from the data. Local regional and centre records were examined to identify past organisational structures and processes, including methods of administrative surveillance, and to gain an understanding of the author's perspective of relevant topics or events. Like other researchers I expected team records to provide a primary source of data as to the types of services CHCs provided (Duckett et al 1980; Morey et al 1980; SCHRU 1987; Thomas 1980). I therefore analysed CHC team records to identify: services developed and provided and the population to which they were directed; processes used to establish, provide and monitor services; and mechanisms used by regional administrators to guide, direct and/or support implementation processes. Reports, minutes of meetings, correspondence, and interviews provided a source to deduce the orientation of practitioners and the nature of relationships between team members, managers, regional administrators and other services. I sought to identify changes in perspectives and action over time. Scott (1990, p.56) has explained that ‘concepts and methods reflect the cultural underpinning of state and private action’ however application requires translation into ‘specific administrative procedures’ (Scott 1990 p.62). Team records provided data that revealed processes which, as Dunkerly (1988) has argued, constructed a ‘vital link between action and structure – the latter being incomprehensible without an appraisal of the former' (p.83). To understand the actions, motives and intentions of participants I had to be able to identify and describe them and attribute meaning. Documents, records, and interview transcripts were read for meaning. I sought to identify values and deduce relationships (Scott 1990). As Scott (1990) argued, I had to make choices between ‘concepts which differ in their connotations, and this choice cannot be resolved on the basis of theoretically neutral observations’ ( p. 57). As a supporter of the CHP policy I had to question my ‘truth’ of my interpretations. As my aim was to understand an event I

77 needed to understand the conditions under which documents and records were produced and practices evolved (Hodder 2000 p. 711).

Attribution of Sources This study drew upon four sources of data; documents and archives, interviews with participants, and participant observation. Different sources were drawn upon more heavily than others in different Chapters. Chapters 5 to 8 draw upon publicly accessible official documents and archives and academic literature more than interview data. Chapter 7 draws upon data collected from internal team records while Chapter 8 draws heavily upon local newspaper and official Regional reports. By contrast Chapter 9 draws mainly upon interview data. Participants are quoted, often at length, to reflect the views of individual practitioners, from different discipline groups, who comprised multidisciplinary teams. Interviewees are identified by an interview Number and discipline where this does not compromise their confidentiality. Two sources of interview data are drawn upon: first, interviews conducted for this study, interviews 1 to 69; and second, interviews I conducted for an earlier study, interviews 1.1 to 1.17 (Schulz 1989).

Research Standards−Trustworthiness Much of the discussion about standards in qualitative research focuses on issues of validity and reliability as the criteria for assessing these qualities differ from those used in conventional positivist research (Bryman 1984; Denzin & Lincoln 2000; Morse & Field 1985; Fielding & Fielding 1986; Sandelowski 1986; Stake 2000; Yin 1984). McWilliam (1996) points out the individualistic and personal nature of interpretive research ‘precludes attainment of objectivity’ yet techniques can be used to promote credibility and applicability of a study’s findings. How a study is designed and conducted is central to the issue of credibility or trustworthiness. The design of this study represents a set of logical steps and its quality can be judged against selected logical criteria. The approach and methods selected were consistent with the purpose of this interpretive study. Form followed purpose. Rigour, depth, and breadth were added by using multiple sources and methods to collect the data (Denzin & Lincoln 1994, p.2). The sources of evidence used were authentic and purposefully selected to reflect multiple perspectives. The authenticity and dependability of the findings were increased by triangulating data across methods, sources and sites, creating an extensive data base, and writing a comprehensive and detailed report (Diesing 1972; Gifford 1996; Morse 1994; Yin 1989). Researcher bias was minimised by collecting data from multiple sources, using multiple methods, and handling it honestly. Contact was maintained with key interviewees as data were collected, analysed and the preliminary report written (Yin 1984). In writing the report I sought to leave a trail demonstrating how the study findings were gained and its conclusions reached. The credibility and relevance of the findings were assessed by discussing the findings with selected interviewees (Yin 1984) and presentations to regional, national and international conferences (Schulz 1993a (Edmonton), 1993b (Newcastle), 1995a

78 (Newcastle), 1995b (Montreal); Schulz & Short 1993 (Sydney), 1996 (Hobart); Schulz-Robinson 1997a (Sydney), 1997b (Edinburgh).

Ethical Issues Detailed ethics approval was not required in the early 1990s, but overall permission from the Area Health Service was sought and readily obtained. My wish was to collect data from administrative records and to interview practitioners, rather than clients, so no objections to data collection were raised. However, ethical issues were duly considered. I did not seek written consent from interviewees but the assurances of confidentiality and anonymity I gave, while having the potential to reduce the reliability of the data, had to be honoured. Most interviewees, nearly all employees of the NSW health system, appeared to express their views without fear of exposure or censure. In offering confidentiality and anonymity I imposed limitations on the way in which the findings of this study were reported. Milio (1988a) resolved this issue by reporting her findings without directly quoting individuals and presenting a highly analytical, abstract, report. I chose to report the findings of this study in a more descriptive manner to make the event more accessible and understandable. I sought to maintain confidentiality by omitting interviewees' names, numbering tapes and storing them in a secured cabinet accessible to me only. Names and code numbers were stored separately. I sought assistance with transcription of interviews with the interviewees' consent but transcribed those conducted with senior administrators or those containing sensitive material myself. There were two exceptions. When I discussed the issue of confidentiality with Drs Sidney Sax and Geoffrey Olsen, both gave me permission to quote them. Sax was one of the architects of the CHP policy, and Olsen, a project officer and then Regional Director of the Hunter Region. It is for this reason that their quotes are explicitly acknowledged. To protect the identity of interviewees, but to provide sufficient information about their position, I have identified interviewees by Interview Number and discipline. I have conflated all allied health disciplines and referred to centre managers, team leaders and senior nurses, as administrative officers when to do otherwise would reveal their identify and breach their confidentiality. When reporting on public documents where I had no responsibility to maintain confidentiality since the matter was public and had not been revealed to me confidentially I have taken the approach commonly used by historians and political scientists when reporting matters of fact relevant to their findings. I have referred to key stakeholders by name and position to assist understanding of the event reported, and have limited comment to those aspects in the public domain at the time.

In Summary This study was designed and conducted as a single case study as in my view this offered the greatest potential for increasing understanding about the context in which the CHP policy was implemented. I expected this in-depth study to be what Yin (1989) refers to as a 'revelatory case'. Unlike earlier studies,

79 which were conducted under constraints of time and expectations of funding bodies, this exploratory qualitative study was conducted to gain an understanding of a past event. The question this study sought to answer, the approach selected, its design and how it was conducted have been described in detail. A case study was conducted because it offered me a way to use multiple methods to collect and analyse data which I could piece together to present a contextualised account of policy implementation. The study was designed and conducted to gain an understanding of what occurred from the perspective of those involved, and of the opportunities and constraints which shaped how practitioners and administrators approached this process and what they achieved. I tried to piece together a mosaic, a picture that would tell their story. Denzin and Lincoln (1994) have described the qualitative researcher as a Jack-of-all-trades, a ‘bricoleur’ who uses the tools best suited to their needs to produce ‘a complex, dense, reflexive, collage-like creation’ which represents their ‘images, understandings, and interpretations’ (p.3) of what it is they are studying. The following Chapters present the mosaic I created beginning with an exploration of the policy context.

80 CHAPTER 5 THE NATIONAL AND STATE HEALTH POLICY CONTEXT: TRYING TO TAKE CONTROL

...policy development-initiation, adoption, implementation, evaluation, reformulation is... a continuous, but not necessarily linear, social and political process. Policy substance (content) changes under the influence of both changing social, political, and economic conditions (social climate) and the changing perceptions of interested parties. As conditions change there is a change in the views of groups on the shape, pace and direction of a policy that best enhances (or least harms) their interest.

It must be remembered that policy is made within a set of broadly shared and implicit expectations derived from historical, socio-political and organizational experience (Milio 1988a p.266).

Introduction The previous chapter explained the purpose and design of this study and how it was conducted. This chapter explores the problems the CHP policy sought to address and the context in which it was written. It begins by identifying endemic structural problems in Australia’s health care system before focusing on the policy agenda of relevant governments, the Whitlam Labor Government and thereafter the NSW state Government, and the education of health professionals. As the literature discussed earlier illustrates, policy is a way in which governments achieve their political agenda. Policies evolve in response to specific problems. How a policy problem and its solutions are conceptualised reflects the philosophical positions of its developers who are rarely involved in its implementation. Numerous stakeholders participate in or are affected by implementation of a policy and have opportunities to influence the direction taken. Multiple stakeholders were able to influence how the CHP policy was implemented, including health professionals and regional administrators. This Chapter provides a context for understanding the problems the CHP policy was expected to resolve and for reinterpreting the purpose of this policy from the perspective of its architects. The CHP policy is revealed as a policy which reflected contemporary thinking about health care systems and health services and how they could be re-structured to increase people's access to services and in the process promote their health.

The Australian Health Care System By 1973 Australia, as the works of various authors illustrate, had a pluralistic health care system (Dewdney 1972; Grant & Lapsley 1993; Lewis 2003; Roemer 1969, 1976, 1977; Sax 1972a,b, 1975a). An eclectic mix of providers, government, non-government, and private organisations, offered services mostly, as in the United States of America, on a fee-for-service basis. Proposals to establish an NHS had failed (Dewdney 1972 p.27-32) mainly due to opposition from medical organisations concerned with their members' autonomy (Dewdney 1972; Lewis 2003; Sax 1972a; 1984). Whilst I use the term system for ease, it is misleading, as its use implies the complex array of services operating by 1973 worked in unison

81 and shared a common purpose. In reality, as histories and critiques show, this ‘system’ consisted of a plethora of independent services (Dewdney 1972; Lewis 1988, 2003; Sax 1972a,b, 1975a, 1984). By 1973 Australia's health care system consisted of hospitals (public, private general, psychiatric, geriatric, developmental disability), private doctors (primary and specialist), non-government and public health organisations. Established ad hoc over decades by private and non-government organisations and governments these mostly autonomous services had their own reasons for existing and their own agendas. Each state operated differently, each had a significant degree of autonomy, and a mix of organisations and services reflecting their different histories and settlement patterns. No one government or organisation took responsibility for planning new developments or monitoring the effectiveness or relevance of the services offered. Political and fiscal responsibility for health care was divided, a situation creating fundamental problems for health department bureaucrats interested in planning a coherent system. Sidney Sax, a NSW Health Department bureaucrat, doctor, and an architect of the national CHP policy, explains the difficulties confronting administrators, managers and planners in his critique of the Australian health system, ‘Medical Care in the Melting Pot’. Sax argues that the objectives of the Commonwealth and the states whilst …..unstated, can be seen to diverge...why should States expend resources on the promotion of rehabilitation and home care for the disabled, when the infirmed can be maintained in nursing homes supported by the Commonwealth? Why should the Commonwealth allocate resources for development of primary care when the States are providing hospital outpatients departments where most of the medical care does not attract Commonwealth benefits? Why should a hospital administrator strive to reduce hospital utilization, so to conserve State and Commonwealth resources, when not only would it be financially disastrous for his particular hospital to have beds unoccupied and not earning revenue, but his own salary and status would be promoted by expansion of his institution? Why should a nursing home manager aim to discharge a patient, or permit trial leave with a view to discharge, when the consequent unoccupied bed proves a liability? (Sax 1972a, p.174). This ‘system’ lacked common objectives, overall priorities, and incentives to encourage various stakeholders to evaluate performance, competence and service appropriateness (p.175). Lack of planning and control created three major problems, cost, distribution and coordination. By 1973 health care was costly, maldistributed and fragmented. Primary care was a particular problem.

Costly, Maldistributed and Fragmented In 1978 WHO drew international attention to the importance of primary care (WHO 1978). Primary care, entry level care, is important as it offers access to the types of services used by most people most of the time to gain assistance with common problems (Starfield 1992). It focuses on secondary rather than primary prevention (Starfield 1992; WHO 1978). Whether people have timely and appropriate access to primary medical care is affected by the way services are funded and organised (Milio 1970, 1975a,b; Roemer 1969, Walters 1980). Until 1975 when Medibank, a universal health insurance scheme, was implemented, Australians relied on a fee-for-service model of care which, as economists point out, was costly to individuals and governments (Scotton & Deeble 1968; Deeble 1982; Roemer 1969). It was also

82 inequitable. For as the leader of the federal Labor opposition, Gough Whitlam (1957), observed in the late 1950s, people were required to purchase health insurance as protection against the cost of illness and this cost was disproportionately high for those on low incomes. The cost of health insurance was beyond the means of many families as was pointed out by the President of the Doctors Reform Society, Dr Alf Liebhold (1993). Health economists were also finding some 7 to 15% of populations in all states (except Queensland) lacked basic insurance (Scotton & Deeble 1968; Scotton & McDonald 1993). The implications of this situation were wide- reaching. As Liebhold (1993) and Sax (1984) observed, with free care limited to the ‘deserving poor’, doctors and hospitals accumulated bad debts which debt collectors, an integral part of this system, collected. The high cost of primary medical care, even for insured persons (due to fee structures), fostered use of in-patient and specialist care and this was costly to governments (Deeble 1982; Nimmo Report 1969; Scotton & Deeble 1968; Whitlam 1968a,b). Access to primary medical care was limited by cost but compounded by distribution. When the CHP policy was written the H&HSC was finding that the uneven distribution of health care left 15- 20 % of Australians living in ‘under-served’ areas (H&HSC 1973 p.2). The pattern was similar to that in other countries, affluent metropolitan areas being better served than new estates on city peripheries, rural and or disadvantaged areas (Hansard 11.12.1973, p.4538-4558; Hetzel 1970, 1971a; DHNSW 1971; Roemer 1969; Saint 1971; Sax 1972a; Webster 1971). Tudor Hart’s inverse care law (Hart 1971, 1972) likely operated here as overseas (Dutton 1978; Milio 1970, 1975a; Roemer 1969; Walters 1980). Hart (1971 p.405) theorised, based on observation, that ‘the availability of good medical care tends to vary inversely with the need of the population served’. Market forces exacerbated the problem, doctors had to make a living (p. 407). Fee-for-service health care influences where doctors practise. Prior to Medibank doctors relied on patients for an income, now they rely on federal governments. GPs tended to locate their surgeries in areas where they wanted to live or where populations could pay their fees or insurance premiums and specialists flocked to affluent areas near university medical schools (Sax 1972a, 1984). Fewer chose to work in less affluent, rural and/or isolated areas where people likely had poorer health and a greater need for ready access to primary medical care. By the early 1970s, however, it had become evident that people needed access to a broad range of primary care services. This, as I argued in Chapter 3, was why various countries established CHCs.

Contemporary Health Problems and Illnesses By the early 1970s patterns of illness had changed in Australia as in other industrial nations as a consequence of social change, urbanisation, and public health measures (Roemer 1969, p.121). Nationally, infant deaths and deaths from infectious diseases had declined for all but Aboriginal Australians (Hetzel 1970, 1971a; ABS 1974). Adult deaths were mostly associated with chronic incurable conditions and disability (Lawson 1970). Population growth led to the development of new housing estates

83 on the periphery of cities. These suburbs, lacking basic services and a sense of community, placed greater pressure on families (Hetzel 1970, p.1) especially women (Richards 1978; Wyndam 1982). These social changes had implications for GPs. By the early 1970s, as Sax (1972a) amongst others argued, GPs were seeing more people experiencing ‘a preponderance of mental, psycho-neurotic and personality disorders’, conditions ‘known or suspected’ to include emotional causes (p.22). People turned to GPs for assistance with problems associated with alcoholism, stressed relationships, child behavioural problems and chronic illness. There was evidence, as Sax pointed out, of life crises exacerbating physical problems (cardiac, skin, tuberculosis) with remissions occurring as people's situations changed (p.23). Death and illness were observed to be unevenly distributed and higher in lower socio-economic groups (p.23). Public health researchers, Hetzel (1970, 1971a), Lawson (1970), Saint (1969, 1970a) and Sax (1972a), and government bodies, H&HSC (1973) and HCNSW (1973,1977), were recognising that people's circumstances affected their health and that the amelioration of many health problems required psycho- social and environmental, rather than medical, interventions. Populations turned to GPs who, unable to resolve their patients' problems, dispensed medication. Public health researchers and medical academics began arguing for preventive action. Some like Saint (1971, p.11), Dean of Medicine at the University of Queensland, advocated for a ‘positive cohesive joint strategy’ for housing, social welfare, urban planning and health care as health was ‘determined by the social human condition’. WHO (1978) made a similar plea in the Alma Ata Declaration. Medically qualified academics such as Dewdney, School of Health Administration, University of NSW, argued that people's circumstances had implications for their health (1972 p.4-5). Public health researchers and some medical academics argued that prevention was required and promoted use of traditional public health strategies, behavioural and environmental change. Sax (1972a, p.199) argued for ‘preventative-maintenance’ for the ‘asymptomatic sick’ and ‘follow-up’ for chronically ill or disabled persons as, except for dental disease, ‘neither prevention nor treatment’ would eradicate or reduce total morbidity. The impossibility of preventing all illnesses led many authors to focus on how health services were organised. Many recognised that people's access to and use of non-medical interventions could be increased through cooperation between various levels and types of services (Hetzel 1970, 1971b; Saint 1970a, 1971; Sax 1970, 1972; Southby 1971, 1972). In Australia, as overseas, it was acknowledged that a lack of coordination between levels of care (primary, secondary, tertiary) and different professional groups hindered people's access to appropriate care (Deeble 1982; Hetzel 1971a, 1971b; Nimmo Report 1969; Sax 1972a; Scotton 1970, 1974; Webster 1983; Whitlam 1957, 1961, 1968a). To improve people's access to care, changing how GPs practised was considered pivotal. Sax, for example, argued GPs needed to be more involved in prevention, rehabilitation, and providing personal care for those who were elderly, had disabilities, congenital handicaps or mental illnesses (1972a p.21). Personal care was necessary as the …. sicknesses of industrial urban civilization involve so deeply the individual characteristics of the patient his sociocultural environment, the very personal aspects of his history and care will become

84 increasingly important. Major needs are for understanding the multiple causes of a particular patient's problem and then motivating and helping him relieve these. Continuity and personalization of the association between patient and health professional are necessary for the understanding, support and trust that are basic to proper care (Sax 1972a, p.26). Sax, like many of his public health contemporaries held the view that people required access to a broad range of primary health care services. Services focused on ‘health’. However to act upon determinants of health and ensure people had ready access to responsive and appropriate health care services, people required ready access to primary care. Additionally, however, the focus of general hospitals also had to change.

Health Care: Institutionally Focused, Curative and Unresponsive The problem confronting governments in countries with pluralistic health care systems was that their control over the system was limited. Governments could try to facilitate change by making funding available for new developments. This was the strategy used by federal governments to foster growth of CHCs, as was discussed in Chapter 3 (q.v. Alford 1975). As mentioned, federal governments found it difficult to alter the focus of health professionals. By 1973 Australia had an institutionally focused, hospital- centric, health care system. Bureaucrats, medical academics and public health researchers were arguing for change and there was some agreement that the key lay in changing how GPs and general hospitals provided services (Barclay 1961, 1966, 1969; Champion De Crespigny 1971, 1972; Hetzel 1970, 1971b, 1972; Lawson 1970; McCathy, Moran & Deeble 1974a,b,c; McEwin 1970; Saint 1970b, 1971; Sax 1970b, 1972a). Some critics realised that to change how hospitals and GPs provided care community nursing services needed to be further developed. By the 1970s Australia had few nurses working outside of hospitals. Historically, both federal and state governments had a tradition of supporting hospitals. Histories illustrate that nurses worked in communities as private practitioners or for non-government organisations from the late 1800s (Appendix 5.1). However, by the 1950s most nurses worked as employees of general hospitals (ABS 1971). Non-government nursing organisations began to provide care to those excluded from hospitals (labouring women, children, persons with chronic illnesses) and unable to afford a private nurse and later to care for patients of GPs and hospitals (Archer 1976; Blue Nursing Service, 1982, 1994; Cramer 1987; Durdin 1991; Gandevia 1978; H&HSC 1976a; Hurworth 1976; Kreger 1991; Linn 1993; Quadros 1986; Rosenthal 1974; Sax 1972a, 1984; Silver Chain Nursing Association 1994, 1995; South Australian Trained Nurses Centenary Committee 1937; Sydney Home Nursing Service 1994a,b). These services, as happened overseas, were established to assist people who were poor and sick (Rosenthal 1974; Swanson & Nies 1997 p.32-37). Non-government nursing services were maldistributed by the 1970s and the services they offered varied. While most were initially located in what were poor areas, gentrification and a growing urban sprawl meant services were concentrated in metropolitan areas while many large housing estates on the city periphery were under-serviced.

85 By 1973 nursing services offered a variety of services. Those in South Australia, Tasmania, West Australia and Victoria, offered prenatal, child health and home nursing and in Victoria into the 1950s, midwifery usually on a fee-for-service basis (eg. Rosenthal 1974). NSW, the most populous state, had few community nursing services most of which were administered by government departments and hospitals. Non-government organisations established infant welfare services in this state in 1904, employing specially trained infant welfare, or mothercraft, nurses1 to make home visits in an attempt to reduce high death and illness rates amongst women and children (Clements 1986; Gandevia 1978; Sax 1984). The Director of Public Health took responsibility for this service in 1914 due to rising costs (Ganadevia 1978). These organisations continued to train mothercraft nurses with government funding. NSW was the only state to offer such training until the 1930s (Linn 1993). Infant Welfare Centres proliferated through collaborative arrangements between state and local governments and non-government organisations. The state covered most building (75%) and staffing (100%) costs. Bush Nurses, employees of non-government organisations, staffed centres in most states and in isolated areas of NSW (NSWSG 1972 p.603; Linn 1993; Rosenthal 1974). Mothercraft nurses provided a fairly rigid service, screening, monitoring and later immunising infants and educating mothers about child care (ABS 1972, p. 436; Crowley 1974; Dewdney 1972, p.160; DPHNSW 1963; Gandevia 1978; Jones 1989; O’Connor 1989). These nurses worked independently guided by strict protocols and guidelines. These centres appear to have had little effect on health outcomes. Maternal and infant death and illness rates remained high into the 1950s (Clements 1986). Women, however, found them helpful. Attendance at centres increased over time although home visiting by nurses declined (ABS 1972, p.436). Nurses offered a limited service. Only large centres in Sydney (15) and Newcastle (2) conducted prenatal classes or offered women access to specialist private care which they needed but were unable to afford (NSWSG 1973 p.597; 1974 p.602). Nurses offered a different service to that of GPs yet they were viewed as competitors. As Gandevia (1978) and Sax (1972a) illustrate the British Medical Association (then representing Australian doctors), opposed the introduction of this service but they failed to prevent nurses visiting women receiving medical care. Medical opposition to universally accessible services was common in Australia. Concern over the health of children fostered development of universally accessible services from the early 1900s. The NSW state government established school medical services in 1907, prior to taking responsibility for infant welfare, to improve children’s health. As with infant welfare services, school medical services were provided by government employees who visited schools to screen and monitor the physical and behavioural development of children and their immunisation status. Parental consent was required before children were examined. Guidelines and protocols determined the nature of the care provided. Doctors (salaried) could refer children who had vision and hearing problems to specialists but

1 In NSW such nurses were registered general nurses, qualified midwives, who had also completed a child welfare course. By the early 1970s these nurses were employed by the Bureau of Maternal and Child Health as ‘maternal and child health’ nurses but referred to as mothercraft or baby health nurses. I use the latter terms interchangeably.

86 other problems had to be referred to a GP. The problem with this approach, as Sax argued, was that whether a child received relevant care depended on their resources and the motivation of their parents. Proposals to provide poor children with free hospital care had been opposed (Sax 1984). School medical doctors and nurses identified children with previously unidentified problems. During 1971, for example, doctors and nurses found over 10% of NSW children (21,086 of 169,953) had health problems (ABS 1972, p.437). Child Guidance Centres employed allied health professionals (speech therapists, social workers, psychologists) while doctors assessed and treated children with behavioural and other non-medical problems (ABS 1972, p.437). Parents made little use of these guidance centres for behavioural problems (Wyatt 1962, p.12-13). Maternal and child health services were governed by strict protocols and guidelines and were covered by legislation (Gandevia 1978; Sax 1984; Jones 1989; Linn 1993). These services focused on women and children and persons with, or at risk of, contacting communicable diseases. In 1947 the NSW government established a Tuberculosis Division to find and treat ‘new cases’ (NSW DGPH 1973, Sax 1972a). Tuberculosis continued as a problem into the 1970s although sexually transmitted diseases were more common (ABS 1972, p.443). Four strategies were used to identify and monitor those with, or at risk of, communicable diseases: case finding, surveillance, education and home visiting by nurses (ABS 1972; NSW Parliament 1972-1973). During the 1960s federal governments promoted health education activities by funding non-government agencies (eg. National Safety Council of Australia, National Heart Foundation, National Fitness Council and Lady Gowrie Child Centres) to conduct education programs (smoking, nutrition, exercise) and research (ABS 1971, p.417; National Safety Council of Australia 1963; NSW HEAC 1972; Johnson 1972). State governments fostered health education especially about drug use. NSW established a Division of Health Education to develop and distribute educational material and conducted small group programs for youth and drug-dependent persons (ABS 1971, p.417; DHNSW 1972; Douse 1972). Victoria established an Alcoholics and Drug- Dependant Persons Service to conduct public education programs and research (ABS 1971, p.419). Mass media information campaigns and small group programs were the strategies of choice. These health education programs were directed at total and specific populations. Like maternal and child health and communicable diseases services, these services were free. The providers of public health services provided clinic-based services and outreached (eg. visiting schools, home, workplaces) to relevant populations, unlike hospitals. Traditionally hospitals focused only on hospitalised patients. After WW II shortages of beds, labour and building materials and an increase in admissions of elderly persons as women re-entered paid work, prompted some general hospitals to reach out to their patients (Crowley 1974; Boyce et al 1978; Rosenthal 1993). Hospitals began to realise that by providing home nursing they could discharge people earlier and delay or prevent admission of elderly, chronically ill, or disabled persons for social reasons or for basic nursing care (Gibson 1970a,b; Hetzel 1971b, Sax 1970a). Between 1956 and 1970 the growth of home nursing services was fuelled by four federal Acts − Home Nursing Subsidy Act (1956); States Grants (Paramedical Services) Act; States Grants (Home Care) Act (1969); and Delivered Meals Subsidy

87 Act (1970) (ABS 1971, pp.414-431). In response hospitals and non-government organisations developed or expanded home nursing services as official statistics illustrate. By 1970 some 95 organisations, employing 850 nurses, received federal subsidies (ABS 1971, pp.414-431). These acts enabled state governments to exert some influence over where non-government organisations located nursing services and which populations they assisted. In Victoria, for example, the Victorian Royal District Nursing Service was encouraged to focus on midwifery and elderly clients rather than discharged patients (Rosenthal 1974; RDNSV 1993). The experience of this organisation was that some hospitals failed this challenge, continuing to discharge people without planning, notifying other providers, understanding people's home conditions or the services they required with sometimes fatal outcomes (Rosenthal 1974, p.59). Sax (1972a p.24) made the same point arguing that relapses leading to re-admission from ‘breakdown in adjustment’ could be avoided by planning − organising health maintenance, removing adverse conditions or delaying discharge. Problems associated with transferring care from one service to another in his view were indicative of managerial ‘inefficiency’ and ... inadequacies in the deployment of community staff to provide supervision, counselling and service in the home, the program of after-care was seldom planned well in advance and organised in conjunction with the patients' general practitioner to provide an unbroken service of nursing and personal care (Sax 1972a, p.25). Sax proposed that hospitals transfer patient care to GPs. However, in most situations structural impediments precluded this. Large metropolitan tertiary hospitals, where most specialist doctors worked, had little if any contact with GPs. Transferring care from one organisation to another was hindered by the fragmentation of services and maldistribution of nursing services. Until 1986, when area boards were established in NSW, general hospitals were administered and managed idiosyncratically by hospital boards under the Hospitals Act (1929). By the early 1970s the workings of these organisations remained poorly understood as George Palmer (1971) a health economist and Professor of Health Services Management at the University of New South Wales, observed. Sax (1972a p.177) pointed to specific problems, record keeping practices which limited comparisons and departmental costing, primitive analysis of workforce needs, and near negligible data on outpatient morbidity or disease and disability in communities. According to some critics general hospitals were inward-looking, poorly-managed autonomous organisations. Hospital boards could decide which services they would provide. State governments had more control over psychiatric and developmental disability hospitals because they administered them. By the 1960s these hospitals were more outward-looking and less autonomous although problems still arose. A Royal Commission into Callan Park Psychiatric Hospital, Sydney, NSW, for example, found major deficits in care following which systemic changes were implemented in all facilities (q.v. Lewis 1988 p.83-85). The standard of hospital facilities was also poor in Victoria (Dax cited in Hansard 11.12.1973, p.4544). A difference between general and psychiatric hospitals, as organisations, was that in the latter governments could implement policy decisions via departmental officers. During the

88 late 1950s, for example, state governments implemented a policy of ‘deinstitutionalisation’ by creating new positions, mainly for nurses, and developing new services. In NSW (NSW Health Advisory Council 1961; DHNSW 1971) and Victoria (Dax 1961), hospitals commenced early intervention and community treatment programs and restrictive admission policies. Hospitals thereafter declined in size (Stoller 1972; Shiraev 1979). The experience of NSW illustrates the effect of these changes. Between 1965 and 1975 this state closed 5000 Schedule 5 hospital beds, a decline from 3 to 1.2 beds per thousand population (Shiraev 1979). This was achieved, as overseas, by placing long-term residents into community housing (Apt 1971; Barclay 1961; Chu & Trotter 1974; Dax 1961; Kenig 1985; Lindemann 1965; Roemer 1969; Satin 1994; Stoller 1972). The composition of practitioners changed. The traditional doctor nurse dyad expanded with the employment of allied health professionals creating multidisciplinary teams who then established preventive, treatment, rehabilitative services − sheltered accommodation and employment, outpatient clinics, group programs, and day centres (Dax 1961; H&HSC 1974; NSW Parliament 1973; Shiraev 1979; Stoller 1972). New services, focused on people's psycho-social needs, developed with multidisciplinary teams (Henessey 1970a,b; H&HSC 1974).

General Practitioners Most of the population consulted GPs when they had health problems. How GPs responded was of concern to health department bureaucrats and medical academics. By the 1970s, as Sax (1972a p.198) pointed out, GPs were seeing people who would have benefited from preventive strategies, the ‘worried well’ and ‘early sick’ and persons with mental health or chronic problems. Doctors recognised GPs' use of preventive strategies was sporadic and haphazard (Champion De Crespigny 1972). Medical educators such as Saint (1971 p.11), a Dean of Medicine, attributed this to their education, observing they failed to understand the social and environmental influences on health and lacked the required skills and orientation. Others agreed. A report by an adviser to Hayden, Minister for Social Services questioned if ‘the so-called ‘family doctor’ had the capacity to ‘diagnose, let alone to treat, many ... situations’ and noted ‘the pride of the profession’ meant some were unwilling to refer to other professionals (Hall 1973, p.17). The current system of medical education was not providing GPs with adequate preparation for practice. This was a policy issue with budgetary implications. As Sax (1972a p.24) made clear, if GPs failed to recognise lifestyle influences, diagnoses leading to inappropriate and costly treatment could follow because potential and actual influences on a person's health had been ignored. He argued that practitioners (GPs) had lost ‘sight of people’s needs to be made whole’ (Sax 1972a p.24). By the early 1970s the health care system provided what Dreitzel (1971) described as mechanical-problem-orientated care. Dissatisfaction with the way doctors provided care was becoming more widespread (Bryant 1973; Hart 1972; Illich et al 1977; The Boston Women's Collective 1976).

89 National H&HSC Review of Hospitals The architects of the CHP policy conducted a national review of hospitals in 1973 (H&HSC 1974). This important report offers insights into H&HSC Commissioners' concerns about health care and their expectations of the CHP policy. The Victorian Government, which had excluded itself from a review of chronic illnesses, injuries and impairments in May 1968, also excluded itself from this review (ABS 1971, p.427). This decision was prompted by conflict over Medibank leading it to decline funding to establish CHCs in under-serviced areas (Deer Park, Kingston, Eagle Hawke). The organisational problems identified were significant and can be taken to apply to hospitals in NSW. Concerns were raised about administrative and care processes with general hospitals identified as having most problems. The review team identified a lack of goals, procedures and teamwork between disciplines, inappropriate admissions, inefficient and ‘poor quality’ care and ‘less than optimal’ continuity of care upon discharge (H&HSC 1974 p.17). They recommended hospitals institute policies and procedures to facilitate medical and nursing work (p.19). The autonomy granted to doctors and the limits imposed on nurses gave cause for concern. Registered nurses were found to be carrying out and coordinating the care provided by other professionals (junior doctors, technicians, allied health) while oversighting student nurses providing nursing care. For the review team this practice limited nurses’ contact with patients, hindering their ability to see them as ‘whole’ people (p.20). Implicit in this review was criticism of nursing and medical practice. The culture of general hospitals has been criticised by various authors, as Chapters 2 and 3 illustrated. This review raised similar concerns observing that hospitals had been ‘historically unresponsive’ to patients' emotional and social needs (p.37). The reviewers concluded general hospitals were unable to meet the needs of aged, disabled, and chronically ill populations. They proposed establishing new services: community-based rehabilitation units, hostels, domiciliary services and assessment teams and geriatric assessment teams, to prevent unnecessary admission and institutionalisation of elderly persons. To improve the quality of care for the elderly they proposed co-locating psychiatric and general hospitals so nurses trained in psychiatry and rehabilitation could be involved in caring for this population (pp.49-50). General hospital staff, it argued, lacked the skills and knowledge required to care for those with long term problems. The review was less critical of psychiatric hospitals. Facilities were found to be working more effectively with people in need of long term care. They provided preventive, treatment and rehabilitation services and staff were involved in community planning, service evaluation, staff development, research and professional and public education (p.46). The major criticisms of these hospitals was that services were limited in rural areas, coordination between community and hospital services was limited, and from the perspective of patients, rehabilitation was hindered by the impersonal nature and isolation of hospitals (p.48). The review team saw general hospitals as having ‘much to learn from the concepts of multidisciplinary teamwork and patient responsibility practised in psychiatric units’ (p.49). Yet they observed that general hospitals were crucial and

90 ... major components of our community health services which, in turn, interact in complex ways with individual, environmental and social determinants of health. Activity in one sector of the system evokes changes in other components. Consideration of hospitals in isolation could therefore lead to a continuation of the undesirable features now evident. Hospitals must be examined at least in the context of those personal health services which are provided for individuals, as distinct from the environmental health services which manipulate our environment in the interests of the community as a whole (p.73). The concerns of the review team were obvious. The effectiveness and efficiency of general hospitals influenced demand for inpatient care and led to ‘easy crisis-reactive solutions - to build and staff facilities at hospitals to cope with demand!’. A ‘more appropriate’ solution was to improve community health services so that only those who could not be cared for elsewhere attended hospitals (pp.75-76). The reviewers noted that many hospitals were ‘...overstretched badly located, too narrow in their purpose and too expensive’, a problem compounded by a ‘lack of specific rational criteria for determining need, measuring performance, and achieving control over the performance of the institution’ (p.16). The suggestion offered to overcome these problems was to establish a regional administrative structure which gave administrators responsibility for developing ‘quality health systems’ although this would limit the autonomy of ‘some groups’ (p.81). Regional administrators were envisaged as accountable to governments for ensuring that all population groups, even those who failed ‘to win community acceptance’, had access to efficient, effective services (p.83). Cooperation and liaison between public, private and welfare sectors, were considered central to this proposal as with the ..support of CHCs, general practice, nursing homes and domiciliary care, the hospital can reach more people in need and contain illness by attacking it early (p.85). A central role for administrators was changing the usage of general hospital beds (p.91). The political implications of this expectation were understood. Regional administrators, it was argued, would require ‘vigilance’, ‘administrative skill and courage’ (p.99) to change bed usage as ‘the role of the hospital in the community depends as much on social history as upon the patterns of disease in society’ (p.101). A central argument running through this review is that people's needs could more appropriately be met by providing coordinated and continuous rather than episodic care. Its recommendations are provocative as they challenge the autonomy long enjoyed by general hospital administrators, boards and medical specialists while advocating that registered nurses be granted greater control over their practice. The recommendations made were provocative but also consistent with views long expressed by various health department bureaucrats, especially in NSW, and public health advocates, many of whom were doctors. Implementing such proposals would prove difficult for two reasons, the structure of the health system and purpose of professional education.

Professional Education Pre-registration medical and nursing education programs were directed at preparing students to practise in general hospitals, caring for the acutely ill, and training in specialties. This preparation did not reflect the health needs of the greater part of the Australian population as earlier discussion illustrates. Graduates of

91 medical (Administrative Officer Interview 1.1; Olsen Interview) and general nursing programs (Administrative Officer Interview 41; Personal Recollection) recall curricula dominated by a focus on body systems and by internal and procedural specialists. Little changed. By the early 1970s medical schools had begun appointing professors of preventive and community medicine. They and other authors advocated for change but appear to have had little impact on the content or ethos of medical courses or how doctors practised (q.v. Champion De Crispigny 1972; Hall 1973; Hetzel 1971a; McCarthy 1977; Saint 1971; Sax 1972a; Walpole 1984a,b; Webster 1984). Students gained little clinical experience outside hospitals prior to graduating. The concerns of many educators were identified in the Karmel Report (1973) which recommended establishing departments of community medicine and a new medical school in the Hunter Region. Medical education was narrowly focused for all students. The basic education of nursing students varied. An apprenticeship program meant their education varied depending on their employer. By 1966 students in NSW could train as general, psychiatric, mental retardation2, or geriatric nurses. Most undertook general training (ABS 1976 p. 588). As the work of Russell (1990), a nurse, historian and academic illustrates, reviews of nursing education undertaken from the 1960s describe general nursing courses as narrow and inadequate. Graduates of such courses, as Meyers (1970) explained in a paper presented to the third International Hospital Federation Conference in Sydney, were ‘ill-prepared’ to respond to ‘demands placed on them by advances in medicine and changing patterns of disease’ (p.1). In 1978 a report of a Committee of Inquiry into Nurse Education and Training Report conducted for the Tertiary Education Commission saw fit to quote a WHO consultant, Dr Rae Chittick, who in 1968 observed that general nursing students in NSW were provided with a ‘narrow restricted and unimaginative’ education that failed to ‘enlarge their vision’ or raise their awareness of ‘social, political and cultural problems’ (p. 10). Students of psychiatric nursing received a somewhat broader, but also limited, education (Appendix 5.2). Nursing texts and a Nurses Registration Board examination paper (NSW NRB Psychiatric Examination May 1967; Maddison, Day & Leabeater 1963) illustrate students learnt that there are individual, family, social, economic and cultural influences on the development of psychiatric illnesses. However, the acuity or chronicity of illnesses of the patients3 they cared for varied and this affected what students learnt. Many were required to gain acute experience at other hospitals (Personal Recollection). Another major difference between general and psychiatric nursing students by the early 1970s concerned their clinical experience. Structural changes being implemented in psychiatric hospitals meant students were increasingly working in multidisciplinary teams and spending time with domiciliary nurses. General nursing students only gained experience with a district or domiciliary nursing service if their training hospitals provided this service and if they were selected for such a placement (Armitage 1991; McGrath 1974 p.49; Punton-Butler 1993). Such placements were optional, unlike in other countries (eg.

2 This term was used until it was replaced by developmental disability nursing. 3 When I began psychiatric nurse training patients' files were kept in the Medical Superintendents Office. I realised how much could be learnt from files (including biases) during clinical experiences at North Ryde Psychiatric Centre.

92 The United Kingdom). By the mid-1970s domiciliary or community placements had become a compulsory part of psychiatric nursing students' clinical experiences4. Once registered, nurses could undertake further studies. General trained nurses could apply for entry into midwifery, psychiatric or mental retardation nursing programs. Psychiatric nurses could apply for entry in general or mental retardation programs. The recruitment policy of each hospital and their need for staff determined whether applicants were accepted, as students were employees. Courses were also offered by professional organisations (Royal College of Nursing Australia, Melbourne, NSW College of Nursing, Sydney) and state government departments (eg. NSW Department of Health). Pre-registration medical and nursing courses were considered inadequate preparation for professional practice (Andrew 1970; Barclay 1969; Henderson Report 1974; Dewdney 1972; Health Advisory Committee 1961; Hetzel 1971a; Karmel Report 1973; Sax 1970, 1972a; Saint 1971; Truskett Report 1970; Watson 1979). However, by 1973 further study was only mandatory for those seeking entry into specialities. For nurses this meant midwifery or mothercraft nursing. In NSW the Karitane or Tresillian Society, both non-government organisations, conducted mothercraft courses for trained midwives (Gandevia 1978; Linn 1993). While general nursing programs provided students with little exposure to community nursing unlike, for example, in the United Kingdom (Cumberledge 1986), graduates could work as district or domiciliary nurses without further educational preparation. Registered nurses could also teach students without further preparation. This meant, as Russell (1990) found, that most of the nurses employed to teach nursing students were unqualified for their positions. By the mid-1960s the NSW Health Department conducted staff development programs for its employees (Dax 1961; H&HSC 1974: Cummins 1973). Courses in ward management (DHNSW 1968), rehabilitation and community nursing were offered. Nurses occupying, or seeking promotion to, ward manager, program officer, and community nursing positions were required to complete relevant programs (Personal recollection). In 1973, reflecting government commitment to community care, the NSW Health Department had 284 psychiatric, mothercraft, and geriatric nurse employees undertake a community nursing course (Cummins 1973, p.86). The NSW Government provided its employees with relevant education and supported their studies via study leave. Few non-government organisations or general hospitals offered nurses additional education until the 1980s (Archer 1976; Armitage 1993; Blue Nursing Service 1994; Buckley & Gray 1993; Cramer 1987; Durdin 1991; Frith 1975; Gandevia 1978; Gibson 1970; Holtzman 1979; Jones 1989; Johnson et al 1987; Kreger 1991; Linn 1993; Rosenthal 1974). For most nurses, unlike doctors, ongoing education was a personal choice undertaken at personal expense. Nurses could enrol in diploma programs in nursing administration or nursing education most of which were offered in capital cities. Access to education improved during the 1970s with the introduction of distance learning courses such as those offered by Armidale College of Advanced Education (Division of Graduate Studies Dip N. Ed. Course Notes 1979, 1980). Such qualifications were not essential to gain a

4 Psychiatric nursing students were allocated to CHCs from 1975.

93 position as an educator, ward sister or nursing administrator (eg matron) in most settings. In 1985 nursing education changed radically in NSW when responsibility for nursing education was removed from hospitals and transferred to Colleges of Advanced Education (CAEs) and a generic diploma in nursing replaced all certificates as a prerequisite for registration. Most allied health professionals were educated via professional colleges. Responsibility for these courses has slowly moved to the tertiary education sector. In NSW, for example, a College of Paramedical Studies conducted occupational, speech, physiotherapy and podiatry courses. This organisation subsequently became the Cumberland College of Health Sciences (1977) and thereafter offered diplomas in nursing (administration, education, community) (CCHS 1977). The education of social workers and psychologists differed. A degree followed by graduate clinical studies was common. Thus their educational experiences were often broader, academically and clinically, as most had placements with organisations other than general hospitals. The educational and clinical experiences of professionals varied, however, as ABS statistics illustrate. Most health workers were nurses and doctors and most worked in general hospitals with patients who were experiencing acute exacerbations of chronic physical illnesses (ABS 1973, 1984). Their working environments were often rigidly hierarchical. Position was determined by discipline, and within disciplines by length of service. Patients were at the bottom of the hierarchy. As Hart (1972, p.355) observed, in relation to British hospitals, the job of junior doctors and nurses, having been schooled in servility, was to carry out the orders of medical specialists and maintain discipline amongst their patients. The situation was similar in Australian hospitals. Histories of general hospitals portray these organisations as dominated by rules and traditions (Armitage 1992). As various authors pointed out, few doctors recognised the contribution made by nurses and allied health staff who applied skills they lacked (Champion De Crespnigy 1972; Hocking 1974; McCathy et al 1974a, 1974b, 1974c; MJA 1973; Saint 1972; Sax 1972). Some recognised that nurses' skills were under-utilised and that few practised to the limit of their legal responsibilities (Archer 1976; Champion De Crispigny 1972; Cummins 1973; Durdin 1991; Kreger 1991; McCarthy et al 1974a, 1974b, 1974c; NSWSG 1972; Shireav 1979). Registered nurses remained an under-used resource and this was costly to governments and communities (H&HSC 1974; Mahler 1985; Sax 1972a). The proposed expansion of community care had implications for professional education and practice, especially for nurses and GPs. In her report for the National Health and Medical Research Council (NHMRC) Ruth White, a nurse and PhD, argued that the joint trends to make more effective use of hospital beds and to broaden the concept of health to include ‘the effects of social and economic deprivation’ created new responsibilities for nurses such as ‘case finding and identification of persons at risk due to social and behavioural maladaption’ (1972, p.21). White argued that nurses’ current responsibilities, teaching and advising, only became meaningful by extending the ‘concepts of disability and rehabilitation ... to include mental and emotional impairment and preparation for family and community roles’ (p.21). The problem for governments was to find a model of care to facilitate integration of treatment,

94 rehabilitation and preventive services across all levels of care, primary, secondary and tertiary and to involve all professional groups. The most promising model was community health centres, CHCs.

CHCs a Solution to Contemporary Problems By 1970 medical academics and health bureaucrats internationally were advocating CHCs as appropriate venues for providing health care. There was recognition that health professionals required a preventive orientation to address contemporary health problems (Roemer 1969; Sax 1972a; Milio 1975a,b, 1976a,b, 1979). Education programs and general hospitals had yet to promote a preventive focus. GPs, as Roemer (1969, p.123) observed, being ‘fully occupied meeting the demands of sick patients’ had little time or ‘interest in seeking out others for attention’ or access to the staff they required to provide routine preventive services. Academics like Saint (1971 p. 11) saw the solution as providing GPs with access to allied health professionals and nurses. The organisational structure with the greatest potential for teamwork was CHCs. The problem, as discussed in Chapter 3, was how to implement CHCs. In the United Kingdom slow progress was made between 1946 and 1970s (Hall et al 1975). By 1971 some 1625 doctors practised at 307 centres scattered across England and Wales (p.277). Disputes over whether doctors, communities or local governments should control centres, and the purpose of centres, had been addressed (Fraser 1984; Hall, et al 1975). Services were offered to total and specific populations and issues associated with poverty were being addressed (Fraser 1984). Distribution issues had been addressed by encouraging GPs to rent NHS premises in under serviced areas which co-located them with nurses and midwives (Campion De Crespigny 1971; Hall et al 1975; Roemer 1969, 1977). By the 1980s almost a quarter of GPs worked from CHCs (Ashton & Seymour 1990). The situation differed in the United States of America where mental health and neighbourhood centres (part of a federal anti- poverty program) had flourished with government support (Caplan 1964; Chu & Trotter 1974; Gross 1973; National Association of CHCs 1995; Roemer 1969, 1977; Satin 1994; Singh 1971; Whittington 1972). Centres focused on specific populations. Neighbourhood centres, managed by local boards, were mostly located in disadvantaged and minority communities. In the United Kingdom the NHS established CHCs to resolve distribution problems and to co-locate GPs with nursing and other government services. In the United States of America CHCs were established to provide disadvantaged and/or minority populations with access to medical and other services. Canada took a more universal approach. The Canadian Health Ministers’ Health Centre Project Report demonstrates that there CHCs were considered a means for addressing contemporary health problems and resolving structural issues confronting their health system. The report describes CHCs as .. an effective response to many problems other than costs in the existing way health services are provided. It is suggested that they offer a setting in which the community's resources can be brought to bear in a more dynamic relationship with the health professionals and services in trying to solve people's health and related problems. This newly aroused interest in "people centred" and "problem centred" approaches to health care had arisen amongst other sources from the Castonquay-Nepveu (Commission of Enquiry on Health and Social Welfare, Quebec 1970) and Celdic Reports (Commission on Emotional and Learning Disorders in Children, Toronto 1970) in Canada, the

95 American O.E.C and H.M.O experience, and current developments in the United Kingdom and elsewhere, as well as from a general awareness that better ways are needed for meeting the many- sided problems people, families and communities now face (Report of the CHC Project to the Conference of Health Ministers 1972, p.362). This committee considered CHCs as a model of service delivery which could focus attention on the total needs of communities. Here, as in the United Kingdom, development was slow (Church 1993; Lomas 1985; Report of the CHC Project to the Conference for Health Ministers 1972; Sutherland & Fulton 1990, 1994). Only Quebec acted on the Castonquay-Nepveu (Commission of Enquiry on Health and Social Welfare, Quebec, 1970) and Lalonde (1974) Reports to pass legislation enabling 200 community-controlled Community Local Service Centres to be established (CLSCs) (Hall 1973, p.26). These centres offered free, comprehensive (social, primary medical, nursing, preventive, public health) services for geographically defined populations taking account of disadvantaged and minority populations. By 1994, as my report to the NSW Nurses Registration Board illustrated, most centres were located in French speaking areas of Quebec and offered a broad mix of public, occupational, and personal health services. Communities could become involved in decision-making via boards of management and community meetings (Schulz 1992c). By the early 1970s support for CHCs was evident in Australia. Two groups promoted this form of organisation; health department bureaucrats, especially in NSW (Eglington 1968; H&HSC 1973, 1974, 1976a; Meyers 1966, 1972; McEwin 1970; Starr 1969), and medical academics (Andrews et al 1972; Barnes et al 1972; Beard 1973; Champion de Crespigny 1971, 1972; Editorial, MJA, 1973; Hetzel 1971b; Saint 1970a 1971; Webster 1984). Champion De Crespigny, for example, demonstrated the importance attributed to health centres by this time by observing they were mentioned in all developed countries when ‘the future of general practice is discussed’ (1972, p.1308). There was some recognition amongst doctors that CHCs would benefit GPs and their clients (Andrew 1971; Andrews et al 1972; Andersen, Corlis, Davis, Hennessy, Latham, Norton, Rundle, Saxby & Tracy 1972; Gordon 1972; Hetzel 1970; McCathy et al 1974a,b,c; Pang 1973; Saint 1970, 1971; Sax 1970, 1972a; Webster 1971). Labor Party politicians supported CHCs seeing their potential for resolving problems associated with the cost and distribution of health care (Hansard 11.12.1973; Sax 1984; Scotton & McDonald 1993). In Australia, as in Canada and the United Kingdom, disagreement arose over the purpose of CHCs and who should manage them. Greatest support was evident for medical control as the greatest benefit of CHCs was seen to lay in assisting GPs respond more appropriately to contemporary health problems. For academics like Champion De Crespigny (1972) and Saint (1970, 1971) in Queensland and Anderson et al (1972), CHCs were beneficial because they could be used as teaching centres where medical students could learn about multidisciplinary practice. The expectation, I suspect, was that students would transfer what they learnt at CHCs when practising in other settings. For doctors concerned with public health issues and health service provision CHCs were a means to foster coordination between services and levels of care (Beard 1973; Sax 1972a; Roemer 1969; Webster 1971).

96 Doctors were considered the most appropriate managers for CHCs (Barnes et al 1972, p.130; Hetzel 1970). Hayden, as Shadow Minister for Health, held to this view (cited by Sax 1984). A NSW State Government Task Force to examine the benefit of CHCs, conducted by the Royal Australian College of General Practitioners, also promoted medical management (Andrews et al 1972). Overseas experience, however, was demonstrating that doctors were ill-prepared to manage CHCs (Roemer 1969). By 1972 most CHCs in Australia were being managed by GPs (Beard 1973; Combes, Rose & Farrell 1971; Crouch & Colton 1983; H&HSC 1976a; Scotton & McDonald 1993). Few centres employed salaried doctors, a practice opposed by the Australian Medical Association (AMA), or outreached to communities being mostly concerned with people actively seeking care. There was some acceptance of CHCs as Andrew illustrates when observing that: I think we have reached a point in the history of medical development when there is an astonishingly uniform agreement by many actively and intensively studying the problem, not only on the merits of CHCs to solve many of our problems, but on their absolute necessity (Andrew 1971, p. 238 ). Amongst doctors there was some acceptance of CHCs as an organisational form. What remained unresolved was the purpose of CHCs. By this time some state governments had clear ideas about how CHCs might be established and for what purpose.

New South Wales’ CHP Proposals By the 1960s, a decade before the national CHP policy was written, NSW Health Department bureaucrats had plans to establish CHCs. By 1970 centres were operating at Queenscliff, Manly-Warringah, Blacktown Hospital, Western Sydney and Glebe in inner Sydney (Blacktown Health Centre 1972; Australian Government Commission of Inquiry into Poverty 1977; Crouch & Colton 1983, p.17; Queenscliff Health Centre 1971). The Glebe CHC, a joint venture between Royal Prince Alfred and Balmain Hospitals, local Councils and the NSW Health Commission, acted as a student teaching facility for nursing, medicine and allied health students (Crouch & Colton 1983, p.17). A comprehensive range of services was offered by each to defined populations. Mental health centres (eg. Erskine Street) were operated in other areas (Darcy 1972; Cummins 1973). When implementation of the CHP policy began in 1973 NSW already had CHCs and mental health centres operating, mostly in Sydney. From 1966 the NSW Liberal Government had been developing plans to establish a community health program (CHP) as reports of Meyers (1966), Eglington (1968), Starr (1969), Advisory Committee on Personal Health Services for Metropolitan Regions (1972) and a Consultative Document (1972) demonstrate. These reports recommended developing an integrated system of hospital and primary care services to support GPs. Community nurses were foundational to each proposal. The Meyers Report proposed building nurse centres near doctors' surgeries so nurses could coordinate services and provide primary care (Meyers 1966; Sax 1984). The Eglington Report supported regional planning, flexible regional administration, integrating acute and preventive services, health policy, hospital outreach and government control of public hospitals (1968 p.6). The Starr Report proposed the establishment of a

97 Health Commission (1969, p.19) the responsibilities of which, outlined in a Consultative Document (1972), were to promote, protect, develop, maintain and improve the health of the population of NSW. An important feature of these reports is that they view community nurses' responsibilities and their relationships with GPs differently. The Eglington (1968) report, for example, taking a public health approach, expected nurses to take responsibility for case finding and providing health education, support and advice. Some doctors (Champion De Crespigny 1972; Hennessy 1974; McCathy et al 1974a, 1974b, 1974c; McEwin 1970; NSWDHSRP 1971; Sax 1972a, 1984; White 1972) were supportive of nurses providing primary care as they did in the USA (Widdington 1972), the United Kingdom (Health Visitors Association 1994; Tate 1973) and in Canada (Canadian PHN Association 1990; Shardt 1973). The Royal College of General Practitioners did not share this view (Andrews et al 1972). Implementation of the CHP policy began as these issues were still being resolved in NSW and as a new organisation, a Health Commission, began operating. The enactment of a NSW Health Commission Act in 1972 created three Bureaus, Personal Health Services; Manpower and Management Services; and an Environmental and Special Health Services. The latter administered ten divisions and four branches. The Division of Health Education, then trying to encourage hospitals to provide health education programs for patients and the public, was one of these Divisions. It also administered various Acts: Public Health Act 1902; Noxious Trades Act 1902; Fluoridation of Public Water Supplies and Clean Waters Act 1970; Therapeutic Goods and Cosmetics Act 1971; Private Hospitals Act 1908; Venereal Diseases Act 1918; Pure Food Act 1908; Clean Air Act 1961; Poisons Act 1966; Radioactive Substances Act and the Anatomy Act 1901. The Health Commission Act enabled the NSW Government to establish health regions and delegate to regional administrators the authority to operate preventive, treatment, child, adult, general, psychiatric and primary nursing services. This Act enabled the government to establish a regional structure through which to develop and administer health services and for this reason it was integral to the processes used to implement the CHP policy. The Health Commission Act was opposed and supported by health department bureaucrats. The Director of Public Health, Charles Cummins, opposed it for reasons he explains in a history of Public Health Administration in NSW (1979). Other senior officers, the Director, State Psychiatric Services, Bill Barclay, the, Director, Developmental Disability Services, Allan Jennings, a Senior Psychiatrist at North Ryde Psychiatric Centre, Brian Hennessy and the Director, Division, Health Services Research & Planning (DHSR&P), Department of Health, Sidney Sax, were supportive according to Sax (Interview 1991). Research conducted by the Division of Health Services Research and Planning prior to the Health Commission Act being legislated provides some insights into why the CHP policy was implemented so vigorously in NSW and the ensuing conflict that arose over the responsibilities of GCNs.

Expectations of Community Nurses Official reports demonstrate that by 1973 NSW had well-established plans to establish a CHP. The responsibilities of community nurses remained contentious. Essentially, conflict between various

98 stakeholders revolved around two issues, how much autonomy nurses should have and whether they should work as generalists or specialists. Between 1971 and 1973 two generalist nursing projects were undertaken in NSW. These projects illustrate what some bureaucrats expected of nurses. One project was conducted in south-west Sydney, a growth area and electorate of Gough Whitlam, Leader of the Australian Labor Party, and the other in Brewarrina, western NSW. The project conducted in south-west Sydney was opposed by two groups − GPs and maternal and child health nurses (Brady, Buck, Harris & Logan 1982, NSW NA Archives; NSWDHSRP 1971; Sax 1972a, 1984, Interview 1991). The project conducted in Brewarrina was opposed by doctors (Administrator Interview 1.13). A report of the first project, conducted by a research officer, Jenny Gormley, and oversighted by Sax, portrays a broad role for GCNs. Nurses engaged in traditional ‘case work’ and community development activities were to assist residents of new suburbs form communities and groups. While positive about GCN potential, the authors observe that to undertake a generalist role nurses required ‘proper training’ in social and behavioural sciences (NSWDHSRP 1971, p.25). Staffing levels proposed were two nurses in a neighbourhood of 10,000 to 12,000 persons providing primary care, school medical, baby and mental health and possibly domiciliary nursing (p.35). A potentially contentious proposal was to attach generalists providing baby health services to the Sydney Home Nursing Service and then second them to neighbourhood centres or sub-regional hospitals (p.30). Such a proposal would have enabled baby health nurses to be redeployed to the burgeoning under-serviced suburbs on the city periphery. The focus of this report is not reflected in later reports. The Advisory Committee on Personal Health Services within Metropolitan Regions (DHNSW 1972) was more influential. This report proposed that five principles guide service development: promotion and maintenance of health; prevention of disease, early detection of avoidable disease; diagnosis and management of disease and disability; and rehabilitation for the disabled. Four criteria were set for evaluation: quality, accessibility, continuity and efficiency. The stated aim of a health service, it was suggested, was to provide comprehensive services using the ‘most up-to-date knowledge and techniques’ (quality) available ‘where and when’ needed beyond episodes of illness (accessible, efficient) by professionals who had established a relationship with clients (continuity) (p.4-5). Like the earlier Meyers Report (1966) it recommended delineating regions, areas, neighbourhoods and localities and specifying care levels, primary (non-institutional), specialist and hospital, district and referral. Primary care centres were a central part of this proposal. Staffing ratios and responsibilities were clearly stated. It recommended that two nurses, student nurses or nurse aides, and two or three doctors work in a locality of 10,000 to 12,000 people. A nurse working with <6000 people would: outreach, coordinate care, liaise with other services, offer social intervention, health screening/counselling, home nursing, and surveillance of those at special risk of breakdown. Their focus was prevention, mobilising support for the very old, isolated, recently bereaved, persons with chronic illness or disabilities, newly discharged from hospital and at risk populations (1972, p.8). It was expected that nurses would advise, treat, follow-up, refer, mobilise services, assist doctors to care for persons with

99 psycho-social, chronic physical, psychiatric or developmental problems and form links between services. These nurses were envisaged as being supported by Neighbourhood Centres (for 40,000 people) offering child health and guidance, immunization, mental health, health education, dental, social work consultations, home aide services, equipment, accommodation for voluntary workers and ‘appropriately transferred’ hospital services (DHNSW 1972, p.9). Assistant Regional Directors, Community Health, based at district hospitals (for 160,000), were envisaged as guiding centre development in consultation with local doctors who would be encouraged to use community services (DHNSW 1972, p.11). The Advisory Committee and Meyers (1966) Reports reflect concern for elderly, disabled and chronically ill populations. By contrast the Department of Health and the Hospitals Commission Report (NSWDHSRP 1971) is concerned with the needs of families living in new suburbs with few services. Bureaucrats with the NSW Health Department, Divisions of Maternal and Infant Care and Psychiatry, such as Drs Barclay (psychiatry), Jennings (developmental disability) and Sax (geriatrics), were concerned that total populations had ready access to comprehensive primary care services. Such services were expected to take account of the needs of specific population groups, aged or mentally ill persons and families. The concerns and perspective reflected in these reports regarding nurses' responsibilities had implications for the way the CHP policy was subsequently implemented in NSW. The views of Sax, Chair of the H&HSC, concerning the responsibilities of administrators are also important.

Expectations of Administrators Sax made his expectations of administrators clear before being appointed interim Chair of the H&HSC (1972a, 1972b, 1984, Interview 1991). Administrators were responsible for bringing people in need of care together with practitioners. He considered the interactions between practitioners and clients more important than buildings as: The clinic or the hospital do not have the intrinsic function of providing care; they are the facilities where health personnel associate and where the organisation of teamwork is facilitated. The administrator's role is to help these providers and the consumers of care to achieve their mutual goals, and he [sic] should seek to understand those goals. To succeed, he must be sensitive to the expectations of health service clients, and seek means of identifying those attitudes and beliefs which influence people's decisions to participate in, or reject care. In any individual the decision may be influenced not only by personal and family characteristics, cultural background and social environment, but also his knowledge and experience of the health care process. Warped knowledge, or unsatisfactory experiences, may result in unwillingness to seek care or in neglect of advice when it is received. Steps must be taken, therefore, to identify these factors so that levels of awareness and personal motivation in the community can be raised (Sax 1972a, p.174). By 1973 Sax was clearly dissatisfied with the status quo, with the way health services were being administered, as Hospitals and other facilities provided now will influence future patterns of supplying health care and may pre-empt the options for change. Innovation should be encouraged, therefore, and can be thought of as a recurring cycle of inquiries which 'each time round (as it were), produces some improvement, or at least keeps services abreast of changing need and demand' (Sax 1972a, p.178).

100 For Sax the outcomes of health care were limited and evaluating end results of any interventions was difficult. He saw ‘good care’ as requiring ‘intelligent cooperation between practitioners and their clients in general... coordinated with social welfare work’ and a preventive orientation (p. 179). Cooperation between departments, different organisations and/or sectors was essential and dependent on administration. Sax considered effective administration paramount to improving the effectiveness of health care systems. The role of administrators was to document procedures in order to maintain relationships and standards, and to control economic resources, to provide training and opportunities for advancement, and to reduce intra-organisational conflict (p.186-187). It was not to direct change. For Sax change began at the ‘workface’ with individuals who, guided by standards to measure achievement, decided what was important, inspired by leaders who did things with them rather than to them. Line management, in his view, was ‘old-fashioned’ while ‘good management’ was a ‘joint exercise by managers and workers with decision making, setting and ‘attaining goals for the organisation’ involving workers who took as well as ‘helping to devise’ instructions (p.187) as: In addition to relationships with and amongst staff, the management of a health service must be concerned about cooperation with community activities which have a bearing on its own goals, and it needs to promote its own achievements and objectives in the community to secure public understanding. It should develop procedures for testing consumer opinion so that clients' wishes will be taken into account when planning hours of services, and their location, procedures, amenities and staff attitudes (p.187). Professional advisory committees were considered essential to: ... help in the setting of technical standards, and in developing procedures for the supervision of performance and referrals, and for the appropriate use of all personnel. Areas of responsibility must be clearly determined. The administration should develop relationships with other medical care programmes in the community, and joint planning may help in the arrangement of referrals, follow-up of patients to provide continuity of care, and a sharing of responsibility in the maintaining of standards. These may be developed in relation to the community generally, or to the professional providers of care, or to the setting in which it is provided (Sax 1972a, p.187). Effectiveness, efficiency and productivity were important as he pointed out: Considerations of productivity lead inevitably to the conclusion that the benefits derived from a programme should be related to the costs of their production. Several management techniques are available for the calculation of these relationships. They include cost benefit analysis and programmes budgeting. Both are difficult to apply in the health field. Information is lacking and, on the broad front, it may not even be clear what information we seek. Outcomes are affected not only by medical care programmes but by the efforts of welfare agencies, relatives and neighbours. Will their contribution be measured? Will productivity be measured in terms of effort or effect? The one measures attendances, tests done, injections given and so on; it has no known relationship to effect in the sense of lowered mortality, improved work capacity or lessened domestic dependency (Sax 1972a, p.189). By 1973 there were politicians from all political parties advocating for more accessible health care. However, they disagreed as to whether services should be universally accessible, free at point of entry, or restricted and only free to persons identified as being unable to pay (Hansard 11.12. 1973, p.4538-4559). This ideological sticking point fostered conflict amongst stakeholder groups and affected how the CHP policy was implemented in different states.

101

The Australian Labor Party’s Health Reforms Wilensky and Lebeaux (1958) identify two conceptualisations of social welfare, residual and institutional. From a residual perspective, based on a free market ideology, individuals are perceived to be responsible for their own welfare. Requests for help are considered abnormal and stigmatising. An institutional perspective, reflecting social democratic values (security, equality, humanism) views members of contemporary society as having needs that become ‘ipso facto ... a legitimate claim on the whole society’ (p.139). Providing universal free services to assist people gain satisfying standards of life, health, personal and social relationships ‘in harmony’ with community become, from this perspective, a normal function of government. In 1972 both ideological positions were evident, however a residual perspective dominated, being enshrined in health funding and organisational structures. Various authors argued that in the Australian health care system federal governments had a tradition of assisting private rather than public sector services (Dewdney 1972; Sax 1972a, 1984). This was not the position of the Whitlam Government. This government was interventionist but from an ‘institutional perspective’, promoting growth of public rather than private sector services. Between 1957 and 1972 Whitlam expressed the view that federal governments required greater control of health care to: reduce the cost of health care to governments, individuals and families; increase access for populations; and expand non-inpatient ambulatory services. He wanted to establish a National Health Service to enable federal governments to control the cost, distribution and the orientation of the Australian health care system. The sticking point was a Constitution that precluded civil conscription of doctors (Scotton 1970; Whitlam 1977). Section 96 empowered federal governments to provide financial grants and under Section 51 (xxiiiA) fund hospital benefits, medical and dental services, pharmaceutical schemes and grants for domiciliary nursing services. As Whitlam (1977 p.60) argued in his 1961 Curtin Memorial Lecture, the Constitution did not preclude the socialisation of hospitals. The Commonwealth could: ... provide hospitals and clinics but would usually be duplicating existing facilities by doing so. It is clear that the proper approach in the Australian context is for the Commonwealth to make additional grants to the States on condition that they regionalise their hospital services and establish salaried and sessional medical and ancillary staffs in hospitals. Such measures would attack costs where they are greatest for the individual and for the community. The greatest hardship is to a breadwinner brought about when he or a dependant is admitted to hospital. It is in hospitals that medical care is most expensive for the community. The best way to achieve a proper National Health Service is to establish a National Hospital System. Quite apart from the economic advantages there is a great social advantage of providing both patients and doctors with an alternative to the present system. Patients would be free to consult the salaried staffs; doctors would be free to join them. Doctors and patients and communities are alike unable to provide an alternative. Only the Commonwealth can give them choice. There is no sphere in which government initiative can be such a liberating force (p.60-61). By 1968 Whitlam supported forming an NHS based on Commonwealth hospitals, staffed by salaried doctors, providing extensive ambulatory care services for elderly, chronically ill and disabled persons (Whitlam 1968a,b, 1977). His reasoning, as he explained to medical students (using Royal Newcastle

102 Hospital as an example), was that his proposal would reduce costs by capping salaries and reducing hospital admissions and so inpatients (Whitlam 1968a). It was a tenable position supported internationally by numerous authors who argued that providing accessible coordinated, hospital, ambulatory, community nursing, midwifery and primary care was easier via an NHS (Andrews 1973; Baggott 1994; Fraser 1984; Kohn & White 1976; Milio 1975a,b; Roemer 1969, 1971, 1977; Scotton 1970; Stoller 1978; Whitlam 1957; White 1985). In his 1972 election speech, however, Whitlam committed Labor to developing a system of CHCs, preventive programs and employing salaried doctors rather than an NHS. He stated that: A Labor Government will set up an Australian Hospitals Commission to promote the modernisation and regionalisation of hospitals. The Commission will be concerned with more than just hospital services. Its concern and financial support will extend to the development of community-based health services and the sponsoring of preventative health programs. We will sponsor public nursing homes. We will develop community health clinics. These services will call for the employment of increasing numbers of salaried doctors. Let me emphasise that far from restricting the choice of doctors or patients our proposals will widen them and will in fact provide a new avenue of employment and community service to members of the medical profession (Whitlam 1972, p.16). This change in policy direction reflects tensions that arose within the Labor Party between various groups regarding the benefits of an NHS and about Medibank. Whitlam (1961, 1968a) supported establishing a system of Commonwealth hospitals, and medically qualified politicians wanted a system of CHCs in order to resolve problems of maldistribution (Everingham, Hansard 11.12.1973, p.4538-4559; Scotton & McDonald 1993). The impetus for developing a CHP policy is disputed even by those involved. The focus it seems shifted over time. According to Scotton, an economist, attention moved ‘from the mechanisms of insurance’ to how services were organised (1970, p. 87). Palmer (1979), a part-time H&HSC Commissioner, agreed, observing that between 1969 and 1972 concern arose over service delivery. Later Scotton and McDonald (1993) argued the CHP policy evolved to appease left faction members opposed to Medibank5. According to Sax the NSW Government's existing plans to ‘expand community services and develop regional systems of administration’ were influential (1984, p.102, Interview). Whitlam was aware of these developments partly due to Sax, as Director of the Division of Health Services Research and Planning, forwarding reports to his electoral office (Interview). Public speeches reveal a deep understanding of NSW health services and support for regional health systems (Whitlam 1961, 1968a). The differences, as Scotton and McDonald (1983, p. 155) illustrate in their analysis of Medibank, was that many medically qualified bureaucrats and politicians viewed hospitals as ‘part’ of a health care system whereas for Whitlam they were the ‘cornerstone’. Members of the federal Labor Party and health bureaucrats in NSW had similar concerns. Sax provides a tight analysis of these concerns in a paper given to the Australian Association of Health Administrators on the ‘Organization and rationalisation of health services’ (Sax

5 The medical profession opposed Medibank on the basis it that it was the first step to nationalisation while medical members of the Labor Party opposed it for supporting private fee-for-service medicine.

103 1972b). According to Sax (Interview 1991) it was following this conference that the Shadow Minister for Health, Bill Hayden, who attended, offered him the position of health policy adviser to federal Labor. This decision was an important one for the birth of the CHP policy. Whitlam and Sax shared many similar concerns but differed on significant policy issues. For Sax and many of his peers CHCs were fundamental to creating an integrated primary, secondary and tertiary regional health service. But Sax, was ideologically opposed to an NHS, unlike Whitlam, Cass and Everingham, for reasons discussed in Medical Care in the Melting Pot (1972a). He saw NHSs as dominated by budgets and income rather than policies, goals and objectives and as failing to promote accountability or offer providers incentives to promote population health. Sax argued for central administration developing a framework of policies and goals to guide service development based on ‘objectives derived from expressed and tested needs’ rather than available monies, as he explained: A strong goal-orientated central administration is necessary for another equally important reason - to prevent the system from becoming excessively concerned with day-to-day crises which can become so energy-sapping that it responds to the pressures of the day on minor issues and neglects the broad perspective of health care (Sax 1972a, p.169). He argued for development of interlocking regional systems with discipline responsibilities defined and greater, more appropriate use being made of auxiliaries, assistants, and nurse practitioners (p.205-207). These views can be seen as rather radical. The AMA supported the status quo, especially the right of doctors to retain their position as gate keepers to care (p.208). Sax by contrast advocated the ‘promotion and protection of the principles of local autonomy’ conforming to central policies with communities participating in decision making. His conclusion to this monograph makes his vision clear as he states that: If this book had done nothing else, it should have shown that high quality health care can be provided most effectively and economically when local communities enter into arrangements with substantial local medical groups, and hospitals, in self-administered and self- regulated comprehensive schemes. A nationalized health service would abort any such scheme at its conception. It would be intolerable (Sax 1972a, p. 210). The need for effective management, evaluation of services, rationalisation of general hospitals, creative leadership and involvement of innovative voluntary agencies, to develop community health services was acknowledged, however, in his view: The most important challenge is to individuals. The successful planning of community health services requires action by informed and energetic persons. It is they who convey to their friends, associates, committees an understanding of changes in health care needs, and the goals that must be framed to meet those needs, it is they who will challenge the professions, the governments, the medical schools and the voluntary agencies to act (Sax 1972a, p.211). NSW Government reports portrayed CHCs and community nurses as instruments to alter how doctors and populations used inpatient, non-inpatient and primary care (Eglinton 1968; HCNSW 1977a,b,c,d,e,f; NSW Parliament 1976-1977; H&HSC 1974; Lawson 1968; Meyers 1966). Sax shared the Labor Party’s desire to establish an equitable health system but disagreed with the means chosen to achieve this goal. In 1973 Whitlam, committed to establishing Commonwealth hospitals,

104 asked the interim H&HSC to conduct a national review of hospitals to gain support for this venture. A Review Team was established and included Paul Gross (economist), George Palmer (academic), Brian Hennessey (psychiatrist), Pauline Pilkington (nurse administrator) and Sidney Sax (chair) amongst others. This team, as Sax (1984, Interview 1991) recalled, fought Whitlam on the issue of Commonwealth hospitals on the basis that: ... an equitable spatial distribution of hospitals would improve the efficiency and effectiveness of services only if the facilities were part of a comprehensive integrated system planned and managed under a single authority. Hospitals have a relationship to each other, to nursing homes, and to community health services, and they are influenced by community characteristics, the supply and distribution of doctors, transport patterns and demographic features (Sax 1984, p.119). An alternative proposal was developed which Whitlam accepted, the terms of reference for the review were broadened (Sax , Interview 1991; Scotton & McDonald 1993, pp.154-155, p.161). Thereafter the team reported to the Minister for Health, Douglas Everingham, on strategies to meet the health needs of Australians (H&HSC 1974, p.1). Major health problems were identified, some preventable and some associated with chronic illness, disability, psycho-social and environmental circumstances, and the team proposed establishing more community based preventive and rehabilitation services (for aged, mentally ill, congenitally handicapped, accident victims and disabled persons) using some CHP funding (H&HSC 1974, p.74). Funds were to be allocated to state governments as tied grants to control expenditure (Hansard 11.12.1973, p.4538-4558). In early 1973 the interim H&HSC developed roles and a structure for a national H&HSC. The H&HSC Bill tabled in Parliament in November 1973 (assented to on April 10th 1974) identified its responsibilities as: allocating funds to develop health services; organising a regional base for hospitals; developing community health and related services; rationalising existing services; manpower planning, conducting research and promoting cooperation between government and non-government organisations (Hansard 11.12. 1973, pp.4538-4559). This broad brief, like the proposal to establish a system of CHCs earlier, caused concern amongst Liberal and Democrat members of the House of Representatives.

A National Community Health Program The national CHP policy was written quickly, in five weeks, and tabled in Parliament in June 1973 by which time the Review of Hospitals had begun and funds had been committed for a Women’s Health Centre at Leichhardt, NSW (Crouch & Colton 1983, p.27). Implemented quickly, without legislation or prescriptive guidelines, it was funded separately to Medibank and left vulnerable to funding cuts after a change in government from December 1975 (H&HSC 1976a; Milio 1988a; Lloyd & Reid 1974; Freudenburg 1977, 1987). The policy identified primary (first level) care (not primary medical care) as its key. Primary care included: • preventive, diagnostic and therapeutic services, medical, X-ray, pharmacy and laboratory facilities; • complementary activities, day care, domiciliary care, transport to and from health services, personal welfare services, health education and environmental health activity; • dental, mental health, rehabilitation, alcoholism and drug services, family planning, case finding social

105 intervention and adequate follow-up programs (H&HSC 1973 p.5).

Primary care involved the services used by most people most of the time for common problems or to gain access to specialised services. The document a ‘Community Health Program for Australia’ offers some insights into the authors' expectations of how this policy’s objectives could be achieved. They needed to use up-to-date techniques and knowledge to focus on prevention; establish effective efficient management to coordinate local, regional and state services and create teams who could provide ‘courteous and prompt’ coordinated and continuous care (p.4). Wording was similar to that found in NSW reports. A diverse range of services are identified including: information and counselling for people with or without existing health problems; preventive action; detection of disease; diagnosis and treatment; rehabilitation; and for people with chronic disorders, support to assist them adapt to sheltered living or working conditions (H&HSC 1973, p.4). Four populations were identified as recipients of services: aged, chronically ill and disabled and those experiencing problems associated with psycho-social, economic or environmental circumstances. To enable services to reflect changing community profiles, characteristics, needs and values, ongoing evaluation and change were identified as essential (p.4). Clearly the authors of this policy envisaged the administrators engaging in policy development and dialogue and forming relationships with the practitioners who would implement it and the people who would use it. Strategies proposed to develop appropriate services were novel at this time. For example, giving and receiving information and health outreach were considered essential strategies for ensuring services were responsive, along with effective social advocacy to assist people to access appropriate personal health and welfare services (p.6). Successful implementation was also described as depending on interdisciplinary education programs; acceptance by providers and recipients; coordinated implementation; ongoing evaluation; and information (p.6). The central premise underpinning the CHP policy was that by offering alternatives to hospital admission and assisting people and communities to meet their own health and welfare needs ‘dependence on institutions’ would decline (H&HSC 1973 p.1). The notion of hospital use declining was attractive to the NSW treasury (Sax Interview 1991). Locating different professions in one facility was a way to broaden primary care and make teamwork, essential for coordination and continuity of care, easier. The size and composition of teams was not defined but clearly teams were expected to include doctors, nurses, psychologists, physiotherapists and social workers with decisions delayed until after a population's needs had been assessed (H&HSC 1973 p.6). Two types of need were identified, that judged by requests for services (expressed need), and that following analysis of qualitative, quantitative, epidemiological and census data (identified need). Knowledge of both ‘needs’ was essential with assessment taking account of medical, other primary care and welfare services, to preclude polarisation. The focus of pre-registration education programs was a concern. As the authors observed, appropriate professional education was essential to prevent implementation of this policy being 'jeopardised' (H&HSC

106 1973, p.7). Financial incentives were given to relevant institutions to place students at CHCs and to encourage them to agree on 'functions, inter-relationships and training programs of health personnel'. The Australian Psychological Association, for example, proposed that psychologists conduct research and evaluation, provide preventive health education, and work with volunteers (Viney 1974). Concern over status was evident. Clarifying generalist nurses', community health aides' and program administrators' responsibilities was considered essential in order to prevent further divisions arising between disciplines already divided by remuneration and status (H&HSC 1973, pp.6-8). The flexibility envisaged is reflected in the idea of CHC teams making ‘creative’ use of local, regional and state differences and responding to diversity rather than offering a 'uniform array' of services (p.6). Evaluation of qualitative and quantitative objectives, instead of merely counting contacts like general hospitals, district nursing and public health services, was viewed as a means for improving services by enabling the relevance, efficiency, effectiveness and service value to be measured (p.9). Appropriateness and responsiveness, it was suggested, could be judged by the degree to which: • need is assessed and re-assessed using data on maternal, infant and other age-specific mortality, morbidity and other disability, immunisation status, and other indices of community health status such as absenteeism from work or school, unwanted pregnancies, the availability of facilities for special groups like mentally retarded persons or the children of working mothers; • patient and professional satisfaction, as assessed by their perceptions of health encounters, is achieved; • the individual's understanding of health disorder and self-help is increased; • advice is complied with; • services are accessible in terms of location, transport, hours of availability or waiting time; • services reach the population at risk; • categories of professional personnel are available to specific populations; • the eligible population makes appropriate use of the services; • services are comprehensive and coordinated and offer continuity; • there is audit of professional and management performance; • costs can be ascribed to units of service; • there is community participation in management (H&HSC 1973 pp.9-10).

Teams were seen to require support to develop documentary, recording and communication systems so evaluation was possible (pp.4-6). Good management was essential (to develop 'community health resources providing comprehensive and integrated health and personal welfare services' p.6). Local support was considered vital and achievable by inviting participation in evaluation via outreach, public meetings, circulating discussion papers and appointing individuals to advisory boards. Community participation was perceived as a way of influencing community expectations and promoting a sense of service ownership and personal responsibility for health. Teams were expected to foster personal relationships: ... between patients, their families and members of the team.....to enable the patient himself to become closely involved in his own health care regimen and to help him to identify and manage many of his own problems (p.15). Relationships between providers, clients and community members, were viewed as a means for learning and gaining an understanding of the social and environmental circumstances in which communities and

107 populations lived in order to focus on the 'whole person'. H&HSC reports make clear that the feature differentiating CHP services from other services was a philosophy that focused the attention of professionals towards prevention, teamwork and personal care (H&HSC 1973, 1974, 1976). It was assumed that offering people accessible, appropriate service teams would prevent unnecessary distress and reduce use of other services by anticipating and resolving preventable problems. The H&HSC (1976a,b) had funded 119 projects by 1974, CHCs, day hospitals, community geriatric services, women’s CHCs, rape crisis centres, specialist consultative teams, a rural aerial health service, community health administration, community health training programs, regional orientation programs, a GP training program and a Diploma in Community Nursing (Cumberland College of Health Sciences 1977; Rice 1985). The Family Planning Association was encouraged to use CHCs and train community nurses (H&HSC 1976a, p.51). By 1975 some 727 state projects and 19 national projects had been funded (HHSC 1974, 1976b). There is evidence of the H&HSC trying to influence professional education. The largest single grant was allocated to the Royal College of General Practitioners to develop a Family Medicine Training Program to prepare GPs. Distribution was skewed. Nearly half of all funded projects were in rural and under-serviced areas (327/45%) (H&HSC 1976a, p.13). Projects involving nurses were also supported as ‘special’ members found 'previously unidentified or unrecognised health need' in 'areas of suspected need' (H&HSC 1976a, p.12). Support was also evident for projects directed at social and behavioural disorders associated with alcohol and drug abuse, lack of follow-up and continuity of care. Rehabilitation projects received 40% of all funds for 1975/1976 (p.13). Health education and occupational health projects received little support. In early November 1975 the Whitlam Labor Government was dismissed and a Fraser Coalition caretaker government installed. Funds by this time had mainly been allocated for projects seeking to develop services that hospitals, nursing services and private doctors were not providing. Capital works (1/13) were not supported and consequently by 1976 few teams had adequate facilities (H&HSC 1976a, pp.37-48). The CHP policy, like NSW proposals, extended nurses' responsibilities for caring and supporting individuals, families and communities (H&HC 1973; H&HSC 1976a, p.15; NSWDHSRP 1971). Further it removed them from the control of hospital and medical administration (Barclay 1969; DHNSW 1972: H&HSC 1974; NSWDHSRP 1971; Sax 1972a). Responding to criticism it had acted too hastily the H&HSC noted that: ... the reason for the rapidity of action was (and still is) the need to provide services in what can only be described as 'health disaster areas', where services are grossly deficient or non-existent. The Program has never accepted that speed is inconsistent with good management (H&HSC 1976a, p.21). Political issues, state and federal governments' relationships, influenced implementation nationally (H&HSC 1976a; Scotton & McDonald 1993). Progress was slow in Queensland, Victoria and West Australia, due to government opposition to Medibank (H&HSC 1976a; Scotton & McDonald 1993, p.187; ACHA 1986). In Victoria the state

108 government drafted, but did not pass, legislation preventing non-government organisations from receiving CHP funding (Scotton & McDonald 1993). Most of the CHCs funded in this state were operated by non- government organisations managed by community boards (H&HSC 1976a; Hurworth 1976; Scotton & McDonald 1993, p.187). South Australia developed differently with CHCs there established by government and non-government organisations and private doctors (H&HSC 1976a). Governments in NSW and Queensland implemented and administered all CHP projects. Fewer projects were implemented in those states with state-wide nursing services, Victoria (149), South Australia (56), state administered geriatric services, Queensland (55) and West Australia (48) or general hospital-managed maternal and child health services, Tasmania (50) (H&HSC 1976a; Rosenthal 1974, Linn 1993, RDNS 1993). Most projects were implemented in NSW where nursing services were limited in number and maldistributed like primary medical services. By 1976 nearly half of all funded projects (48%, 350), mainly (210) CHCs, operated in this state (H&HSC 1976a, p.88). Here the Liberal Government gained block funding for all projects, giving them control over location, focus and funding for all projects. The General Practitioners' Society and AMA, which opposed the CHP policy, managed to limit the work undertaken by salaried CHC doctors to administration while those in other states provided services on a fee-for-service basis (H&HSC 1976a; Scotton & McDonald 1993). Between 1973 and 1975 rapid implementation of the CHP policy led to an estimated 2000 employees providing services to half the 15-20% of Australians living in ‘under serviced’ areas (H&HSC 1976a, p.2). These employees were likely additional to the nurses employed by district nursing services (ABS 1972, p.431), school medical doctors and nurses, and mothercraft nurses nationally (ABS 1972, p.436-7). Whether this included staff employed under the Mental Health Services Related Assistance Act from 1973 -1975 prior to their integration with CHP projects is unclear (H&HSC 1976a, p.7). A H&HSC report released in early 1976 offers insights into the progress made by late 1975 when the Whitlam Government left office. The report acknowledges that submissions for CHP funding were assessed on set criteria, funds were capped ‘not open-ended’, allocation was merit-based, and progress was monitored into 1975. During 1973 and 1974 the Commonwealth provided 100% of operating and 75% of capital costs and 90% of operating costs from 1975 (H&HSC 1973, 1976a). Budget allocations were substantial, $17.1 million in 1973/1974, $36 million in 1974/1978 and $66.9 million in 1975/76 (Budget Speech 1975-1976). There was evidence of CHP services being accepted and achievement of CHP objectives which: ... favoured evolutionary change in the patterns of health care delivery mainly because there have been very few guidelines concerning the 'right' way to go about changing the health care system or, in fact, what the structure of the system should be (H&HSC 1976a, p.2). A lack of structure and direction was seen to have facilitated change in services and practitioners' approach although it was not envisaged that CHP projects would remain unchanged for: By proposing to stimulate attitudinal change, the Program becomes self-limiting: in time, it may be seen as having gone far enough in providing an impetus for change and, therefore have achieved its original purpose (H&HSC 1976a, pp.2-3).

109 What this report makes clear is that the CHP policy was viewed as a catalyst: ... to encourage the development of a wide range of health resources that deal with specific health needs in the community, ... the Community Health Program is concerned with the supply of health services and attitudinal change to the delivery of health care (H&HSC 1976a, p.6). It was therefore a strategy to: • change professional and public perceptions of the purpose of health services and to change practice and limit use of institutional services • integrate previously administratively separate services and • introduce capped funding (H&HSC 1976a, p.9). It was a means to promote flexibility, diversity and development of generalist, rather than specialist services. By 1975 some professionals had begun changing their practice. Some projects had not worked as expected. For example, the Royal College of General Practitioners Family Medicine Program had focused on acute rather than chronic and social problems. By contrast Diplomas in Community Health Nursing (H&HSC 1976a, p. 18) had focused on chronic conditions and social problems (Cumberland College of Health Sciences 1977; NSWHC 1976g). There were indications that psychologists, social workers, and mental health staff retained a specialist treatment-focused orientation as community nurses moved to generalism (H&HSC 1976a, p.39-43). Services were being advertised and evaluated. Advertising had been limited to prevent GPs viewing CHCs as competitors (H&HSC 1976a, p.53), however the Commonwealth had made a film, produced pamphlets and published a Community Health Bulletin which promoted evaluation and research (ADHHSC 1975-1980). Some progress was evident on evaluation. Evaluating outcomes is difficult, mainly as the 'impact’ of a service needs to be assessed (H&HSC 1976a, p.25). A study had been conducted in Brisbane, Queensland, to assess use of and demand for different professions and institutional and community services (H&HSC 1976a, p.26). An evaluation package had been trialled at five CHCs in four states (H&HSC 1976a, p.27). According to the H&HSC the CHP policy had fostered more evaluation (via seminars, exchange of views) in two years than had occurred in the prior two decades (H&HSC 1976a, p.27). While asserting gains had been made in just over two years this was considered insufficient time to appraise attitudinal change in health professionals and communities and it was noted that more quantitative research was required (H&HSC 1976a, p.62). Some expectations remained unmet. For example, the proposed integration of domiciliary nursing services with CHCs scheduled for January 1st 1976, failed to eventuate (H&HSC 1976a, p.65). It is unclear why, but political opposition from hospitals and non-government organisations is likely. The H&HSC had difficulty predicting future funding for existing projects and there was a backlog of 300 eligible projects by December 1975 (H&HSC 1976a, p.29). H&HSC Commissioners viewed the policy as a success despite implementation not proceeding as intended. There had been failures to establish procedures and processes to enable practitioners to evaluate their work, this had hindered progress; issues of ‘skill sharing’ were unresolved; preparation for teamwork remained poor; and community involvement in decision making had been limited. The H&HSC report on projects between 1973 and 1975

110 (taken to reflect the expectations and intent of the original Commissioners) advised hospitals to improve links with community services. It further suggested using CHP funds for: health hostels; more health education and health promotion at community level; and professional education and training. Responsibility for day-to-day management of CHP projects transferred to state governments but the H&HSC did not retain responsibility for policy development as proposed (H&HSC 1976a, p.77). The H&HSC was disestablished in 1978 but it is clear that this body ceased operating effectively long before this. As various authors illustrate, within weeks of the Fraser Coalition Government assuming power Commissioners were being replaced by Departmental staff (Milio 1984, p.24; Sax 1984; Scotton & McDonald 1993). The 1976 report reflects changes in emphasis but none of the proposals contained in it conflict with the CHP policy, recommendations made by the National Review of Hospitals, NSW CHP proposal, or the published works of the H&HSC Chairman, Sidney Sax.

In Summary In 1973 when the CHP policy was written the Australian health system had entrenched structural problems that affected service quality. Services were costly, maldistributed, fragmented, and illness focused. Newer understandings of how people's circumstances affected their health and influenced how they used health services and health professionals were not reflected in the way services were organised and provided. Medical and nursing education remained predominantly hospital- and profession-centric and curative in focus. Internationally greater emphasis was being placed on preventing preventable health problems arising through increasing access to primary care and promoting the development of community based local health services. The CHP policy, reflected emerging international trends, teamwork, prevention and personal care. Its fundamental premise was that the organisation and funding of health care influenced the orientation of health professionals. This policy was a strategy, a catalyst, for changing entrenched structural and attitudinal problems within Australia’s health care system. H&HSC Commissioners and NSW health department bureaucrats viewed the CHP policy as a means for controlling the distribution, location and orientation of primary care, increasing services in areas of scarcity, and extending the responsibilities of non-medical health professionals, in particular nurses, an under utilised resource. The H&HSC did not expect implementation of the CHP policy to result in CHC practitioners offering the same services to all populations. They did expect managers to assist practitioners to develop services relevant to the context in which they worked. The next Chapter explores the context of one region in NSW and the circumstances in which the population lived and in which CHC practitioners and administrators implemented the CHP policy.

111

CHAPTER 6 THE HUNTER REGION: RESOURCE RICH ― HEALTH POOR

The distinctiveness of a place depends on a certain predictability about what happens there. … time is an essential ingredient in the realisation and reproduction of place… . Space is so generalised: place is so particular (Stilwell 1992 p 23-24).

Occupation remains the most important determinant of wealth, social standing and well-being for most people in Australian society (Forster, South Australian Health Commission cited by Glover et al 1992 Volume 1 p.30).

Introduction The previous Chapter explored the purpose of the CHP policy and its commonalities with the plans of the NSW Liberal coalition government to establish its own CHP. It revealed that the purpose of this policy was to promote development of relevant accessible primary health care services. This chapter explores the historical, socio-structural and political context in which the CHP policy was implemented in the Hunter Region in order to gain insights into the circumstances in which the population lived and the practitioners worked. The regional context needs to be understood for, as Milio (1975, 1981) has long argued, people's circumstances, past and current, shape the ‘amount and type of disability and vigour, of death and of life’ they experience (Milio 1981 p.215). Socio- structural influences beyond the control of individuals influence individual and population health. Culture, traditions, beliefs and the values of societies influence people's health practices and lifestyles (Helman 1984; Kleinman 1980; Milio 1970, 1975a,b,1981; Starfield 1992). This policy sought to broaden the range of services available to populations and alter how health professionals practised. It was expected to act as a catalyst and foster change. It is difficult to change the modus operandi and the culture of organisations and professional groups yet this is what the CHP policy sought to do by introducing CHCs into an established ‘hospital-centric’ health care system. This Chapter explores the regional context. It illustrates that the Hunter region was rich in natural resources while the health of the population was poor. It further shows that this population relied on the most accessible health services, general hospitals, as it had few other readily accessible options. This Chapter sets the scene for Chapters 7, 8 and 9 and begins by exploring space and location, a matter of extreme importance to CHC practitioners, especially GCNs, who worked in and with communities.

Rivers, Coal and Convicts The geography, history and socio-economic development of the Hunter Region shaped the circumstances in which the population lived between 1974 and 1989. This large river valley covers four percent of the east cost of Australia and lies 160 kilometres north of Sydney, the NSW state capital (Figure 6.1). Newcastle, the

112 Figure 6.1. Map of the Hunter Region.

113 regional capital, is Australia’s sixth and NSW's second largest city (ABS 1974, 2004). It is, as Robinson (1981) a local geographer pointed out, a true region isolated from its surrounds by natural barriers, highlands, mountains and rivers. It is a region rich in natural resources, fertile land, coal and water. Prior to European settlement it was inhabited by several tribes of Aborigines. When British soldiers stumbled upon this region while chasing escaped convicts its isolation and visible coal deposits led to it being chosen as an appropriate site for a second penal colony. Europeans first settled in Newcastle and Maitland (Crowley 1974; Maitland Council 1963). Settlement commenced at Newcastle in 1801 with convicts and soldiers who established the region's first light industry and coal mining (Turner 1980). Free settlers went to Maitland, some thirty kilometres inland up the Hunter River where they established primary industries, an administrative centre and river port. Newcastle was declared a free town in 1823 as convicts and the gaol were transferred north to Port Macquarie. By the 1880s Newcastle was the regional capital and port. As assisted immigrants arrived to work in the local coalmines from deprived areas of Northern England and Wales, fewer from Scotland or Ireland, the population grew rapidly (Docherty 1983; Gray 1989; Metcalfe 1988; NH 12.4.1995; Walker 1945). Most early immigrants were tradesmen, mining then being a craft undertaken by hand (Laffan 1998).

Steel, Industry and Immigrants Abundant coal, a position on a river near an ocean, and a deep safe harbour saw Newcastle chosen by Broken Hill Proprietary Limited (BHP) as a site for steel making. The population expanded as more immigrants arrived to build and work in a large steel making plant at Mayfield, on the Hunter River or as it was then known the Coal River. By 1930 the Hunter had a population of 100,000. More immigrants arrived following World War II, this time from the war-ravaged areas of Europe. Most came from Germany, Yugoslavia, Italy, Poland, the Netherlands and Greece and some were refugees (ABS 1972, 1991). When the White Australia Policy ended in the 1960s official statistics reveal a new wave of immigrants arrived this time from Asia, Africa and South America. Despite waves of immigrants the population remained predominantly Anglo-Celtic, English speaking and Protestant (ABS 1971, 1986, 1991; Glover et al 1992). A small, diverse, proportion of the population came from non-English speaking backgrounds and few were indigenous Australians.

Poor Living Conditions The immigrants who came to the Hunter to work in the region's heavy industries faced harsh living conditions. Many townships lacked sewerage and running water (Gray 1989). During the 1920s it was not uncommon for miners and their families to live in makeshift houses and tents until mines were deemed viable, a decision that could take years (Metcalfe 1988; Walker 1945). Many mining families often lived a precarious hand to mouth existence typically in small wooden iron- roofed cottages which could be dismantled and moved if required.

114 Living on mine-owned land, close to work, exposed them to eviction if and as mines closed for political and other reasons (Newcastle and District Historical Society 1991 p.78; Walker 1945). Miners were not the only workers to live in poor circumstances. During the great depression of the 1920s and 1930s economic hardship affected many families. Across the Region, those unable to afford rent built makeshift houses or tents on crown land establishing what became known as ‘depression villages’ (Walker 1945). By the 1950s most such dwellings had been demolished the residents having been provided with accommodation on one of the many large public housing estates built in inner and isolated areas of Newcastle and Lake Macquarie (Appendix 6.1). As the Hunter Valley Research Unit shows, however, few public houses were built in the City of Cessnock from the 1940s to the early 1970s (HVRU 1971). The ‘depression villages’ erected here in the 1930s remained, surrounding the city on three sides, with local Councils providing water and electricity and charging occupants rent (Walker 1945; Newcastle and Hunter District Historical Society 1991). Many Hunter residents continued to live in inadequate overcrowded conditions into the 1950s as newspaper reports illustrate (NH 23.7.1941.p.2; NH 19.3.1942 p.1-12). New immigrants continued to live in what were called ‘migrant camps’ or hostels, army bases in isolated areas of Maitland and Newcastle until 1972 (Keating 1997). From 1955 most housing estates, public and private, were built in Lake Macquarie making this local government area one of the largest and fastest growing (84% - 55,000 people) areas in NSW and the Hunter Region (HVRF 1971, p.6). Public housing estates contained houses built of asbestos sheeting. Public housing estates, mining and ‘depression’ villages and townships, were distinctive and easily differentiated from the more affluent private housing estates springing up across the region. Employers sometimes built houses for their employees. One subsidiary of BHP, for example, provided small brick houses to its British immigrants and as a result several streets were known as ‘pommy town’ (Claridge 2000). Elegant houses were also built on the hills overlooking Newcastle and near central business districts in other large townships for the owners and or managers of local businesses (Maitland Council 1963; Historical Photographs, Newcastle Reference Library; Turner 1988). However, housing remained a continuing problem for many residents.

Reduced Opportunities The Hunter Valley is a geographically diverse Region. The physical features making it attractive, highlands, mountains, rivers and a large salt water lake, also made travel out of and across the region difficult. The opportunities of many residents for education and employment were influenced by their proximity to Newcastle. The inner suburbs of Newcastle were initially unsanitary places, however, it was here that most public services, transport, educational facilities and employment opportunities developed. Residents living in the region's more isolated suburbs and townships had limited access to services due to poor transport. By the

115 1940s the region was crisscrossed by roads and railway tracks however most led to ports, many were private and nearly all served the needs of industry (Gordon et al 1984; Tonks 1979). For the residents of Newcastle’s inner suburbs, most of whom relied on local industries for employment, this was less of a problem as they walked, rode bicycles or caught buses to work. Newcastle and East Lake Macquarie were served by public bus services, but residents of other areas had to rely on private bus services or private vehicles. Families were poorly served by transport systems with bus timetables being synchronised with shift changes at BHP and its subsidiaries. Residents of more isolated suburbs and townships whose shifts differed from those of BHP tended to rely on private vehicles. Families expended their meagre resources on cars (Walker 1945). Travel between suburbs was difficult. Direct travel was only possible between some suburbs using workers' buses before or after shift changes (Personal Recollection). People had to walk. An elderly man recalled walking home from Maitland Hospital after a tonsillectomy (Personal Recollection). Many roads were ‘quaintly primitive and dangerous’ and drivers had to share them with coal trucks ‘thundering juggernauts pulling heavy cargoes to and from the coast’ (Leeder NH 4.6.1981b, p.2). In lower and upper Hunter many were also subject to seasonal flash flooding. Travel could be slow and dangerous. Driving to Sydney could take up to four hours while the train took three into the 1980s (Personal recollection). The isolation that many experienced fostered parochialism, localism, and limited opportunities. Education is an important determinant of individual, family and population health (WHO 1986). By the 1940s most Hunter townships and suburbs had infant and primary schools, however, until the 1960s most high schools were located in Newcastle City (HVRF 1966, 1971, 1978, 1979; Metcalfe 1988, p.104). This, poor transport, and the industrial character of the Region deterred attendance at and completion of high school. Historically many elderly residents, especially in rural areas, completed primary school. Young people tended to leave school as soon as possible seeking employment in the same industries as their parents. This was especially so in mining communities. Colleges of Technical and Further Education (TAFEs) provided the only source of tertiary education in the Region between 1895 and the late 1940s. The benefit of these colleges was that they offered the children of the predominantly blue-collar population access to employer funded training courses. Dressmaking, millinery and other courses were attractive to women. Educational opportunities increased with the building of a Teachers’ College (1949) and a College of the University of New South Wales (1951). This meant recipients of scholarships or those whose parents could afford tuition fees were able to study in the Hunter Region. New residents, professionals and students, were attracted to the Region. However the industrial character of the Hunter continued to be reflected in a greater proportion of students attending TAFE (10,000) rather than University (3500) or Teachers College (1250) into the early 1970s (HVRU 1974). The industrial character of the Region limited women’s employment opportunities (Gray 1989). They worked in factories (clothing, mills) and service industries (eg. shops, offices, nursing, teaching). Many employers, for example hospitals, banks, and some shops, expected women to resign upon marriage into the

116 1960s. The expectation of women was that they would confine themselves to caring for their families which included raising children. Family life, as in other industrial regions, was often dominated by seven day rosters, day, afternoon and night work (Donaldson 1991; Gray 1989; Metcalfe 1988; Tonks 1978, 1995; Walker 1945). Unsociable working hours for men and lack of child care acted as a barrier for those women seeking to return or remain at work. Family incomes were affected.

Changing Economic Profile National, state and regional reports demonstrate that the Hunter made a significant contribution to the GDP (ABS 1970, 1974; HVRF 1974; Gordon & Smith 1976). The Region produced coal, steel, electricity, grapes, and wool. Tied to secondary industries, the local economy was tied to global markets and vulnerable to depressions (1890, 1930) and booms (1960s). Dependence on BHP, which owned most mines, iron and steel manufacturing, shipbuilding and shipping firms, made the Region vulnerable to shifts in global markets (Tonks 1979). Dependence on BHP also led many to accept pollution, industrial accidents and fluctuating employment as part of life in an industrial town. Signs that the local economy was changing were evident from the late 1950s. Demand for coal fell globally as mechanisation increased production. Tonks (1979), a local labour historian, observes the Region lost thousands (7,934) of mining jobs between 1953 and 1964, few (1138) of which were regained. Mining townships were hardest hit having fewest options (Metcalfe 1988; Tonks 1979). The opening of a link road between the coalfields and Newcastle in 1961 did little as Newcastle industries were already cutting their workforces. By the 1970s many small manufacturing shops had closed ending local employment for many men (HVRF1974; Datex Cooperative, Newcastle 1976). The Newcastle Herald reveals the 1950s and 1960s to have been a turbulent time for local industries. Disputes occurred at BHP, in mines, and at the State Dockyard as workers resorted to traditional means to save their jobs, striking. Industrial strife was nothing new to this Region, as labour historians and regional newspapers show. Unions had long provided a focus for collective action by workers trying to protect their wages and conditions and also provided their members with social (education, health, financial support) services (ABS 1971; NH 6.10.1983; Gray 1989; Metcalfe 1988; Noble 1999; Newcastle Sun 16.12.1929; Tonks 1979, 1995).

Dependent but Defiant Unions had played an important part in the Region’s history. By the 1970s an entrenched culture of mistrust and antagonism had evolved between workers and managers. Conflict had become the norm, especially in the mining industry. Why becomes clearer if local history is considered. During the late 1800s and early 1900s Hunter mines had become the site of historic battles as miners engaged in strikes to resist employers' and governments' attempts to reduce their wages and alter their working conditions (ABS 1973, 1986; Metcalfe

117 1988; Laffan 1998; Longworth NH 6.10.1983). The circumstances were complex (Laffan 1998). Long-term strikes (1888, 1949) were broken by police and soldiers (NH 6.10.1983; Metcalfe 1988). Mine owners closed mines. During the 1920s, for example, the owner of Minmi mine closed it and a private town when miners attended the funeral of a miner killed at work (Newcastle and District Historical Society 1991 p.78; NH 20.10.1995 p.4). Evicted families moved to Lake Macquarie or Cessnock. Cessnock became the site of further conflict. During 1928, for example, miners were ‘locked-out’ of one mine for fifteen months bankrupting the town, its doctor and businesses some of which remained closed into the 1940s (Walker 1945 p.7; Metcalfe 1988 p.146). The trigger for this event was a government decision to cut mine owners’ profits and miners' wages in response to a global depression. Owners reacted by locking mines and offering miners a 12.5% drop in wages to reopen them. The miners rejected the drop. Total communities were affected. Some women, according to a local doctor, became ‘intensely depressed’ (Walker 1945 p.10). In December 1929 at Rothbury mine police and soldiers fired on striking miners killing one and injuring many (NSW Northern District Miners Federation 1979). Industrial disputes and unemployment led to hardship for some Hunter residents into the 1970s. Rural communities were affected by disruptive natural events. Major droughts (1886 and 1903) and floods (1903, 1949, 1955) led to crop and livestock losses or damage to homes and civic buildings (Crowley 1974; HVRF 1974; Turner 1988). Recovery often took years. Industrial strife fuelled collective action on the part of workers but natural events, like the 1955 Maitland flood, attracted help and support from outside the affected community.

Health Risks for All Strikes, unemployment, and natural events affected the lives and posed health risks for individuals, families, communities and populations. Poverty and poor living conditions remained commonplace in Australia into the 1940s (Crowley 1974; Gray 1989; Sax 1984). Such conditions exposed populations to the risk of illness (Milio 1981; Sax 1972a). Maternal and infant death rates remained high in the Hunter, as nationally, into the 1950s (Clements 1984; Crowley 1974). Outbreaks of communicable diseases affected early settlers. Between 1848 and 1918, for example, outbreaks and epidemics of smallpox occurred at Maitland and Newcastle; typhoid at Tighes Hill; influenza, leprosy, smallpox and cholera, bubonic plague, tuberculosis, typhoid and diphtheria across the Region; and pneumonic influenza and typhoid at Wickham (Lowe NH 6.10.1983 pp.21-22). Poliomyelitis (1937-1938) and tuberculosis remained problematic into the 1950s. Special hospitals catered for those affected. Tuberculosis, a disease associated with poor living conditions, remained problematic amongst miners at Cessnock into the 1970s (Cummins 1979; NSW, Parliament, 1972-73). By the 1960s patterns of death and illness had started to change. Heart disease became a major health problem, especially for men in Cessnock, as did cancer. Industrial accidents leading to injury, disability or death, remained relatively commonplace, especially in mining.

118 For many residents of the Hunter Region self-sufficiency had become the norm by the early 1970s. Historically access to health and social services had been limited by a lack of services (Gray 1981; Metcalfe 1988; Punton-Bulter 1993). By the time implementation of CHP policy began the Hunter population had access to hospitals, GP, and maternal and child health services and charities provided some welfare services. Governments built hospitals for soldiers and convicts at Newcastle, and migrants at Maitland, while the Sisters of Charity built another for the urban poor at Waratah (HVRF 1974). Mining communities built hospitals assisted by mining companies and governments (Punton-Butler 1993; Metcalfe 1988). Miners at Kurri Kurri had built and managed a small hospital until the depression, at which time the state government took responsibility for this facility (Metcalfe 1988). Women received little formal support caring for ill family members.

Social and Leisure Activities By the 1880s a plethora of churches of all denominations were scattered across the Region. Attending church was an important activity for many residents (Laffan 1998). There were two Cathedrals, one at Maitland (Catholic) and another at Newcastle (Anglican). While most early settlers were Methodists and Baptists, supporters of temperance, this did not deter the prolific building of hotels, a prominent feature of mining townships and suburbs, or the culture of heavy and frequent consumption of alcohol that evolved amongst the men working in local industries. Here, as elsewhere in Australia, pubs, as hotels were called, remained the domain of men and barmaids, with women restricted to the ‘ladies lounge’ into the 1960s (Caddie 1953). By the 1930s many townships had cinemas. Mechanics' Institutes provided communities with meeting places (Laffan 1998). By the 1950s eisteddfods, drama groups, weekly town hall dances were well established and Workers and Returned Service Men's Clubs were providing entertainment seven days a week. Traditionally sport played a major role with many townships having their own teams allowing local rivalries to be played out on sports fields (James 1995). From early in its history the Hunter also had a Communist Party, Orange Lodges and secular halls (Gray 1981; Laffan 1998; Philips 1998). Politically the Region remained divided. Residents of the Region's working class, blue-collar, industrial areas continued to support Australian Labor Party (ALP) candidates while rural areas like Maitland and the Upper Hunter favoured conservative representatives.

A Disadvantaged Region By 1974, when implementation of the CHP policy began in the Hunter, despite improvements in living conditions this Region remained disadvantaged. Official statistics and histories illustrate ongoing differences between the population of NSW and that of the Hunter. These differences were largely socio-structural. Between 1974 and 1989 the Hunter population included a higher, but declining, proportion of people on low incomes, receiving aged, disability or single parent benefits, unemployed, or employed in unskilled or semi-

119 skilled occupations or as coal miners, holding trade qualifications, single parents or living in houses without cars. The proportion of high school graduates, holders of non-trade qualifications (especially women), women in paid employment or persons employed in professional or white collar professions was low but increasing. These changes mirrored changes occurring in the regional economy which, between 1974 and 1989, shifted from an industrial to a service base. Comparisons between residents of Local Government Areas, Lake Macquarie, Newcastle, Maitland and Cessnock and Dungog Shires, also illustrate intra-regional differences consistent over time. Variations in income, education and occupation reflect historical patterns of settlement. Australian Bureau of Statistics (ABS) data show the total population to be less advantaged compared with that of NSW. By the 1980s the Australian Bureau of Statistics had developed a Relative Index of Social Disadvantage (SEIFA). This complex statistical tool allocated a numerical measure of advantage (>1000) or disadvantage (<1000) based on: education, occupation, family structure, ethnicity, housing conditions, costs and economic resources; characteristics known to influence health and people's need for health care. Glover and Woollacott (1992) used this index to create a Social Health Atlas of Australia. This index identified the Hunter Statistical District (990.5), Newcastle (985.4) LGA, Newcastle (956.2) and Cessnock (965.1) as disadvantaged and Maitland (1.004), Lake Macquarie (1.0035) and NSW (1001.4) as advantaged. The low score given to the Region was attributed to the population including a high proportion of single parent families, unskilled and semi-skilled workers and people living in dwellings without cars. Intra-regional variations illustrate that some populations were more advantaged than others and that they had more ready access to resources (income, education) than others. From the perspective of health workers these variations are important as they point to a population’s need for, and access to, health and other social services.

Socio-demographic Variations From the 1970s until 1989 ABS and other data illustrate that the Hunter population remained relatively homogenous (ABS 1971,1986, 1991; Glover et al 1992). The indigenous population was small (<1%). Despite being built on immigrants the Region's proportion of residents of non-English speaking backgrounds remained small (<5%). The Hunter population increased in size as did the population of all Local Government Areas (LGAs) with the exception of Newcastle as Figure 6.2 shows. Demographic change also occurred in relation to age, family structure, income and education (Appendix 6.2). All are important changes for a study concerning a health policy. Family structure remains an important determinant of health and of people's need for and use of health care. Access to supportive families and friends can alleviate people's need for social services by promoting well-being and providing emotional and material support in times of need (Brown & Harris 1978; Caplan 1964; Klienman 1981; Oakley 1979; Sax 1972a; Richards 1978; Young & Willmott 1986). From 1974 the proportion of married persons declined as that of never married, divorced and single parents increased (Figure 6.3). The population also aged. The proportion of over 65 year olds was near double that for NSW

120 121 122 while the under four year old population was declining. These changes in family structure can increase people's vulnerability during adverse situations, including periods of illness, and increase their need for assistance from health and welfare organisations. Education and income also influence people's health and their use of health services. Opportunity, the expectations of significant others, motivation and ability affect people's aspirations and achievements (Connell, Ashenden et al 1982; Oakley 1979; Spender & Sarah 1980; Williams 1985; Willis 1977). Historically, most of the Hunter population looked to industry when considering their employment options. Perhaps not surprisingly in such an area high school retention rates remained low amongst women, coalfields and rural populations and lower than expected into the 1980s (Glover et al 1992). As in the past many adults held trade qualifications but the trend was to more holding tertiary qualifications. By 1986 the proportion of men and women living in Newcastle and women in Lake Macquarie holding tertiary qualifications exceeded the rate for NSW with Maitland exceeding the Regional rate for men and women. Only Cessnock had a tertiary educated population below NSW and Regional rates. These demographic changes reflect economic changes. By the late 1980s Newcastle University and the Area Health Service had become the Region's largest employers. Tertiary educated professionals migrated to the Region to work and study. Income remains a significant predictor of health status and need for health services (Australian Government Commission of Inquiry into Poverty 1975; Davis & George 1993; Milio 1981; National Health Strategy 1992; Navarro 1986; Taylor 1979b; Townsend et al 1982; Townsend, Phillimore & Beattie 1988; Whitehead 1988; WHO 1981, 1987). Low incomes have greater implications for aged and young persons. The effects can be ameliorated by education and exacerbated or mediated by cost of living, housing, employment, education, age, family size and composition, health status and access to welfare services (Australian Government Commission of Inquiry into Poverty 1975; Glover et al 1992; National Health Strategy 1992c). In the Hunter the growing aged population included a high proportion of people receiving government benefits (Glover et al 1992). Between 1974 and 1989 the proportion of families on very low or very high incomes declined and that on middle incomes increased. More families in Lake Macquarie and Maitland received higher incomes than in other areas. By the early 1970s structural changes beginning in the 1960s had altered the employment prospects of the Region's adults and young people. Unemployment rates rose from low levels in 1974 to exceed those for NSW by 1986. The early 1980s were difficult. Unemployment for men rose 203 percent (near double the high 121% rate increase for NSW) while for women it remained under that for NSW. In the mid 1980s unemployment increased for young adults (under 25 years) and women (Gordon et al 1984 p.70). By 1986 the unemployment rate for 15 to 19 year olds was double (nearly 31%) that of other non-urban centres (12.5%) in NSW (Glover et al 1992). The changing local economy fuelled the rise in unemployment and the increase in middle income earners.

123 By the 1980s the Region's fastest growing industries were the professions, finance, commerce, transport, building and education (Hunter Area Health Service 1985; Gordon et al 1984; HVRF 1990). Traditionally, proportionally more of the Lake Macquarie, Maitland and Cessnock populations worked in trades. In 1976 the proportion of miners was higher for Cessnock and Lake Macquarie, a situation which continued into the 1980s as employment in open cut and underground mines increased (Smyth 1992). By 1986 Newcastle had a higher proportion of professionals than NSW or the Region. The proportion of para-professionals had also risen in Lake Macquarie, Newcastle and Cessnock to one higher than that for NSW and the Region. Between 1974 and 1989 the Hunter population was ageing, men married later, women’s participation in paid employment, adults' levels of education and income remained low (compared with NSW and national rates) but were increasing. Importantly, due to the growth of mining, a high proportion of men remained employed in occupations known to expose them to the risk of death, injury or chronic illness (Lawson, 1993 p.10; Taylor 1979a; Office of Population, Census & Surveys 1978). Stories of men employed in the steel manufacturing and mining industries illustrate the risks to which they were exposed (Beneath the Valley 2005; Cranney 1999). When implementation of the CHP policy began the blue-collar character of the Hunter Region had implications for the health of population (National Health Strategy 1990,1992c). For, as the United Kingdom's Office of Population Censuses and Surveys (OPCS 1978) has argued, The nature of the tasks he (sic) performs for eight hours each working day might consequently be expected to exert some influence on his health. He is unlikely however to be aware of the diversity of these influences, what they are and how they are felt (p.1).

Occupation influences the socio-economic status, income and health of men and that of their families (Brown 1988; Broadbent 1985; Dreitzel 1971; Glover et al 1992; McMichael 1985; National Health Strategy 1992c; Townsend & Davidson 1982; Office of Population Censuses and Surveys 1978). By 1974, as implementation of the CHP policy began, the predominantly blue collar, or working class, population had a clear need for health care.

The Hunter Population’s Need for Health Care Until the 1970s information regarding the Australian population’s health, or its health problems, was limited (Sax 1972a). More was known about death and illness than about health or social need. In the Hunter death and illness rates, for all causes, were high compared with those for NSW. In 1974 Hunter men had a rate 18 percent higher than NSW men. Death and illness are negative and inadequate measures of health. However, like socio-economic indicators, they can point to differences between populations: more and less affluent persons, men in unskilled and professional occupations (Brewer 1980; Brown 1988; Health Wiz 1993; Lawson & Brown 1993; McMichael 1985; Taylor 1979b; Townsend & Davidson 1982); employed and unemployed persons (Brewer 1980; Kerr 1983; New Doctor 1982); and married and unmarried men and women (Bernard

124 1972, cited by Schaffer 1980). Between 1970 and 1988, consistent with NSW and national trends, crude death rates declined, although more slowly, but remained higher for all causes (Dobson, Gibberd, Cooper et al 1979a,b; Dobson, Gibberd & Leeder 1980; HHSU 1990; Lam et al 1988). Local studies, conducted to argue for more resources, demonstrate that death rates, crude and standardised, remained higher in the Hunter than for NSW or Australia. Rates for Cessnock and Newcastle, standardised for age and sex, remained high and higher than expected for Cessnock. Between 1970 and 1988 differentials between Hunter and NSW men rose from 3 percent to 5 percent to near 7 percent (Page, Lam & Gibberd 1990 p.5). Deaths rose, rather than declined, for women in Lake Macquarie and Newcastle. Reflecting national trends, most deaths involved circulatory and respiratory diseases, cancer and accidents (O’ Connell, Lam & Gibberd 1987; Page, Gibberd et al 1990; Page, Lam et al 1990, Glover et al 1992). Causes of death varied for men and women. Death for women from breast cancer rose from a low rate to one similar to that for NSW. Contrary to national trends acute myocardial infarction remained a major cause of death (Glover et al 1992; Page, Lam et al 1990). Death rates for many physical conditions were low for women and higher for men and residents of Cessnock and Newcastle. In the Hunter, as for NSW, local studies show that while death rates declined intra-regional variations remained. Deaths associated with mental disorders increased steadily between 1979 and 1988 (Page, Lam et al 1990 p.11). Rates were higher for women than men, higher for Cessnock and Newcastle, lowest for Maitland, and lower for Newcastle and Maitland women than Cessnock or Lake Macquarie women. Death rates remained high for respiratory and cardiovascular diseases and neoplasms, conditions likely to cause distress and disability before death. Importantly death and illness rates remained highest in areas where the population was identified to be disadvantaged and to have unmet psychosocial needs. The NSW Health Commission, with a stated purpose of improving the heath of the total population of NSW, sought to identify regional needs to meet this objective. Gwynne (1974/5), a doctor with the NSW Division of Research and Planning, developed criteria using census data and population-to-GP ratios. The Hunter Region was not identified as an area of need as the GP to population ratio lay within the 1 to 3000 parameter defined as acceptable. Vinson and Hommel (1976) and Leeder (1977) reached a different conclusion using socio- structural criteria. They identified areas and population groups as having unmet needs. Gywnne developed criteria to assess and quantify ‘need’ using socio-demographic census data and GP to population ratios for populations of 50,000 (Gywnne 1974/5). Despite high hospital admission and death rates the GP to population ratio fell within acceptable limits (Gywnne 1974/5, p.64). From 1971, as GP numbers rose, the GP to population ratio rose in all areas (Glover et al 1992). However by 1989 the ratio was lowest (Cessnock) and highest (Newcastle) in areas with high death rates and lower in areas with low or as expected death and illness rates (Lake Macquarie and Maitland).

125 Death and illness rates are not the only indicators of need for health care. Vinson and Homel (1976) used 17 socio-structural indicators and death rates to rank 72 areas in NSW to identify populations with a ‘disproportionate’ share of health and social problems. They found residents of Maitland ranked 8th , Lake Macquarie 11th , Newcastle 22nd and Cessnock 40th for first admission to psychiatric hospitals. Residents of Lake Macquarie ranked 5th for divorce petitions and those of Cessnock 18th and Newcastle 41st for attempted suicide and self inflicted injury. Applications for cash assistance were high for Cessnock 8th, Newcastle 15th , Lake Macquarie 16th and Maitland 17th. Child care orders were high for Newcastle 10th, Cessnock 31st, Maitland 40th, and Lake Macquarie 41st. Six populations were found to ‘generate a greater requirement for social expenditure’, non-British migrants resident under four years; persons over 65 and under 4 years; divorced or widowed persons; inmates of institutions and unemployed persons (1976, p.4). Based on these criteria the Hunter population included groups likely to make demands on health services. In a study of well-being Vinson and Homel (1976) identified populations ‘at-risk’ and ’non-risk’ for health and social problems. They found families living in ‘at risk’ suburbs had a lower sense of control and made less use of preventative health and child guidance services than residents of non-risk suburbs. Some problems (infant deaths, premature births, dependence on relief, notifiable diseases, unemployment, mental illness, divorce, truancy) were concentrated in 5% percent of the population with some suburbs having double the incidence of juvenile delinquency, three times more adult crime and six times more drug offences (p.37). Adults living in ‘at risk’ suburbs were found to see their lives shaped by fate, luck, chance (external) rather than personal effort, behaviour or characteristics (internal). Attachment to locality was low as was their involvement in community organisations. Young employed people, especially women, wanted to move (p.39). Vinson and Homel concluded the Hunter Region required more health services but pointed out that objective data, death and illness rates and indices add little to understanding ‘subjectively rewarding’ aspects of living in a specific area or the ‘subjective difficulties’ and so cautioned against focusing on negatives, as Anyone 'looking in' on Newcastle's at risk areas could hardly avoid the impression that people living in these localities lead comparatively stressful lives. But is that just the view of the outsider whose preoccupation with relatively objective measures has led him to miss much that is subjectively rewarding to the residents of such areas? (Vinson and Homel 1976, p.39)..

Leeder (1977a) used eight indicators identified by Vinson et al (peri-natal mortality, pedestrian injuries, first admission to a mental hospital, suicides, male mortality ratios, blood alcohol levels of convicted drivers, child care orders and hepatitis) for his study. He identified men (with death rates 16-19% above national rates), children, families and chronically unemployed persons as having unmet health needs. Leeder identified Newcastle as needing services for adolescents, adults over 45 years of age, immigrants and mentally ill and identified road accidents and drunk1 driving as problems. Lake Macquarie required services for young families,

1 People were charged with ‘drunk’ driving at this time.

126 parents, and people experiencing marital breakdown while Maitland and Cessnock needed services to address mental illness, suicides and high death rates for men. Many people, it seems, had personal problems but little was known about health care needs. The population's circumstances contributed to health problems. Death and illness rates increased between 1974 and 1989 for the Hunter population in contrast to that for NSW and Australia.

Hunter Health Services When implementation of the CHP policy commenced in the Hunter Region there were some indications that death and illness rates were high and various populations had unmet needs for health services. In the mid 1970s researchers at Newcastle University and the Hunter Health Statistics Unit began to conduct in-depth studies illustrating the poor health of the Hunter population vis-à-vis the population of NSW and Australia. Prior to CHCs being established the Hunter health system consisted of hospitals, public health and primary medical services. Compared with the population of NSW that of the Hunter made greater use of hospitals and less use of primary medical care. Domiciliary nursing services were limited and unevenly distributed. Charitable organisations provided some welfare services, mostly in Newcastle. General hospitals were important to communities. Hospital separations, data collected on discharge, provide an indication of why people were admitted.

Hospital Admissions Hospital separations record who has been discharged from a hospital and why they were admitted. Like death and illness rates, hospital separations are negative indicators of health. To what extent they reflect levels of illness in a community or practitioner choice, or a family's social situation remains contentious. Importantly for this study official statistics illustrate that the Hunter population, and thus its medical fraternity, relied on hospitals because admission rates for this Region were higher than for NSW. Between 1974 and 1988 admissions to general hospitals were higher for rural areas, highest for Cessnock, high for Kurri Kurri and as expected or lower than expected for other populations (Hardes & Olsen 1982; HAHS 1992, p.25). The ratio of hospital beds in the Region at 6.4 per 1000 population was lower than for Inner Metropolitan Sydney, 10.4 per 1000, but higher than for another industrial area, Illawarra, 4.3 beds per 1000. Prior to CHCs being established admission rates were three to four percent higher than that for NSW (NSWHC 1974). Detailed examination of admission rates began in the mid 1970s. As tradition influences use it is reasonable to assume that the patterns of use and reasons for admission were similar when CHCs were established. The Hunter Health Statistics Unit compared reasons for admission and length of stay overtime. The first study compared use over two years, 1977-1978 (Callcott, Cooper et al 1981) and then five years, 1979-1983 (Hardes & Olsen 1982; HHSU 1988a). These studies found admission rates highest for children

127 under ten years (14%), adults over 70 years (12%), women between 20-34 years (19%) and in rural areas (Callcott et al 1981). The rate for Cessnock, even adjusted for high death rates, was 42 – 58 % above that for NSW while that for Newcastle was 10% below. Admissions were found to be low or lower than expected for residents of Maitland and Lake Macquarie but significantly higher than expected for residents of Cessnock and Newcastle, for men and some conditions. Admissions also increased for cancer amongst residents of Newcastle and Lake Macquarie although remaining under the NSW rate. Admissions were also high for diseases of the ear (children), complications of pregnancy, and significantly high for hysterectomy and gynaecological procedures, vasectomy, investigations and elective surgery at private hospitals (Callcott et al 1981). In 1983 the number of conditions for which admissions were significantly high rose for residents of Cessnock, declined for those of Maitland, while being ‘significantly lower than average’ for residents of Newcastle and Lake Macquarie (HHSU 1988a, p.6). The Hunter Health Statistics Unit found admissions to general hospitals also increased for mental illnesses from 1970. Between 1979 and 1983 admissions increased for neurosis, other mental disorders, suicide and self-inflicted injury (HHSU 1988a). Intra-regional and gender differences were evident. Admissions for neurosis were high for Cessnock men and women, higher for Maitland women and highest for Cessnock women. Admissions for attempted suicide and self-inflicted injury were high for Newcastle and Lake Macquarie men and Newcastle and Maitland women while remaining under the NSW rate. Admissions for mental health problems increased even amongst populations with low or lower than expected rate of admission for physical problems. Tables 6.1 and 6.2 illustrate the range of conditions for which hospital admissions were significantly higher than expected between 1977 and 1983 for residents of Region by CHCs catchment area.

Table 6.1 Hospital Separations and Diagnosis for 1977-1978 and 1979-1983 for conditions which were significantly higher than expected for men and women living in the Local Government Areas of Newcastle and Lake Macquarie, the catchment areas of Windale and Newcastle CHCs. 1977-1978 1979-1983 Newcastle City and Greater Newcastle Cancer, breast, women Cancer, breast, women Cancer, bladder, men and women Cancer, bladder, men and women Diseases, ear, Cancer digestive organs, peritoneum, men Diseases, cardiovascular system Cancer, trachea, bronchus and lung men Diseases, digestive tract Cancer, genital organs, men Endocrine, nutritional and metabolic, women Lake Macquarie, East and West Cancer, breast women Cancer, bladder, men and women Cancer, genitals, women Cancer, bladder men and women Cancer, trachea, bronchus and lung Diseases, ear Cancer, digestive organs and peritoneum men Diseases, cardiovascular Diseases, lymphatic and haematopoietic tissues (leukaemia) Diseases, digestive tract men

Source: Callcott, Cooper, Dobson, Gibberd and Leeder 1981, Hunter Health Statistics Unit 1988a. Figures were compiled using residential addresses in each CHC catchment area.

128 Table 6.2. Hospital Separations and Diagnosis for 1977 and 1978 and 1979 to 1983 for conditions significantly higher than expected for men and women living in Maitland and Cessnock Cities, the Lower Hunter CHC catchment area. 1977-1978 1979-1983 Maitland City Diarrhoea enteritis, malignant melanoma men Diseases, ear Diseases, cardiovascular Diseases, eye men and women Cessnock City Diarrhoea and enteritis, Infective and parasitic disease Infective and parasitic Diseases, ear Diabetes mellitus Diseases, cardiovascular Diseases, respiratory ,system Diseases acute respiratory Diseases, teeth Diseases related to teeth Diseases, urinary tract Motor vehicle accidents Chronic and asymptomatic ischaemic heart disease Infections, skin, subcutaneous tissue Diseases, men and women Diseases, eye men and women Symptomatic heart disease Haemorrhoids men and women Essential benign hypertension men and women Diseases, endocrine, nutritional and metabolic women Cancer, digestive organs and peritoneum, women Cancer, bladder women Diseases, pelvic organs women Chronic nephritis, nephrosis women Cancer, genital organs men Diagnosis, hernia, men

Source: Callcott, Cooper, Dobson, Gibberd and Leeder 1981, Hunter Health Statistics Unit 1988. Figures were compiled using residential addresses.

The incidence of neonatal death and low birth weight babies is higher amongst disadvantaged populations and in areas with inadequate prenatal care (UNICEF/WHO 1981; UNICEF 1987). Researchers in the Hunter focussed mainly on adults. In the Hunter between 1985 and 1989 the rate for low birth weight (LBW) babies was similar to NSW (5.9%) and national (6%) rates with rates higher for Cessnock and Newcastle (6.2%) than for Maitland (5.7%) or Lake Macquarie (5.6%), with all below the Regional rate. Hospital admission rates can reflect need for health services, bed availability, and/or medical preference (HCNSW 1974c; HAHS 1993). In the period of interest to this study, 1974 to 1989, admission rates in the Hunter were highest amongst residents of Local Government Areas with high death and illness rates and a high proportion of elderly and/or low income families. In 1974 when implementation of the CHP policy began the Hunter population had access to hospitals (public, private, state, general, psychiatric, developmental disability), nursing homes, public health services and primary medical care. Counselling and welfare services were offered in Newcastle. General hospitals were the most visible providers of health services.

129 Hospitals: Schedule 2, 3 And 5 Hospitals are referred to by that schedule of the Hospitals Act under which they operate. By 1974 the Hunter Region had sixteen public and six subsidiary units, three psychiatric, developmental disability and geriatric hospitals providing 5,368 (4473 general) beds with private hospitals (7) and nursing homes (28) providing additional beds. Most were old having been built before 1960. Administrators had had little success gaining funding to extend or refurbish their facilities. As Table 6.3 shows, hospital bed numbers declined between 1974 and 1989 with one exception, aged care. Schedule 5 hospitals had begun reducing beds in the 1960s when ‘deinstitutionalisation’ began. Long term residents were transferred either to community housing or, if elderly, to an aged care facility at Cessnock. Allendale Hospital was built as a psychiatric hospital but commissioned as a geriatric facility (Sax Interview). From 1970 to the mid 1980s Schedule 2 and 3 hospitals lost 864 beds (4473 to 3611) and Schedule 5 hospitals 272 (2077 to 1805). Developmental disability services at Stockton and Morisset Hospitals were separated from psychiatric services and then amalgamated. Most hospitals and beds were located in Newcastle (2512 beds) while growth areas such as Lake Macquarie and Maitland, and rural areas like Cessnock and Dungog, had smaller hospitals with fewer beds (721 beds).

Table 6.3 Schedule 2, 3 and 5 hospitals located in the catchment areas of four CHCs showing year established and increases and declines in bed numbers between 1974 and 1988. CHC Schedule Hospital 1974 1984 1988 Newcastle 2 Royal Newcastle (1861) 657 516 401 Royal Newcastle Rankin Park (1926) 110 72 103 William Lyne (1951) Wallsend District (1893)** 134 165 185 3 Newcastle Mater Misericordiae (1921) 302 297 274 Newcastle Western Suburbs Maternity (1896) 134 65 69 St Josephs Convalescent Home (1946) 175 173 158 5 Newcastle Psychiatric Centre (1872) 136 136 112 Stockton (1910) 841 - 996* Windale 2 Royal Newcastle, Belmont (1964) 108 103 103 Newcastle Western Suburbs, Dudley 81 81 81 Maitland 2 Maitland (1843) 221 164 153 Maitland- Clevedon—Gresford 8 closed Dungog and District (1892) 38 38 30 Cessnock Kurri Kurri District (1904) 169 104 92 Cessnock District (1914) 229 150 127 Cessnock District, Abernethy Home 30 30 30 5 Allendale (1963) 415 414 414 5 Morisset (psychiatric) (1908) 685 685 283 Total 4473 3193 3611 Sources: Cessnock District Hospital Annual Report 1974, 1981, Health Commission Annual Report 1974, Health Commission of NSW Eight Annual Report 1979-80, 1981, Hunter Valley Research Foundation 1979, Hunter Health Service 1985, Hunter Area Health Service Annual Report 1987/88, 1989/90, New South Wales Department of Health 1986/87 and 1987/1988 Annual Reports. * Includes Morisset. ** Wallsend District Hospital was closed in 1991.

130 Ambulatory Care, Domiciliary and District Nursing Nationally the number of home visits made by nurses more than doubled between 1964 and 1971 (334,000 to 706,000) and the cost of each visit rose from $1.27 to $1.73 (Australia, Parliament 1974, No. 232). The Hunter’s larger hospitals provided outpatient medical clinics and home nursing services. By the late 1960s Royal Newcastle Hospital was also conducting some specialist clinics away for the hospital. For example, staff specialists conducted prenatal clinics at baby health centres in Lake Macquarie. While some clinics closed due to poor attendance those at Windale and Belmont Hospital continued (HCNSW 1972; HCNSW 30.6.1973; NSW, Parliament 1972-73). Speech therapists conducted clinics at other hospitals (eg. Kurri Kurri) and at special schools. By 1974, with CHP policy funding, Dr Paul Moffat, an endocrinologist, had established a Diabetic Education Centre to teach people how to manage their condition (RNH Annual Report 1974). Specially trained registered nurses conducted clinics across the Region to monitor and reduce actual, potential, and long-term effects of this disease. By 1974, as histories and official reports show, Royal Newcastle, Mater Misericordiae and Wallsend District, Maitland and Cessnock District Hospitals provided home nursing services (Armitage 1991; HCNSW 1976, 1977; Punton-Butler 1993). Royal Newcastle and Wallsend District Hospitals established their services in the 1940s, Cessnock and Maitland District Hospitals in the 1950s as did the Mater Misericordiae Hospital in suburban Newcastle. While each ran independently there were commonalities and differences in the way each was organised and the type of care provided. It is necessary to understand how these services operated to understand local hospital administrators' responses to CHCs and, in particular, to GCNs. Matrons selected the nurses who provided home nursing services as they selected those working on the wards. As one nurse recalls Matron asked her one day if she wanted to move to home nursing (GCN Interview 19). Positions were not advertised. A special uniform differentiated these registered nurses from those working on the wards (for example, a suit and a hat). Services were provided between 8am and 4pm Monday to Friday. Nurses, some accompanied by students, began their day by collecting a hospital car when they ‘clocked’ on. In essence these services provided what Armitage (1991 p.131-2), in a history of ‘the Royal’, described as ‘a hospital in the home’. One difference was that registered nurses, rather than students, administered medication (by injection), monitored therapies, and changed dressings as per medical orders on a daily, weekly or monthly basis. Wallsend and Maitland District, and Royal Newcastle Hospital nurses also helped elderly and/or disabled clients bathe and dress two or three times a week. Many of the patients cared for by Royal Newcastle Hospital nurses had had three or more months of rehabilitation at William Lynne (Gibson 1970b). Miss Margaret Mort, an occupational therapist, and Dr Richard Gibson, a geriatrician, oversighted the rehabilitation of people following a cerebral vascular accident (CVA). The treatment offered involved encouraging them to use every function they had rather than trying to ‘regain function’, then the standard physiotherapy treatment. Upon discharge a strict regime was followed that included weekly or fortnightly housekeeping (cleaning, laundry), meals-on-wheels (3 /52), the loan of equipment (bath board, shower /toilet chairs) and nursing, two to three times a week, to

131 ‘reinforce’ rehabilitation and to prevent injury. Wallsend District Hospital nurses also assisted elderly people, initially without benefit of rehabilitation. By the 1970s nurses from this hospital were also providing post-discharge support and education to ex-patients who had asthma, diabetes and cardiac problems (Punton-Butler 1993). During the early to mid 1970s Maitland (1974) and Wallsend District (1978) Hospitals each established rehabilitation units similar to that at Royal Newcastle Hospital. The Wallsend unit was oversighted by the Medical Superintendent, Dr Bruce McKillop, previously Community Physician at Windale CHC. By 1975, when implementation of the CHP policy began in earnest in the Hunter Region, Royal Newcastle Hospital was running a large medically dominated home nursing service employing seven registered nurses and two students (on two week rotations). By 1978 Wallsend District Hospital had extended its service to five nurses. AS Table 6.4 illustrates, daily visits varied from an average of twelve (Wallsend) to sixteen (Mater Misericordiae) and twenty three (Newcastle) in Newcastle and Lake Macquarie. At Cessnock one nurse averaged forty visits a day (5000 a year), while the nurse at Maitland made twelve to sixteen visits between 8am and 12pm prior to running outpatient clinics. An indication of their workload is provided by looking at 1978 when some thirteen nurses provided approximately 28,696 services to over 1,238 patients, that is about 109 visits daily. Between 1972 and 1984 the number of nurses providing home nursing services increased. However, by 1984 the nurses employed by these hospitals provided fewer home visits (16,238) despite a growing ageing population. It is not clear why. Obtaining exact numbers is difficult as the way each facility recorded and reported occasions of service changed. Prior to the Hospitals Commission being disestablished in 1972 Annual Reports for Royal Newcastle Hospital reported visits as district (acute) or domiciliary (aged care). From 1974, as CHCs were being established, home visits and outpatient statistics were combined. According to one nurse who worked for this service and allocated clients, referrals from GPs declined from 1975. By the early 1980s their clientele consisted almost entirely of patients discharged from this hospital (CNS Interview 26). Referrals to Wallsend District Hospital increased by 1984 as had the number of nurses providing home care. The Annual Reports for the Mater Misericordiae Hospital provide little information about nursing home visits, combining them with attendance at outpatient clinics. What Cessnock District Hospital recorded is unclear. Nursing and outpatient services were likely combined or visits/treatments counted separately. With outpatient services counting as a proportion of an inpatient day counting each person's treatments would have been advantageous (eg. Injection + dressing = two services).

Some Gruelling Daily Schedules and Little Control The nurses who provided home nursing often had demanding workloads. Some had as little as ten to fifteen minutes to spend with some patients giving them little time to cater for their social and/or emotional needs. Safety, as one nurse recalled, was sometimes compromised for speed (CNS Interview 26). Nurses from Royal Newcastle Hospital, for example, routinely ‘dropped off’ students to start care while they ‘did’ another patient before returning to assist. Concern for patients led some nurses to work unpaid overtime,

132 in meal breaks and after work, paying bills and collecting people's groceries without informing their nurse or medical managers. Hospitals administered and managed services differently. Nurses at Wallsend, Maitland and Cessnock District Hospitals accepted direct referrals from specialists, GPs, and other nurses. They took responsibility for assessing and monitoring patient progress and communicated with referrers as necessary. A nurse who worked at Wallsend District Hospital before becoming a GCN recalls that they covered practically the whole of Newcastle-Lake Macquarie. There were the three of us and we used to break it up into three areas, and each day we changed round the three areas. We'd do Lake Macquarie, Shortland, and then sort of into Newcastle, down the east side of the Lake. People have different needs and one would speak to me and if they wouldn't speak to me they'd speak to one of the others and that way we got a better overall picture, whereas there are some people who take a long while to trust a person, whereas another person may trust instantly. So we used to sit down at the end of the day for the last at least half-hour, tried to be an hour, to discuss what we'd found out, so we got this whole, overall picture for each person and were able to meet their needs better (Interview 19).

Royal Newcastle Hospital operated differently. A socio-medical philosophy underpinned this service (Gibson 1970b; Armitage 1991, p.129). The medical director, Dr Dick Gibson, a geriatrician, made decisions about who would receive services. GPs, nurses and patients had little input. Prior to 1966 services were restricted to hospital patients. Thereafter referrals were accepted from GPs as an ‘essential preventative element’ of care (Gibson 1970b, pp.119-123). Nurses recall being prohibited from contacting GPs. Gibson preferred a doctor to doctor approach. Review meetings were held but only the senior nurse attended (CNS Interview 26). The senior nurse allocated patients on a daily basis to prevent dependence developing. For Gibson dependence arose from a patient’s ‘physical and mental disability’ rather than how care was provided (1970b, p.122). Nurses travelled long distances. Each hospital provided care to patients scattered across the Region. Nurses from different hospitals visited the same areas (Personal Observation). Workloads were inequitable. During the 1980s attempts were made to address workloads by using patient allocation systems. The senior nurse at Royal Newcastle Hospital estimated care requirements, 15 to 45 minutes, and allocated each nurse sufficient patients to require 5 to 6.5 hours of direct care so with travelling and report writing they worked an eight hour day. A new senior nurse at Wallsend District Hospital introduced a similar system but limited nurses to three patients needing assistance with bathing to equalise ‘heaviness’ (NUM Interview 26). She accepted referrals. Nurses, however, were free to contact a patient’s doctor and refer them to other services. Royal Newcastle and Wallsend District Hospitals operated day centres. Royal Newcastle Hospital focused on providing respite for carers. A bus collected patients from across Newcastle and Lake Macquarie, a three hour round trip for some. At the centre they made gifts for annual fetes and played games to improve mobility and their treatments were attended to. The centre was run by an occupational therapist and a registered nurse assisted by volunteers. The nurse and volunteers who ran the day centre at Wallsend District Hospital had a different focus, helping lonely local residents socialise. GPs, district nurses, families or individuals could refer. The nurse and volunteers brought people to the centre in cars and involved them in interaction and craft and

133 attended to their treatments (HCNSW 1976g; Punton-Butler 1993, p.7; Wallsend District Hospital Annual Report 1974). Between 1975 and 1978 rehabilitation units were established at Maitland Hospital (1975), Kurri Kurri District Hospital (1977), funded under the Federal Rural Employment Development (RED) Scheme, and Wallsend District Hospital (1978). Growth of these services was promoted by Dr Dick Gibson following his secondment in 1973 from Royal Newcastle Hospital to Regional Office to form a geriatric assessment advisory team (Geraghty 1978; Gibson 1970a,b). The unit at Kurri Kurri District Hospital was unable to provide a home nursing service because it lacked a domiciliary nurse.

Table 6.4 Home Nursing Services provided by Schedule 2 and 3 Hospitals to the populations of Newcastle, Lake Macquarie, Maitland and Cessnock Local Government Areas 1972, 1974 and 1984. Hospital Nurses 1972 1973 1984 Daily 1973# Royal Newcastle 7 + 2 students 15,578(807)! 18,293(960)! 1851 20-23 981(86) 1,204(76) Mater 1 2,094 2,131 ---- 16 Misericordiae Wallsend District 1 1,616 1,456(202) 8,693 12 4 (83) Maitland District 1 ------12-15* Cessnock District 1 5,111 5,622 5,694 43 Total 13 (16) 25,380 (893) 28,696 (1238) 16,238 109 *Patient numbers are identified in brackets if known. ! The first figure for Royal Newcastle Hospital is for aged care and the second for acute care. Data for 1984 were obtained from nurses statistics. # Estimated from total annual visits reported and number of nurses employed. Source: Annual Reports for Cessnock District Hospital (1974, 1984); Royal Newcastle Mater Misericordia Hospital (1975); Wallsend District Hospital (1972, 1973, 1984); Royal Newcastle Hospital (1974).

Schedule 5 Geriatric and Psychiatric Hospital Outreach Services Allendale Hospital provided home nursing to aged persons referred by GPs for assistance and in need of rehabilitation following admissions to general hospitals for trauma (eg. fractured femur) or an acute illness. By 1974 five registered geriatric nurses, including a senior nurse and an enrolled nurse, were providing home nursing and running day centres. Like their general hospital peers they wore uniforms and drove marked cars. Rehabilitation was emphasised by nurses teaching patients to bathe, dress and mobilise safely using loaned equipment, walkers and bath boards. In Newcastle large general hospitals assisted elderly persons and provided care for acute conditions. This did not occur in the Cessnock area. Cessnock Hospital limited its home nursing to acute care, dressing wounds and administering medication (injections). Allendale Hospital nursing service assisted people with bathing and rehabilitation. Coordination was limited. One client had a dressing changed before their bath (Personal Observation). Nurses from Allendale Hospital ran day centres in local halls (Kearsley Progress Association Hall, Paxton Bowling Club) and at the hospital (HCNSW 1976b). Again the focus was to help isolated, house-bound, lonely people socialise. A small fee gained those who attended a hot meal from Meals-On-Wheels kitchens at Kurri Kurri District or Cessnock District Hospitals. Health Commission reports describe these centres as having a ‘friendly’ and ‘natural’ atmosphere with relatives encouraged to attend (NSW Health Commission Report to Parliament June 1974). People self-referred or were referred by a health

134 professional. Nurses in Health Commission vehicles and volunteers using their own cars provided transport to and from these centres. By 1971 psychiatric hospitals operated outpatient clinics and domiciliary nursing services. Unlike general hospitals these facilities provided services for residents of defined geographic areas. Newcastle Psychiatric Centre catered for residents of Newcastle, East Lake Macquarie, Maitland, Dungog and North Coast. Morisset Hospital served residents of West Lake Macquarie, Cessnock, Kurri Kurri, New England and the Central Coast. Each hospital had two domiciliary nurses. One was usually a welfare officer which meant that in the absence of a doctor they could authorise a person's involuntary admission to a psychiatric facility. Nurses visited people in their homes and assisted doctors with clinics. In this system domiciliary nurses were appointed having applied for a gazetted position, been selected, and gained a promotion (Psychiatric Nurse Interview 2). As one Health Commission officer observed the nurses selected for such positions were ‘amongst the best’ (Administrative Officer Interview 46). They mostly worked as autonomous professionals. They attended discharge planning meetings and participated in case discussions along with allied health professionals, psychiatrists and their trainees. When patients were discharged nurses followed up with home visits. Visits were often lengthy, lasting from 30-90 minutes. During visits they assessed patient progress, monitored treatment (including medication regimes), living conditions and assisted them to access services and/or find work (Health Commission 1976g). Visits were also made to ex-long term residents of psychiatric hospitals discharged to group houses and private hostels. Many of the latter, despite depending on Health Commission referrals for their clientele, were considered of poor standard (Thwaites, Arthur & Hickie 1979). The nurses who worked as Activity Officers ran sheltered workshops, living skills and rehabilitation programs and community based satellite group homes. Official reports illustrate that by the early 1970s psychiatrists, with the assistance of nurses, were running outpatient clinics at general hospitals and baby health centres in Lake Macquarie and Lower Hunter (NSW Parliament 1972-73, p.170; HCNSW 1974c; Thwaites et al 1979). They assessed, treated and counselled people who had been referred by their GP or other services or who self-referred. Little is known about the number of visits nurses made or how many people attended clinics. Reports to Parliament detail expenditure, admissions, discharges, re-admissions, patients' age, sex, and diagnosis and staff numbers, but not attendance at clinics or home visits. As such visits did not count as inpatient services for funding purposes, as for general hospitals, less emphasis was placed on this information. Some indication of use of clinics is provided by Dr Bill Barclay, Director, State Psychiatric Services, who stated that between 1970 and 1971 a clinic at Cessnock was attended by 101 people most (93) new to psychiatric services (Director State Psychiatric Services Report 1971). Nurses maintained diaries. Some recall visiting six to eight people a day in their area (Psychiatric Nurse Interviews 2, 44) driving unmarked hospital cars and wearing street clothes. People's privacy was maintained. Home visiting was hindered by reliance on pool cars. A Review of Services conducted in 1971 recommended nurses be allocated cars and educated for community practice, and that consideration be given to how nurses' activity and patient

135 care were documented (DH NSW 1971). The Department of Health responded to the need for education by developing a twelve week community nursing course. By June 1973 over three hundred baby health, community health, geriatric, tuberculosis, and psychiatric nurses (284/1970, 34/1971, 94/1973) had completed this course (NSW, Parliament 1973; HCNSW 30.6.1973; HCNSW 1975). These nurses were all state government employees.

Psychiatric Nurses’ Roles began to Expand Federal Acts and new funding fostered the growth of domiciliary and outpatient psychiatric services. In March 1973 the passing of a federal Mental Health Related Services Assistance Act made state governments eligible for 100% of the costs associated with establishing clinics, day centres and hostels for those with a mental illness, developmental disability or addiction to drugs or alcohol (HHSC 1974, p.46-7). This Act made $7.5 million per annum available for mental health and alcohol and drug dependence programs until 1975 when it was integrated with that for CHP projects. Under this new Act Newcastle Psychiatric Centre established in-patient drug and alcohol treatment, a shop-front drop-in centre and community mental health teams in Newcastle City, Lake Macquarie and Maitland. Morisset Hospital established a drug and alcohol treatment service and mental health teams at Gosford, Cessnock and Kurri Kurri (Lower Hunter). Nurses established day centres for residents with a psychiatric illness at Cardiff (West Lake Macquarie), Cessnock and Kurri Kurri (HCNSW 1976g, 1977; Psychiatric Nurse Interview 44). At Cessnock and Kurri Kurri District Hospitals clinics were conducted to offer ‘Help for lonely depressed, physically handicapped people who have had hospital treatment’ (HCNSW 1976g). As members of mental health teams nurses moved out of hospitals. They were allocated department cars, which they garaged at home, and worked from offices near GP and other services. At Maitland, for example, a nurse and psychologist shared rooms with a community group and a GP's surgery made appointments for clinics and a psychiatrist. In this setting nurses often provided services outside of business hours. Nurses at Cessnock and Kurri Kurri, for example, ran groups between 7pm and 9pm at a baby health centre (HCNSW 1976g, 1977; Psychiatric Nurse Interviews 1. 8, 33).

Hunter Regional Services Between 1973 and 1974 two Regional services were established, an aerial health service and an aged care assessment team (already mentioned). The establishment of an aerial health service extended mental health and geriatric consultations to the North Coast and Inner West. Official reports illustrate that between July and November 1974 forty flights were made (HCNSW HR 1974). The Aged Care Assessment Team, commenced in 1975. This service was established to assess aged persons need for services including their need for placement in an aged care hostel or nursing home. In early 1975 projects established under the Mental Health Related Services Act were amalgamated with those funded under the CHP policy. New training courses were established for nurses. These courses reflected the shift to community care and recognition of the needs of people with psychiatric illnesses and developmental

136 disabilities. In the mid 1960s a new developmental disability nursing course began and developmental disability and psychiatric services were separated. Stockton and Morisset Hospital nurses became involved in establishing group homes, sheltered workshops (hospital and community based) and clinics in Newcastle and West Lake Macquarie (HCNSW 1976g). By 1989 responsibility for Stockton and that part of Morisset Hospital providing care to people with developmental disabilities transferred to the Department of Community Services.

Local Government and Private Domiciliary Services By 1974 hospitals in the Hunter Region had established small domiciliary nursing services. Some covered large areas, for example Royal Newcastle Hospital provided services to residents of two Local Government Areas, Newcastle and Lake Macquarie. The Mater Misericordiae limited services to local suburbs. Only two other organisations provided nursing services. Newcastle City Council began a service for residents over 60 years referred by GPs in 1960. Two part- time nurses worked closely with local GPs. It was a short term service, limited to six weeks during which they would attend to a person's dressings and monitor or administer therapies/medication. These nurses also conducted the Council's immunization clinics. From 1975 the Brown Sisters of St Joseph provided a home nursing service. The Sisters established a service in West Lakes, at Toronto, with support from Regional Office. As demand for their services was limited they moved to Tighes Hill, Newcastle, in 1976. Here they established a 24 hour seven day a week service for frail aged, terminally ill, and poor persons and their families. By 1983 in response to changing local a private nursing service was established in the West Lakes area by the daughter of the then Senior Nurse. Based in Toronto this service offered a 24 hour, seven day a week, medical, surgical, psychiatric, post-natal care and childbirth education service (NH 23.5.1983). These services operated concurrently with CHCs.

Maternal and Child Health Services In the Hunter, as elsewhere in NSW, school medical services began in the early 1900s before infant welfare services (Dewdney 1972, p. 160). By the early 1960s the Hunter Region had four teams, a doctor and two registered nurses screening children living in the Hunter, Wyong and North Coast regions. These teams worked independently in a defined geographic area. Doctors and nurses had clearly defined responsibilities. Doctors examined children at schools and spoke with their parents either at schools or Child Guidance Centres. Nurses contacted schools and negotiated access with school principals, arranged for schools to distribute consent forms to kindergarten children, maintained and prepared records for each school, and conducted vision and hearing tests and assisted the doctor to conduct physical examinations. Children whose parents had consented to the process were examined (hearing, vision, developmental, behavioural problems) as per departmental guidelines. Preparatory screening, medical examinations and parent interviews could take weeks at a large school. The process was difficult at small

137 schools where space was limited. Privacy was required as physical examinations required children to remove all clothes but their underwear. It was a mammoth administrative task. The annual report of the Director General of Public Health for 1973 illustrates just how many children were examined or followed up annually. In 1971 it reports the four Hunter school medical teams visited 580 public and private schools. Doctors examined 14,538 infants and primary school children and reviewed a further 21,077 while nurses reviewed a further 6,379 children. In addition 9,261 high school children were examined (NSW, Parliament 1973, p.170). Nurses provided vision and hearing results to the school (to inform teachers of impediments to learning) and kept a Guidance Centre record. Doctors and nurses worked closely with teachers. Some nurses spoke to children about health, hygiene and nutrition, most distributed educational pamphlets produced by the Health Department. During school vacations doctors were based at Guidance Centres and available for parent interviews. Nurses used this time to conduct follow-up home visits to monitor the outcome of identified problems or referrals and administrative work. Travel to and from schools was undertaken in each practitioner's own vehicle. They were expected to keep detailed records of travel and submit them monthly to obtain a mileage allowance. School medical nurses wore street clothes. They were more involved in education and undertook more outreach than baby health nurses (School Medical Nurse Interview 1. 5). Infant welfare services commenced as a home visiting service, however, with transfer of responsibility to the Director of Public Health, clinics proliferated. By 1973 the Hunter Region had 62 baby health centres scattered across the Hunter, Central Coast and Northern Sector. Some 37 were located in Newcastle, Lake Macquarie, and Lower Hunter with most (25) built before 1940. These centres were collaborative ventures which involved state and local governments and various community groups, the Joint Coal Board, the Country Women’s Association and the ALP (Dewdney 1972, p.161; Jones 1989; NSWSG 1986). Some communities engaged in intense lobbying to obtain a centre and trained mothercraft nurse. Nurses ran drop-in clinics for mothers where, consistent with guidance notes, they monitored the weight, vision, hearing, development and immunisation status of their infants and offered relevant information, advice and support and made referrals to GPs if required (DPH 1963; Jones 1989). As this service was covered by legislation and by Agreements ‘Under Seal’, any deviation from the number of clinics specified (eg. closures for public holidays, staff illness or lack of relief) had to be reported to the relevant authorities (Administrative Officer Interview 52). Although some centres had been built as residences by the 1960s most were unused outside clinic hours until Regional Office began using them for psychiatric clinics. Between 1974 and 1989 the number of centres operating and clinics provided changed. Newcastle and Lake Macquarie gained new centres. Maitland and Cessnock lost them. Mothercraft nurses, like school medical teams, worked within a defined area. Baby health nurses had a circuit determined by schedules not proximity. Clinics were conducted weekly, fortnightly or monthly. Some circuits required nurses to conduct a morning clinic at one centre and an afternoon clinic at another. Circuits in Newcastle and Lake Macquarie (eg. Wallsend, Lambton, Charlestown and Newcastle City) and Maitland and Cessnock were smaller than in rural areas as more clinics were offered (Baby Health Nurse

138 Interview 1.10). Population size and attendance determined the number of clinic sessions offered. Registry of Births and Deaths records provided nurses with information about birth and deaths occurring in their circuit. This enabled nurses to identify mothers who had not attended a clinic and to make home visits. Home and hospital visits were conducted outside clinic hours. Travel between centres, homes or hospitals was undertaken using public transport or personal cars and a mileage allowance was paid. Hunter women used centres. Records illustrate that between 1970 (117,207) and 1971 (130,375) attendance increased (Report of the Director General of Public Health 1973, p.169). Fewer home (3,838) or hospital (4,891) visits were made. Royal Newcastle hospital also offered a well-baby clinic and prenatal classes (1,297 women attended). Baby health nurses were professionally isolated except for occasional visits by nurse inspectors (to assess and monitor services) and they had little contact with each other (Administrative Officer Interview 1.13). Most nurses had adopted street clothes and abandoned their traditional striped uniform and veil by the early 1970s (Jones 1989). By 1971 the Hunter Region (then including Wyong and the Northern Sector) had 61 school medical, child guidance, baby health and public health officers. There was a Medical Officer of Health, a deputy, an assistant medical officer, a psychiatrist , one senior and four school medical officers, two psychologists (1 part-time), two social workers, a part-time speech therapist, seven school nurses, an assistant nurse inspector, five tuberculosis nurses and 25 baby health nurses. The Region's public health staff also included food and health inspectors, an engineer and clerical staff (NSW, Parliament 1973, p.166). It is unclear how many worked in the Hunter Region. When boundaries were redefined in 1973 the number of mothercraft nurses allocated to the Hunter Region declined below its Establishment and some clinics ceased. By 1973 Regional Office administrators of the State Department of Health proposed to locate school medical teams, a medical officer and two nurses, at baby health centres and use these centres as CHCs (HCNSW 30.6.1973). They also ‘intended to use generalist community nurses to relieve the shortage whenever their skills are appropriate’ (HC 30.6.1974, p.90). In 1974 responsibility for maternal and child health services transferred from the Bureau of Maternal and Child Health to Regional Offices. This change left the Hunter Region with a deficit of five baby health nurses and hindered its ability to provide a satisfactory standard of home visiting (Health Commission Report to Parliament 1974, p.13). In response clinics were cut and pre-natal, preparation for parenthood classes, and mothercraft discussion groups ceased (HC 3.6.1974, p.90). By this time clinics were busy places with nurses working beyond clinic hours, in lunch breaks and after 5pm, to see the women remaining in their waiting rooms and record statistics, number attending and the purpose of each visit (Personal Recollection). By 1976 maternal and child health services, baby health and school medical, had been integrated with CHCs as had community mental health teams.

Nurses' Responsibilities The nurses who became members of CHC teams worked under different conditions, different industrial awards, and perhaps more significantly, they had had varied experience working as autonomous members

139 of multi-disciplinary teams. Some had experience organising their own work loads, accepting referrals, taking responsibility for assessing, planning and providing care to clients over time, using their initiative and working preventively. General hospitals made no attempt to limit their services to geographic areas or to coordinate the service they provided with that provided by other hospitals.

Distribution, Access and Costs The traditions and purpose of the services provided by hospitals and public health services and the way they were organised and provided affected their accessibility. By 1974 baby health centres remained the most evenly distributed services and because they were free and offered on a drop-in basis they were easy to access except in rural areas where clinic times acted as a barrier. Domiciliary nursing services were concentrated in Newcastle. The need for a medical referral could impede access. A GP referral sufficed for most services. The number of GPs working in each LGA more than doubled between 1974 and 1989, however access to care by GPs continued to be limited by cost as many refused to bulk bill once Medibank was introduced in 1975. Nor did a GP referral guarantee access to domiciliary nursing as the major provider, Royal Newcastle Hospital, limited services to patients referred by the medical director, a staff specialist. Like the service offered by Newcastle Council it was directed at older people. By 1974 all but one hospital allocated one nurse to domiciliary nursing. By the mid 1980s Wallsend District Hospital was the only one to have increased the number of domiciliary nurses. This limited access to care. The distribution of, and access to, psychiatric nursing services increased after nurses were placed in community clinics facilitating self-referrals. However the number of nurses employed remained static. The Child Guidance Centre offered free services but its location and adherence to business hours and waiting lists limited access. Nurses' opportunities to make independent decisions varied from one service to another. Baby health and school medical nurses had greater autonomy but their work was constrained by clinic schedules or the need to screen a certain number of children each year. These services however provided continuity of provider as nurses were allocated to defined geographic areas or a clinic circuit. By contrast the general hospitals with the largest domiciliary services ensured nurses' contact with individual patients was spasmodic and discontinuous because clients were allocated on a daily basis. In 1971 the NSW Government contributed 60 per cent of Schedule 2 and 3 hospitals' recurrent costs ($140,000,000). According to Dr Roderick (Rocky) McEwin, Chair, NSW Health Commission, the disestablished Hospitals Commission had distributed funds to hospital boards 'according to their need' with ‘a limited degree of accountability' (HCNSW 1972, p.13). Schedule 5 hospitals (psychiatric, developmental disability, geriatric) by contrast were administered by the state government, and managed by a tripartite executive, a chief executive officer (CEO), a medical superintendent and a matron, all of whom were salaried employees of the NSW Public Service Board. Schedule 2 and 3 employees were mostly waged where Schedule 5 employees were mostly salaried. This had implications for the cost of running services. Nurses in Schedule 2 and 3 were paid shift allowances and penalty rates those in Schedule 5 hospitals were salaried and paid allowances for acting in a higher position, night work and

140 overtime (cf 'The Lamp' 1976, NSW Nurses' Association; NSW Government Gazette 1976). Wages, a major cost, were more predictable in the latter and contained by nurses working 12- not 8-hour shifts2. According to the Hunter Valley Research Unit the Hunter Region received $13,116,000 in health funding in 1975. More was spent in Newcastle ($2,140,000), less in Lake Macquarie ($506,000), Cessnock ($138,000) and least in Maitland ($73,000) (HVRU 1976 p.65). More funds were thus allocated to the LGA of Newcastle, which had a declining population (but a medical school was being established), than to areas of population growth. The Hunter Health Statistics Unit (1988a) viewed hospital utilization, measured by separations rates, as an indicator of problems with bed supply rather than ‘illness' or 'need' (1988a, p.11). In 1978 the Region had 6.4 general beds per 1000 population, below rural and Inner Metropolitan areas but above that for Northern, Southern and Western Metropolitan Sydney and Illawarra Regions. From 1974 to 1988 admission rates, adjusted for age, sex and death rates, declined but exceeded those for NSW (Olsen 1982a; Smyth 1992). Hospital admission rates remained significantly higher for those areas with the highest crude and standardised death rates but lower for Newcastle and Lake Macquarie where death rates were higher than the NSW rate for men. Regional planners paid little attention to the population's circumstances until the mid 1980s when concern over funding levels and a new Regional Director prompted development of a funding allocation formula which took account of death and illness rates (Hardes & Olsen 1982). In 1988 intra-regional variations in admission and death and illness rates led the HHSU to suggest such differences might point to differences ‘in living conditions, occupational hazards and other environmental determinants of health’ as socio-economic status ‘is also associated with health status’ (HHSU 1988a, p. 3). The Hunter population's circumstances had been particularly challenging from European settlement yet it took until the 1980s for planners to question whether high death, illness and hospital admission rates might be associated with people's social circumstances, with disadvantage, and thus as an indicator of a need for more rather than fewer hospital beds (Hancock & Gibberd 1992; Smyth 1992). Hospital admissions remained highest for chronic problems which had the potential to compromise the physical, emotional and social health of individuals, families and aged persons living alone (widows) on low incomes in houses with limited amenities. Despite GP to population ratios falling within defined parameters, use of GPs remained lower than expected in some areas. Vinson et al (1976) found persons living in ‘at risk’ suburbs made less use of preventative services. Higginbotham, Heading, Pont et al (1993) asked why residents of Cessnock and affluent areas of Newcastle considered themselves and their families, not doctors, as being responsible for their health. Use of GPs services was lower where hospital admission rates and death rates from preventable or remedial conditions remained high.

2 Nurses worked 40 hours per week. In Schedule 5 hospitals they worked 12 hour shifts, two hours being allocated to meal breaks, while in Schedule 2 hospitals they worked 8 ½ hour shifts, with a half hour lunch break.

141 Education of the Region’s Health Professionals Where health professionals, especially nurses, were educated provides an indication of problems raised in a previous chapter and insights into the demands placed on practitioners employed to form new CHC teams. Many of the Region's nurses had trained at local hospitals where most other professionals, even those who grew up in the Region, gained their education outside the Region into the 1980s. Nearly all hospitals, Gresford and Dungog being the exceptions, operated schools of nursing mostly with nurses lacking teaching qualifications (Watson 1990?3). Until the mid 1960s students attended lectures on their days off and after work while general nurses attended lectures in the middle of their split shift (10am to 2pm). This ended following the introduction of a block system of lectures. By 1972 the Health Commission had removed control of nursing education from matrons and hospitals in the Hunter and established a Regional School of Nursing (HCNSW 1978; Watson 1990?). The location of this school, on a TAFE campus, created anger amongst senior nurses who wanted nurse education to move to universities. Marion Watson, the first head and an outsider from Sydney Hospital, established a needs based curriculum. Principles and psycho-social care were emphasised. Teachers were Public Service appointees and qualified, having Associate Diplomas or Diplomas in Nursing Education (a qualification unobtainable in the Hunter Region). Most came from outside the Region thus ending a parochial system whereby hospitals appointed their graduates as educators. Despite the hostility generated by the course, hospital based educators had to interact with one another and TAFE teachers to develop a curriculum and teaching tools. Students had ‘theory’ blocks (4 - 8 weeks) and employees of all but Royal Newcastle and the Mater Misericordiae Hospitals had to attend four week ‘Controlled Clinical Experience’ at large hospitals (Scott 1973). In 1977, despite continuing vehement opposition from some doctors, nurses and nursing organisations, psychiatric nursing education transferred to this facility (Russell 1990; Watson 1990?; Armitage 1991). The Regional School thus co-located students and teachers of psychiatric and general nursing. Community nursing theory was included in both courses (Year 3 Course Notes 1981). The new school increased contact between nurses working at different hospitals and led to a broadening of student experience. Wallsend District and Stockton Hospitals exchanged students. And Wallsend sent students to the Mater Misericordiae Hospital maternity unit. Royal Newcastle Hospital sent its students to Shortland Clinic, a psychiatric unit it administered. Stockton and Morisset Hospitals sent students to Sydney hospitals to acute admission units. Developmental disability nursing students attended lectures at the Department of Special Education, Newcastle College of Advanced Education. By 1974 nursing courses, encouraged by state government initiatives, were more generalist. When nursing education was abruptly transferred to Colleges of Advanced Education in 1985 a generic Diploma became the prerequisite for registration, a decade before this occurred nationally. New developments in medical education also occurred in this Region. In 1975 when CHCs were established Royal Newcastle Hospital was the only local hospital allocated medical students, and then

3 No publication date is provided. 1990 is an estimate.

142 only since 1972. None of the others were considered adequate. A new medical school changed this situation. The first Dean, David Maddison, a psychiatrist and author, previously Dean of Medicine, University of Sydney, developed a community focused, problem-based, student/patient-centred curriculum. Established in 1975 the school took its first students, selected on academic and personal criteria, in 1978. Community representatives participated in the selection process. Clinical placements began in year one (not year 5) and included community placements. The aim was to prepare doctors for general practice. Medical specialists, medical organisations and hospitals who had lobbied for a medical school, were supportive. Those who saw a Regional School of Nursing as taking resources (students) from hospitals embraced the medical school, expecting funds to flow to the Region to upgrade local hospitals. This did not occur. The new academic heads of medicine, surgery, pathology and gynaecology wanted to upgrade local hospitals to a standard suitable for training doctors. The new educational programs established for nurses and doctors were expected to redress specific policy problems. The Regional School of Nursing was established to redress high attrition rates and high failure rate in state examinations associated with inadequate clinical experience and theoretical education. Qualified educators were attracted to the Region, students were successful in state examinations and hospital control of nursing education ended. The new Medical School offered medical students a choice of courses and attracted medical specialists to the Hunter Region. These schools flourished under an Askin Liberal/Coalition State Government whose plans included rationalising hospitals and increasing community services. The CHP policy provided funding to further expand the Region's limited resources. Regional Office negotiated with the Department of Psychology, Newcastle University, to establish a Clinical Masters program for graduates with a psychology major. Graduates were attracted to the course and took positions in local Schedule 5 hospitals and CHCs. By 1977 Newcastle College of Advanced Education (CAE) had begun diploma courses in Nursing Education and Nursing Administration so when the state governments transferred nursing education to colleges from 1985 it already had academically qualified nurses on staff. A Diploma in Nursing began in 1985. By 1988 the newly named Hunter Institute of Higher Education (HIHE) offered nutrition, occupational therapy, radiography and welfare. Mothercraft, physiotherapy, social work and speech therapy had yet to be established. Medical students remained isolated from students undertaking other health professional courses.

In Summary The Hunter Region retained its industrial and geographically isolated character into the 1980s. This character was reflected in the higher percentage of adult men employed in unskilled or semi-skilled occupations in heavy manufacturing and coal mining. Unemployment levels remained high, income and education levels remained low, as did women’s participation in the paid workforce. The population remained relatively homogeneous and mostly Australian-born. Death and illness rates remained high and differentials between the Hunter and NSW populations increased despite incomes rising. Hospital admission rates also remained high. Use of mental health services increased. By 1986 use of primary

143 medical care remained low and lowest in those LGAs where death and illness from preventable disorders remained highest. Health services remained institutionally focused. Domiciliary nursing services were available although limited in number and scope. New nursing and medical education programs were emphasising psycho-social, environmental and community care. In the late 1980s the Region's planning unit observed that the characteristics of this Region may account for the health profile of its population. Between 1974 and 1989, the period of concern to this study, the Hunter remained resource rich, from an industrial perspective, but the health of its population remained poor compared with that of the population of NSW and its traditional health services remained institutionally focused.

144 CHAPTER 7 ESTABLISHING CHCS DURING A PERIOD OF FISCAL AUSTERITY: PROVIDING PEOPLE WITH A RELEVANT OPTION

People's health is an indelible record of the journey from conception to death. The damage recorded along the way is never erased even when illness is cured. We can moderate the damage done and we can prevent some of it. Doing so slows the aging process - something that is different from chronological, or calender aging (Milio 1983 xv).

Introduction The previous Chapter explored the circumstances in which the Hunter population lived, their state of health and the services available when the CHP policy was written and implemented. This Chapter focuses on CHCs, their establishment in the Hunter the practitioners they employed and the services they provided from 1974 until 1989. The generalist CHCs discussed here ceased to exist in January 1990 when specialist services, including a Regional nursing service, were established. This Chapter adds another dimension to the Regional context as a basis for exploring how practitioners approached policy implementation. It reveals that CHC practitioners, with few resources, broadened the care options available to the Hunter population and local service providers, and over time GPs' and general hospitals' use of CHCs increased. Consistent with a few earlier studies it shows that most preventive, educative services were provided by generalist nurses (Appendix 3.1). It also reveals that at some CHCs the nature of the services this group of practitioners provided changed over time in response to population need and managers' expectations. Time, change and need are central concepts. Before discussing the findings of this Chapter the purpose of the CHP policy, as discussed in Chapter 5, needs to be restated. The CHP policy was developed to address structural and administrative problems inherent in contemporary Western health care systems (cost, lack of coordination, maldistribution of services, and a curative disease focus) that limited people's access to timely, appropriate care. CHCs were considered a solution to these problems. The Australian CHP policy was intended to develop an organisational structure which would enable practitioners to identify a population's needs and in response establish relevant services. Its priorities were establishing CHCs in areas of ‘health scarcity’ and extending the responsibilities of nurses working outside of hospitals. Practitioners were expected to identify previously hidden needs and develop and offer relevant services. It was not expected that all CHCs would provide the same services. Given that most CHCs were located in areas of need (H&HSC 1976) some similarities might be expected. As earlier studies of CHCs as discussed in Chapter 3 illustrate, by the 1980s practitioners were providing similar services to the same populations, focusing on secondary and tertiary, rather than primary, prevention while taking a similar approach to service provision. This led some researchers, for example ACHA (1987), to conclude that CHP policy had failed to achieve what it was intended to achieve. Others argued that CHC practitioners offered services that were more preventive in intent than those

145 provided by GPs and hospital-based practitioners as they took an educative approach (Duckett et al 1980; Jackson 1985; Jackson et al 1989; SCHRU 1985, 1987, 1988). Most early studies, as I argued earlier, considered the work of practitioners separately from the context in which CHCs were established. The nature of the resources available to CHC practitioners and population needs (both determined and expressed) were generally inferred rather than explicated. Contextual issues, which were and remain relevant, were not central to these mainly evaluation studies. This study, unlike earlier studies, seeks to provide a context for exploring the activities of CHC practitioners. The last Chapter illustrated the historical and contemporary circumstances in which the Hunter population lived. Contemporary authors concerned with determinants of health now illustrate that such circumstances have adverse implications for the health of populations (Badura et al 1991; Beaglehole & Bonita 1997; Berkman & Kawachi 2000; Evans, Barer & Marmor 1992; Milio 1981). By the 1980s it was evident that the Hunter population, compared with that of NSW, had higher death and illness rates from preventable conditions, lower use of primary medical care, and higher rates of hospitalisation. Inter- regional variations were evident between 1974 and 1989 reflecting socio-economic differences and differential access to the types of non-medical and nursing services that were an integral part of health care systems in Canada, the United Kingdom, and United States of America. The success or failure of policy implementation is intertwined with the resources allocated to this process and with how participants interpret a policy’s purpose (Milio 1981, 1986a). As this Chapter reveals, CHC practitioners had access to few resources compared with those available to hospitals, and implementation of the CHP policy began in a politically unstable period during which fiscal problems, federal and state, hindered the ability of their administrators to provide them with adequate resources. Furthermore, interpretations of the purpose of this policy varied.

An Inauspicious Beginning The way policy is implemented, how it is translated into action, has implications for its success or failure. Resources are crucial for success. Difficulties accessing resources can arise from a lack of funds or a resource shortage. Both affected the Hunter Region. Policy implementation began in the 1970s during a period of economic instability. Like most oil dependent nations, Australia was affected by an international oil crisis (Horne 1971). To reduce their costs federal governments made numerous changes to the formula used to fund the CHP policy. The 1970s were politically and economically difficult for NSW. By early 1974, as funds began trickling into the Hunter, the NSW Liberal/Country Party Lewis Government was confronting its own fiscal and administrative problems (Alaba 1994). Major changes had already occurred within the State Public Service, one of the most powerful organisations of its type (Alaba 1994). A Department of Public Health and a Hospitals Commission had been disestablished to form a new Health Commission. Power structures had changed. Senior public servants found themselves in new positions. The focus changed with the forming of a health commission from specific groups or organisations (eg. aged, general or psychiatric hospitals, public health) to the health needs of the populations of NSW and its

146 regions. This change, discussed earlier (q.v. Chapters 5 and 6), required a significant conceptual shift for the officers involved.

Differing Professional and Cultural Concerns The senior officers appointed to the Region’s main office reflected the merging of what had been a Department (Health) and a Commission (Hospitals). This situation created tension as it brought together people from different cultures whose views about health varied. The Hunter, as one of the first health Regions established in NSW, along with Illawarra and Western Sydney, was invited to make a submission for CHP funds in early 1973. Submissions made reflected the concerns and interests of senior officers: Dr J. Krister, Regional Director; B. Geraghty, Deputy Director; Dr W. Vickers (Community Health) and K. Miller (Finance), Assistant Regional Directors; J. Johnson, Regional Nursing Officer; professional advisers, such as Dr R. Gibson, a geriatrician seconded from Royal Newcastle Hospital, and administrative officers. The varied professional and administrative backgrounds of these officers influenced how they interpreted the purpose of the CHP, their views about how CHCs should be administered, the services they should offer and practitioners' responsibilities. From the beginning their positions diverged as to the appropriate responsibilities of generalist nurses.

Dissent As To Purpose Agreement as to purpose, crucial for successful policy implementation, was not achieved (Colebatch 2002; Nagel 1990). Krister (Regional Director), Vickers (Assistant Director) and Johnson (Nursing Officer), taking a public health view, considered preventive care, health education and outreach (case finding) important. Krister had been previously Director, Division of Health Education, at Central Office, in which capacity he had appointed health education officers to the Hunter and Lismore Regions to develop regional education programs. His views had been influenced by having completed a National Health and Medical Research Council Travelling Fellowship to study health education in Europe, North America, and Asia (Krister 1970). From his perspective health education, mass education, was an important part of a CHP. Vickers, Assistant Director, Community Health, was previously Deputy Regional Medical Officer, Newcastle District, responsible for maternal and child health services, sanitation, and monitoring private hospital and nursing home standards. With a Diploma in Public Health, and experience in New Guinea, he was supportive of health education but committed to building up generalist CHCs and developing a role for generalist nurses (HCNSW 1974b; NH 3.8.1972, p.8; Vickers 1958, 1977). Johnson, Regional Nursing Officer, had been a nurse inspector with the Bureau of Maternal and Child Health. Her appointment, reflecting the complexities of the Public Service, had been delayed until 1975 until an appeal by an unsuccessful applicant was overturned (NSWNA Archives 1975). Johnson and Vickers had worked together in the Region and shared a view, then reflected in Department of Health reports, that community nurses’ responsibilities could be expanded to benefit populations. Both supported developing a generalist role.

147 The two other officers, Geraghty, Deputy Director, and Miller, Assistant Director (Finance), had also worked together at the Hospitals Commission (Administrative Officer Interviews 14, 48, 52). They shared a concern to improve the Region's hospitals but from different conceptual viewpoints. Miller, who had completed a Masters, Health Administration, University of New South Wales, was concerned with how hospital beds were allocated (Miller 1968). He had a pragmatic reason for supporting hospital administration of CHCs, believing that this arrangement would reduce administrative costs and duplication, and in his view be easier for practitioners. Geraghty wanted hospitals administering CHCs for different reasons. He believed that medical specialists should control nurses and opposed nurses working as GCNs (Administrative Officer Interviews 14, 46; Geraghty 1978). He had little regard for CHC practitioners or managers as the next Chapter illustrates.

Conflicting Concerns Geraghty and Miller’s views about CHCs were at odds with those at Central Office. The Chair, Dr R. McEwin, and Commissioner for Personal Services, Dr W. Barclay, like Sax, believed CHCs should remain separate from hospitals so practitioners could remain autonomous and to protect their resources (H&HSC 1973; HCNSW 1974a, 1974b; McEwin 1972). Vickers and Johnson shared this view believing that GCNs in particular should be given the freedom they required to identify needs and develop relevant services especially for vulnerable populations. Disagreement as to how CHCs should be established and administered was evident from 1974, increasing from late 1975 when Geraghty became Regional Director. Aside from personal issues conflict was fuelled by a coalescence of circumstances. Of particular importance was a Government decision to establish a new medical school at the University of Newcastle. CHCs' needs for resources were pitted against those of the new medical school. Approval had been given for a community medical school but in order for this facility to function effectively the Region’s hospitals desperately required an upgrade in buildings and ward infrastructure. Funds were not provided for this work (Olsen Interview). This was a political decision. Funds were provided to the new medical school at the University of New South Wales to develop the ward infra-structure required for teaching hospitals.

Missed Opportunities As the head of one of the first health regions established in NSW, Krister was invited to make a submission for CHP funding in 1973. The Region was prepared. Krister knew the State had plans to establish a large CHP program and, importantly he had connections in Central Office and he knew how this intensely political environment worked. This gave the Region an advantage, an ‘inside’ run when it came to making a submission for funds (Administrative Officer 46; Olsen Interview). Vickers’ experience working with nurses and other non-medical practitioners within the Region was another advantage. He understood local needs and local politics as well as being familiar with, and supportive of, Sax’s vision. For reasons discussed later, Vickers and Krister chose a generalist/specialist structure to implement the CHP policy. At this time the Hunter Health Region included the Upper Hunter and Great Lakes. Submissions for

148 funding were made to establish: a coordination team, uni-focus specialist teams, information services, a staff education unit and eight generalist CHC teams: East and West Lakes, West Metropolitan and Inner City, Lower and Upper Hunter, Manning and Great Lakes and Port Stephens. Funds began to arrive in 1973 as the local media reported with some fanfare (NH 26.2.74 p.5, NH 28.2.74, p.2, NH 15.11.74 p.6, 26.11.74 p.3, NH 28.11.74 p.15). The expectation was that CHCs would develop and provide services for geographically defined populations while specialist centres would focus on the needs of population groups, for example the aged. Most projects were funded. Generalist CHCs were the losers with five rather than eight being funded. A similar situation occurred in 1974 and 1975 when submissions were made for: a women's health centre; a community medicine teaching unit; and a regional health education unit (with five specialist sections, mental health, drug education, alcohol and addiction, general health education, information and publication and graphic and visual aids) to run public programs in schools, factories and homes to increase public knowledge about health matters (Vickers, Correspondence, 9.12.1974). The women’s health centre was funded, an outcome which pleased Vickers (NH 26.2.74 p.5). Health education was not funded, then or later. Further submissions were made in 1974, at the Commission's request, for funds to build CHCs at Nelson Bay and Windale and for thirty establishment positions for a regional nursing service. Funds were allocated to build CHCs. None were allocated for a regional nursing service. This remained a source of angst for some senior officers. The Region did fairly well at this time. According to Dr Geoffrey Olsen, then Regional Director of New England, who in the late 1970s became the Hunter Region's Project Officer and then Regional Director, the Hunter Region got ‘more’ than its fair share initially (Olsen Interview). This situation changed from late 1975 when Geraghty became Regional Director. From then on the Region got ‘less than its fair share’ partly, according to Olsen, because while Geraghty put a well-argued case, his combative style put decision-makers at Central Office offside. As Olsen put it ‘no favours were done’. Conflict between key players, a clash of personalities, affected the resources allocated to the Region. Comparing allocations to Illawarra, an industrial region of similar size but with a large non-English- speaking background population, the Hunter fared poorly (HCNSW 1976g; H&HSC 1976b). By 1981, when Olsen was appointed to the Hunter as Project Officer and then Regional Director, there was sufficient evidence to show that the Region’s health care system, including CHCs, had run down and had too few resources. Heads rolled in what a local Newspaper referred to as an ‘Interesting Reshuffle’ (NH 26.6.1981, p.2). The Region's Deputy and Assistant Deputy Regional Director were transferred to other regions. A year later Geraghty was transferred, overnight, to the Ambulance Service, and Olsen, then the Region's Project Officer, replaced him as Regional Director (NH 3.4.82, 6.5.1982; Lowe 23.3.1982). The catalyst for this massive change was a boat that Stockton Hospital had purchased for use by its disabled residents. In the 1980s Geraghty and the Minister for Health, Ralph Hunt, used it for fishing trips (Newcastle Herald 29.5.1981 pp1-3). The scandal arising over ‘the boat’ focused state government attention on the Region's health system. Mainstream services remained in poor shape and CHCs

149 continued struggling. This crisis, precipitating analysis of Regional needs, was beneficial. Olsen and his team wrote a series of reports, including a Strategic Plan for the Region, which included the CHP. Improvements occurred over the next decade. Fundamental problems, however, remained for the CHCs that had been established in areas with few services.

Choosing Locations for CHCs Vickers and his colleagues had little difficulty deciding where to locate CHCs. Although it had not been identified as an area of ‘health scarcity’ the Region had many gaps in services. As in the United Kingdom and North America the areas selected as locations for CHCs were those where the population had limited access to health and other resources (Alford 1975). Windale, Nelson Bay, and Toronto were obvious choices. Windale, an under-resourced public housing estate, had a clear need for a community centre and improved access to health and welfare services (NSW, Parliament 1973; Vinson & Homel 1976; Vinson, Homel & Bonney 1976). The situation was similar at Nelson Bay where the Commission intended to close a private hospital for safety reasons. Toronto, in West Lakes, a growth area, lacked a hospital and needed a nursing service. All were isolated from services in Newcastle City because of poor transport. Some gaps in services had been partly filled by placing psychiatric nurses, funded under the Mental Health and Related Services Assistance Act (1973), in four areas where populations were known to include persons with problems associated with drug or alcohol, mental illness or a disability. Maitland, Charlestown, Toronto, Cardiff and Cessnock were considered appropriate areas for CHCs, or sub-centres. Choosing locations for CHCs was easy; finding suitable premises was not. Few of the facilities obtained for use as CHCs or sub-centres, purpose built or rented, were adequate for their intended purpose into the 1980s.

Space Matters Overseas studies indicate that CHCs can provide populations with a venue for community related activities (Church 1993; Pearse & Crocker 1942). Buildings matter; their design and location can facilitate access to services and render impossible provision of some types of services. Buildings were not a priority of the architects of the CHP policy (H&HSC 1973). Regional administrators were similarly unconcerned. A make- do attitude was evident. They expected additional funds to become available in the short, rather than long, term to build more CHCs and employ more practitioners (Administrative Officer Interview 14). They were wrong. Vickers' and Johnson's view that practitioners, in particular generalist nurses, only needed access to ‘a car’ and a ‘phone booth’ to uncover ‘needs’ had long term consequences. Premises obtained in the early 1970s remained in use as CHCs into the 1980s. Buildings obtained for CHCs were geographically accessible to most residents of a catchment area but too small to house the practitioners located at them. The facilities were also poor. Lack of ventilation made some hot in summer and lack of heating left them cold in winter. Necessities like soundproofing were absent. Confidentiality was compromised. Inadequate furnishing limited the comfort of practitioners and their clients. Purpose built centres were more suitable

150 but still too small. For example Windale CHC, which was built in 1975, had nine offices, an activities room, a tearoom and a waiting room, and was accessible by ambulance. Within a few years it had become too small to house the number of practitioners employed or provide an adequate community centre. Size mattered. Within centres, space was allocated according to Commission expectations. Allied health, specialist nurses and centre managers − community physicians and, from 1976, senior nurses − were allocated single offices. A greater proportion of practitioners, generalists, school medical nurses and from 1986 HACC nurses, were destined to share larger offices. Nurses, located in close proximity to one another, were separated from other practitioners, specialist nurses and allied health. Single offices offered a sanctuary, isolation from colleagues. Space was allocated this way for a reason. Allied health professionals, baby health and mental health nurses were expected to work with clients and run clinics. Other nurses (school medical, generalist, HACC) were expected to work ‘in the field’. From mid-1975 most GCNs were sharing Baby Health Centres (BHCs) with a baby health nurse and returning to CHCs for supplies or meetings. Some travelled kilometers for this purpose.

Accessibility and Useability Most hospitals were old and in poor condition but they were geographically and physically accessible to communities who understood their purpose. Accessibility and useability of CHCs, purpose-built or rented, varied. Maitland CHC operated from a charming three storey former inn rented from and shared with a GP. Useable space was limited and spread over three floors. Reception, on the second floor, was accessed via a narrow steep set of stairs. For elderly, physically disabled or heavily pregnant persons, gaining physical access was difficult. Rooms were used for multiple purposes. Meetings occurred in the office of the generalist nurses. Psychiatric clinics were conducted in the office of the psychiatric nurses. Attic rooms allocated to allied health practitioners for work with clients, and to a senior nurse were small and too hot or too cold depending on the season. When the Centre was relocated to a purpose-built facility at East Maitland in 1984 conditions improved but space remained limited even after an extension. Practitioners here all shared large offices while their manager and senior nurse (until 1998) shared a single office. Use of single offices was restricted to meetings or work with clients. Bookings were required. Practitioners were in regular close contact with one another leading to an increase in understanding of one another’s work and personal problems, and a sense of collegiality. Practitioners working from sub-centres sometimes felt left out and distant from their peers.

The Most Basic of Facilities Sub-centres, mostly BHCs, gave nurses and a few allied health practitioners a base, a desk and a phone. A few, built as nurses’ residences, were large and attractive. Most however were small, dingy and poorly furnished with barely enough facilities for baby clinics. Some sub-centres, like that at Cessnock Ambulance Centre consisting of two or three rooms on the first floor accessed by a stately set of steep

151 stairs, were inaccessible and thus useable only as offices. With cramped conditions the norm, the useability of CHCs and sub-centres was limited (Personal Observation; Stevenson & Hutchinson 1983a,b). Newcastle CHC, originating as a psychiatric service in a residential cottage, was relocated to the Child Guidance Centre in early 1977. This building, adequate for assessing and working with children, was too small to house a CHC and a guidance centre. Other organisations, such as the Family Planning Association which conducted clinics here after hours, had to find a new venue. Planned extensions failed to eventuate despite being lodged and approved by Newcastle Council (TLM 15.3.1978; 22.11.1978). Shifting from one facility to another usually, but not always, led to an improvement in practitioners’ circumstances. There were few gains when Newcastle CHC split to form new centres, East and West Newcastle. Newcastle East was relocated to a cavernous, dilapidated two storey heritage building, obtained at little cost, near Royal Newcastle Hospital and Newcastle beach. Newcastle West was relocated to a cottage with three bedrooms owned by and close to, Wallsend Hospital. It remained there, the number of practitioners growing, until it was relocated to a large purpose-built CHC behind the hospital laundry in a ‘paddock’ of grass or mud depending on the weather, which also provided parking for client and centre cars.

Totally Inadequate Some CHCs were more inadequate than others. Westlakes, which operated from a portable annex located behind Toronto BHC, had the most inadequate facilities for the longest period. Established as a sub-centre it continued to be used as a CHC into the 1990s. No extensions occurred here. Those promised by Central Office in 1975 and approved in 1978 failed to eventuate (TLM 10.5.1978). Less spacious than a cottage it had narrow doorways and corridors and even lacked a safe path to its entrance. Here generalists and, later, HACC nurses shared a smallish office which also housed a filing compactus by the late 1980s (Personal Observation). Lack of soundproofing caused concern (TLM 15.3.1978) but took years to address (TLM 13.2.1981). Telephones were in short supply. Contact between practitioners was limited as they were scattered over two buildings, an annex and a BHC (Appendix 7.1).

Shabby and Uninviting The inadequacy of CHCs was raised by Stephen Leeder (1978), and later by Robin Stevenson and Margaret Hutchinson (1983a,b), the Area Coordinators of Community Health appointed by Olsen. Little could be done without funds. The location of some CHCs like Windale, an area with an image so negative it affected young people's employment prospects, detracted from their use by the wider community, but made it accessible to local residents. Windale CHC was modest, unimposing, but tidy and over time local groups began holding meetings here. Others, like Westlakes CHC, remained untidy and un-landscaped due to a lack of funding (TLM 22.11.1978). It was not an inviting facility. Sub-centres, with exceptions, were less accessible and less useable than purpose-built centres. Because they were inconsistently occupied they were also vulnerable to break-ins (Stevenson & Hutchinson 1983a,b). Charlestown, a sub-

152 centre of Windale CHC used mainly by psychiatric nurses, was the only one to have a receptionist and an answering machine.

Business Hours and After Hours Other deterrents to access and use were CHC opening hours. Unlike hospitals, CHCs operated from Monday to Friday from 8 or 9am until 5pm. Some closed for lunch. This made trying to contact CHCs, or their sub-centres, less than easy even for practitioners whose only contact with a centre from the field was a telephone. A building’s accessibility and useability can be taken to make a statement about the quality and value of the services provided. In this case the poor condition of CHCs was not such a statement, but rather a result of Vickers', Krister's and Johnson’s belief, shared with Sax, that buildings were less important than practitioners (Sax 1972a). They wanted practitioners in the field identifying local needs rather than sitting in buildings waiting for the population to visit (GCN Interviews 2, 63, 1.4, 1.6). Policy implementation is a difficult task. It is made more difficult by a lack of adequate resources, facilities (buildings, cars) and personnel. Most facilities obtained for use as CHCs were initially poor but improved over time. Funding and ideology were problems. Funding influenced how practitioners were employed. Senior officers had expectations of CHCs and of the practitioners employed at them as government reports discussed in Chapters 6 and 8 illustrate. The disciplines of the practitioners selected reflected those expectations.

Finding Practitioners for CHCs Before discussing the disciplines of the practitioners employed to work at CHCs it is important to highlight a central difference between those in NSW and those in other states where most CHC studies were conducted. In NSW practitioners were employees of a state government rather than small autonomous non-government organisations. Their employer was a powerful government bureaucracy, a Health Commission, part of the NSW Public Service. Employment involved lengthy bureaucratic administrative processes. Finding practitioners willing to work at CHCs was rarely a problem. What became difficult was finding those with the qualifications and experience required when it was possible to make appointments. The complexity of making public service appointments, compounded by fiscal and other constraints, created difficulties which affected how many practitioners were employed, when and how they were employed, and over time led to compromises being made and unfilled vacancies. Three strategies were used to obtain practitioners when CHCs were first established: recruitment, secondment and assimilation as Figure 7.1 shows.

153 Figure 7.1. How Practitioners were obtained for CHCs 1974-1976

Maternal and Schedule 5 Mental Health, Drug G eriatric Child Health Hospitals and Alcohol Services

Community Health Secondments to New Posts Centre Team

New Appointees, General Community Nurses, Allied H ealth Workers

Source: Official Documents, Reports, Team Records 1975-1977

Federal initiatives tend to leave states vulnerable to fiscal or policy change (Alford 1975). This was certainly so for the CHP policy. Treasury was concerned about the consequences for its budget if the federal government changed its funding formulas. It was a reasonable, prudent, concern with several changes to funding being made within five years (Milio 1983c). Concern resulted in underspending. The effect of the State's fiscal concerns impeded implementation mainly because freezes were imposed on recruitment and appointments at what were critical points in the process (Hausfeld 1982).

Recruitment was Difficult Recruitment started in 1974 and continued into 1975. Advertisements were placed in regional, national and international newspapers during 1974. By this time only two Regions, the Hunter and Illawarra, had approval to continue expanding. Metropolitan areas were instructed to consolidate. By mid-1974 the Chair, NSW Health Commission, Roderick 'Rocky' McEwin, had imposed the first of numerous freezes on recruitment and appointment in response to Treasury‘s concern over the speed of implementation (NSW Health Commission, Minutes of Senior Officers Conference July 1974). Part of the problem facing NSW was that it had what some politicians considered to be an overly large public sector workforce (Alaba 1994). Vickers had just begun recruiting practitioners for five CHCs when this freeze was imposed. Appointments were delayed. Expanding the CHC workforce continued as a stop start affair. Further problems arose from June 1975 at a federal level as the federal opposition refused to pass the Whitlam Government's budget, blocking supply. This furore ended in early November 1975 when the Governor- General dismissed the Whitlam Government and installed the Fraser Liberal Coalition Caretaker Government. CHP funding was cut as funding formulae were revised (Freudenberg 1977; Milio 1983c).

154 For NSW which had a large program this gave cause for anxiety. By 1976 NSW had a new Wran Labor Government ending a lengthy Liberal Coalition rule. The State’s finances were in poor shape. In 1978 the government reacted by imposing a more far-reaching freeze on recruitment and appointment in response to a further reduction in federal funding. Vickers by this time was trying to convert a sub-centre of Windale CHC at Toronto into a main centre. He had started recruiting new staff, a community physician, senior nurse and more nurses. As NSW’s allocation declined, further recruitment stopped and vacant positions remained vacant as a cost saving measure. Practitioners reacted by starting a campaign to ‘Save Community Health’ (NSWCHA 1981). This pattern, stop, go, stop, was to be repeated over the next decade. Cuts to funding, freezes on recruitment and appointment made implementation difficult.

Whom to Employ The problem confronting Vickers and Johnson in 1974 was that they needed practitioners to work at CHCs and implement a new policy, but had to choose from those who had been prepared for and worked in acute hospitals. The Commission, recognising more appropriate preparation was required for community work, had begun in-service courses for its employees, maternal and child and mental health nurses and allied health (HCNSW 1975b). With relevant preparation for community work unavailable in Australia practitioners were selected on qualifications, professional experience and an assessment of their potential to work in a new, less structured, environment and learn on the job. This required a leap of faith, a belief that practitioners could learn, as nurses had in Western Sydney, with education and support (NSWDHSRP 1971; Sax 1972a). A group of senior officers including Vickers the Assistant Director, Johnson the Regional Nursing Officer, H. Bevis an administrative officer, and sometimes a professional adviser to Regional Office, such as R. Gibson, a Regional Adviser on Geriatrics, conducted selection interviews in 1974. Once community physicians and, from 1976, senior nurses, had been appointed they also participated in this process to select practitioners for their CHCs. Once appointed, these new appointees became probationary and potentially permanent public servants occupying established positions at each CHC (q.v. Alaba 1994). Recruiting, advertising, interviewing, and selecting took money and time, time they often lacked before the next freeze. From late 1974, with funding unstable and the Commission urging consolidation, Vickers had other options and he took them, much to the dismay of some practitioners.

Seconding from other Services Seconding officers from one position to another was established public service practice. It had benefits for all concerned. Practitioners were able to work in a new position for a limited period and then apply if and when a permanent position occurred. Existing public servants gained experience and an advantage over other applicants. Vickers seconded practitioners from maternal and child and mental health services to CHC positions. The issue of permanency was left until later. Those who accepted secondments, like new appointees, decided to move from one position, one service, to another (Administrative Officer 1.5). CHC

155 positions were viewed as an opportunity to do something new and exciting. Few made an informed choice. Most were unqualified and unprepared for the positions to which they were seconded or appointed.

Co-locate and Assimilate A third strategy for gaining more practitioners for CHCs was assimilation. Like division, the fourth strategy, it gave practitioners few options; accept the change proposed or resign and/or return to hospitals. This strategy, used in Queensland with home care nurses (Gibson 1980), was used to assimilate four groups of nurses into CHCs in the Hunter. First, community psychiatric nurses funded under the Mental Health and Related Services Act from 1973 and under the CHP policy from 1976, were assimilated into CHCs in 1974 and 1975. Second, geriatric nurses employed by Allendale Hospital were assimilated into CHC teams during 1975. Third, baby health and school medical nurses and doctors were assimilated into CHC teams in 1976. Generally practitioners were co-located at a CHC operating in the area where they worked. There was one exception. Newcastle CHC was relocated to the child guidance centre. This led to school medical and child guidance staff being assimilated into this CHC or relocated to others. Practitioners’ responses varied. Those who saw themselves as specialists opposed this change. Others enjoyed the opportunities it offered. Some remained resistant, angry, and oppositional until they resigned or retired, years later. Those assimilated into Newcastle and Windale CHCs were amongst the latter. Assimilation began in 1974 and continued into the 1980s assisted by a State Government decision. By 1983, consistent with the recommendations of the earlier Starr Committee (1969), the NSW government had plans to establish Regional Health Services administered by Area Health Boards and to disestablish hospital boards. Regional officers, guided by the Commission, began preparing for this change. By 1984 they were co-locating domiciliary nurses employed by Wallsend District Hospital with CHC practitioners. Although still technically employees of this hospital their responsibilities were broadened, uniforms were abandoned, and later their employment status changed to that of CHC practitioner. This change, as one nurse affected observed, meant they became part of a team and attended team meetings where they could discuss client problems and progress ….someone else might have a different approach altogether that could work with that person. So you've got a collection of ideas and you picked out which one you thought would be best and if that didn't work you still had more to fall back on (GCN Interview 19).

With the establishment of Area Health Boards, for the first time in Australia’s history public sector employees (eg. CHCs, maternal and child, hospitals) were employed under the same administration. This made moving between facilities and changing positions easier. It also meant members of the same discipline worked under the same award with the same conditions and same remuneration. Recruitment, secondment and assimilation increased the number of practitioners working at CHCs despite ongoing fiscal problems. Hospitals were unaffected as their staff numbers were linked to bed occupancy. An effect of these strategies, which had implications for managers, was that by late 1975 CHC practitioners were a mix of those who had chosen to work at CHCs and those who had been

156 ‘shanghaied’. The majority were nurses, however, their interests, concerns and professional backgrounds varied. They had, after all, come from general hospitals (Schedule 2), psychiatric hospitals (Schedule 5) and maternal and child health services. A striking difference between these various groups of nurses in the view of one administrative officer was that those from mental health were ‘more mature’, ‘in their late thirties, early forties’, whose experience …. had never been tainted by the rigidity of the second schedule system….. these were professionals who really knew where they were coming from, in terms of the mental health stuff….. they didn't have the hang-ups of the second schedule sister. (Administrative Officer Interview 14).

Divide or Split The final strategy, used mainly from 1978, sought to create new independent CHCs. Once the number of practitioners at one CHC had reached a critical mass and a diverse enough range of disciplines, they were divided into two or more groups and new managers were appointed. From an administrative perspective it was a relatively easy process. CHCs were established with approximately ten practitioners. By 1977 each CHC had thirty to thirty three practitioners of which almost 70 per cent were nurses (Leeder 1977b). Sub- centres, where practitioners had mostly worked from 1975, formed the foundation of a new CHC structure. New CHCs were formed by dividing their catchment area along political or natural boundaries and allocating practitioners to both the new and old centres. This process began in 1978 when Windale CHC was divided to form a sub-centre at Toronto, Westlakes, which then in 1979 became a main centre. Newcastle was next in 1984 and then Maitland in 1985. From 1984, with an Area Board structure pending, CHCs were more often located in facilities owned by and/or located near to or in the grounds of general hospitals. This brought CHCs and general hospitals closer physically. The introduction of a new Commonwealth initiative, a Home and Community Care (HACC) program also facilitated a closer working relationship between hospitals and CHCs as large numbers of nurses were appointed to CHCs to work specifically with frail aged and/or disabled persons. The fourth and final strategy sought to increase the number of CHCs. This was achieved. Administratively dividing one CHC into two or more was easy. However, relationships formed over time were severed and the negative effects were not so easily addressed. Some practitioners, for example, found the disestablishment of Newcastle CHC to form two centres, Newcastle East and Newcastle West, a professionally disaffirming event. Staff morale, people's sense of ‘self worth’ were affected because ‘rightly or wrongly’ they felt the ‘second best, the left overs’ went to Newcastle East (Mental Health Nurse Interview 2A,B). Assimilation and division gave practitioners little or no choice as to their location. It was possible to apply for a transfer from one CHC to another, but this required a vacant position, a formal interview, and agreement by managers. Transfers were not automatic (Personal Recollection).

157

158 Policy implementation began inauspiciously in the Hunter. The State Government chose to impose limits on growth out of fear. For as Milio (1983) illustrated, NSW spent a fraction of its CHP allocation, choosing to return unspent funds to the Federal government rather than employ a full complement of practitioners. Senior officers tried to increase the number of practitioners and CHCs during a volatile period in Australia’s history. Ongoing fiscal problems compounded difficulties arising locally as to the purpose and value of CHCs. Most problems arose between late 1975, as Geraghty became Regional Director, and the mid-1980s when he was transferred, at short notice, to the Ambulance Service. From 1976 the emerging needs of the new medical school took priority over the needs of CHCs. Political and fiscal problems, state and local (discussed in depth in Chapters 8 and 9) affected how the CHP policy was implemented and, in particular, how practitioners were employed from 1976. Positions could be advertised, interviews could be conducted and a selection made only to find an embargo imposed on appointments. Sometimes the selected practitioners, especially allied health, were lost to the Region and positions could and did remain unfilled sometimes for years (Appendix 7.2). Political and fiscal problems not only impeded the number of appointments to CHCs but also affected how practitioners, especially nurses, were obtained.

Mostly Experienced The majority of those appointed to CHCs, regardless of means, were experienced practitioners. Their commitment to the CHP policy, however, varied. Most, but not all, were supportive. Recruitment, the strategy of choice from 1973 to 1976, had some advantages in this regard. It brought outsiders into a public service renowned for operating as a closed shop (Alaba 1994). Those appointed in the early 1970s, especially nurses, were keen to leave hospitals and try something new. Suggesting dissatisfaction with mainstream services, an advertisement for fifteen generalist nurses resulted in an estimated 400 applications. Senior officers had a large pool of nurses from which to choose (Administrative Officer 1.13). Vickers and Johnson knew what they wanted: practitioners with experience working in more than one health care setting including some outside the Region. These early recruits had five or more years’ professional experience, mostly gained in mainstream facilities, in general hospitals, where they had worked with people experiencing acute, chronic or terminal conditions or in midwifery. A few had worked in psychiatry. The CHP represented an ‘escape’ from the impersonal atmosphere of hospitals and an opportunity to work as a practitioner instead of supervising nursing students (Administrative Officer Interview 41). The first four community physicians recruited were similarly experienced having worked in general practice or public health, in Australia and overseas, and generally in the later stages of their career. One had been ‘dragged from’ retirement. In contrast, most nurses and allied health practitioners were beginning their careers. However, most doctors saw it as appealing to work with other professionals at a CHC where they could focus on prevention and work as a GP. Few understood the potential of the CHP policy and because the Commission bowed to the demands made by the NSW branch of the Australian

159 Medical Association (AMA), ultimately their work was restricted to centre management. Placing doctors into management positions had long term implications for the Region, mainly because, as overseas studies had shown, they lacked the skills required to manage a large number of practitioners from diverse professional backgrounds, in what was from late 1975 a hostile administrative environment. While most recruits were experienced professionals there were exceptions. Here, as in South Australia (SCHRU 1985, 1987), many allied health practitioners were new graduates. Amongst these were psychologists many of whom by 1977 were still in the process of obtaining a professional qualification (Leeder 1977b). This situation had implications for the work they could and would do. Some health education officers were also new graduates, some had teaching qualifications, all lacked experience working in health care. Nurses were the most experienced non-medical practitioners appointed to CHCs from the early 1970s. The strategies to obtain CHC practitioners described here had several benefits for the Region. They brought together, under a single system of management, a diverse array of practitioners working in the same geographic area and co-located them at a CHC or a sub-centre. Locating them in one facility facilitated interaction among disciplines which, in a hospital environment, might have had little if anything to do with each another. As some general hospitals in this Region operated with few, or no, allied health professionals, some nurses lacked experience working with this practitioner group. Some practitioners came from out of the Region. This was unusual in an insular area like the Hunter. Secondment and assimilation also had advantages. Senior officers could gain practitioners without affecting their ‘establishment’. A down side of this trend to assimilation was that some practitioners who saw themselves as specialists became unwilling captives of CHCs, an arrangement which, from their perspective, limited their contact with peers and decreased their opportunities for relevant ongoing education (Psychiatric Nurse 1.16; Baby Health Nurse 22).

More or Less Committed to the CHP Policy Community physicians (until the early 1980s) and senior nurses (from 1976) became responsible for a mixed group of practitioners some of whom chose to work at CHCs to do something new and exciting and others who were assimilated into CHCs against their will. The latter were rarely committed to the CHP at least initially. Some remained opposed to change even as their professional and administrative responsibilities changed. Many came to appreciate working at a CHC for professional reasons similar to those expressed by Crofts (1984) in Victoria. Working at a CHC provided them with easy access to practitioners from other disciplines. Support for multi-disciplinary work increased. A few continued to pine for a return to specialist child or mental health services for reasons made clear in Chapter 9. None returned to hospitals. The outcome was that managers, whose understanding of the CHP policy’s purpose was itself limited, had to manage practitioners whose reasons for working at CHCs, and interest in an understanding of the CHP policy, varied. This is significant as earlier studies associated practitioners’ lack of commitment to the CHP policy and its goals to its failure (Gibson 1980). Practitioners’ early professional

160 socialisation was also seen to influence whether policy ‘goals’ were achieved (Gibson 1980; SCHRU 1987). In the Hunter practitioners had mixed views about the CHP initially, however this changed over time as Chapter 9 illustrates. Practitioners began to view administrators as being antithetical to CHCs and to their attempts to maintain or increase team size and reduce their workloads and this forged a common purpose.

Erratic Growth, Continuous Vacancies Determining how many practitioners worked at each CHC is hindered by idiosyncratic reporting practices. Contradictory estimates can be found for most periods. Despite budget constraints the number of practitioners employed at each CHC increased rapidly, if erratically, from 1975. CHCs were established with about ten practitioners: a community physician, one to three psychologists, sometimes a social worker, usually a speech therapist, and six or more nurses mostly of whom were generalists. By 1977 this number had trebled. Estimates, like composition, varied depending on who was counted, when and how. In his report on the Hunter CHP for Bernie Geraghty, Regional Director, Stephen Leeder, the Foundation Professor of Community Medicine, Faculty of Medicine, Newcastle University, estimated that thirty to thirty three practitioners worked at each CHC. Based on Regional Office data Leeder estimated that the Region had 120 practitioners employed with CHP funding. This number included practitioners who had been seconded to or assimilated into CHCs and new recruits. He included a CHP coordination and specialist teams in this calculation. Only new recruits were an addition to the Region’s community based services. Despite his high estimate Leeder argued the Region’s CHP had too few practitioners and that CHC teams required more. It was an observation that displeased Geraghty whose antipathy to CHCs, especially their managers, increased over time. He continued to exclude centre managers from regional meetings while including professional advisers and inviting newly appointed members of the new medical school to attend. Leeder, who became increasingly involved in research into morbidity, mortality and life expectancy in the Region, was rarely consulted. Between 1975 and 1989 replacing practitioners who resigned became increasingly difficult. Attracting members of specific disciplines to the Region was difficult but more often vacancies were the result of decisions made external to the Region or at Regional Office which precluded appointments being made. Changed federal funding formulas and state-imposed embargos on appointments, by lowering establishment ceilings (the number of funded positions) or imposing temporary freezes, left some positions unfilled for weeks, months, and even years (Hausfeld Report 1982; NSWCHA 1981). Generalist nurse vacancies were usually filled on a temporary or casual basis until permanent appointments became possible. Health Education Officer positions were vulnerable. Senior officers and CHC managers could choose to leave positions unfilled and they did. The manner in which positions had to be filled played some part in their making this decision but so did ideology.

161 Anyone will Do From 1976 generalist nurses were increasingly employed on a temporary or casual basis under Section 44 of the Public Service Act. According to the Hunter Community Nurses Branch of the NSW Nurses Association the Region had thirty three nurses employed under this section by mid-1978 (NSWNA CNHB Minutes, 25.7.1978). Nursing numbers were maintained using a ‘catch as catch can’ approach from the late 1970s. Nurses with limited professional experience were employed to ‘fill-in’ at short notice for short periods. Most, approached by CHC practitioners they knew, had been out of the workforce for up to a decade. Few felt confident in their ability to do the job. One nurse, asked to help out at a CHC by a friend, viewed herself as lacking ‘confidence’ and ‘work skills’ so had rejected a position at a hospital on the day she was to start. However, she felt she might ‘be able to learn to work in the community’ (GCN Interview 64). Part of the problem arose because staff/population ratios had not been established for CHCs. Hospitals operated on patient/nurse ratios established by the Hospitals Commission and the NSW Nurses Association. Practitioner/population ratios, proposed by Meyers, Eglington and an Advisory Committee prior to 1972 and discussed in Chapter 6, were never used or reached. The outcome of fiscal constraints, imposed intermittently from 1975 to 1985, was that the number and discipline mix of practitioners at a particular CHC could vary from week to week. How many practitioners were employed at any one time was affected by various factors such as the number of resignations, retirements, and persons on leave (recreation or sick) and from 1979, the strategy being used to establish new CHCs. Continuity of some groups of practitioners, for example GCNs and social workers, became an issue along with that of centre managers (Appendix 7.3).

Unstable and Changing Stability and continuity are important for organisations implementing new policies. The CHCs discussed here experienced significant changes. Practitioners changed; some were permanent others casual although this was not unusual in a health service, what was unusual was that positions were left unfilled. Perhaps more important were the numerous changes which occurred at the level of CHC management given the volatile political climate in which implementation occurred. Most change occurred in Eastlakes and Westlakes, partly because managers were seconded to Regional Office to relieve other positions (eg. Deputy Regional Director, Regional Nursing Officer) or to working parties. Secondments had the effect of increasing instability and also, on occasion, of reducing the number of practitioners working at a CHC and leaving officers ‘acting’ in positions of significance. For example in 1976 Geraghty established a Mental Health Working Party to review the Region’s mental health services involving three officers: Myron Arthur, Senior Regional Psychologist; Margaret Hickey, a psychologist; and Dr Brian Thwaites, Medical Superintendent, Newcastle Psychiatric Centre. Seconded from their substantive positions for almost two years these positions were either unfilled or filled by someone ‘acting’ in their place. Hickey’s secondment left Windale CHC, which had an establishment of

162 three psychologists, with just one, which was then filled by an Acting Team Leader, Tony Turnbull, (Thwaites, Arthur & Hickey, 1980, p.95). Even at CHCs located in areas with a high proportion of young families and high levels of psycho-social problems, vacancies amongst allied health professionals were tolerated. Another issue was stable management. The community physician and senior nurse at Westlakes CHC had colleagues ‘acting’ on their behalf for up to nine months in one year. They had to deal with the difficulties of managing a CHC while having little authority to make significant decisions. By the early 1980s, when what the Newcastle Herald referred to as an ‘intriguing reshuffle’ of the Region's senior officers occurred, so many practitioners were ‘acting’ in positions it was suggested the Region join ‘Actors Equity’ (Allied Health Interview 66).

Vulnerability The CHP policy was vulnerable to funding cuts. Some years were worse than others. In 1978 the Commission, seeking to achieve a six per cent ‘across the board’ reduction in the state CHP budget, imposed another freeze. Vacant positions were deliberately kept this way to reduce salary costs. This had the effect of keeping allied health positions vacant. Westlakes CHC had so many changes in practitioners it is almost impossible to determine who was working there at a given time. Changes in management were greatest from 1978, the year practitioners in NSW began a campaign to ‘save community health’. Westlakes community physician, Tom Boleyn, and senior nurse, Ruby Miller, were seconded to Regional or Central Office leaving others to ‘act’ in their positions sometimes while continuing their own work. For example once community physicians were replaced by a ‘team leader’ they could be relieved by practitioners of any discipline. Once this happened senior nurses ‘acted’ as centre managers while continuing in their own position. This, as one nurse said, ‘made it hard’ (Senior Nurse Interview 42). This practice continued into the mid-1980s as Area Health Boards were being established. Opportunities to make new appointments remained fleeting during the 1980s. CHCs situations were vulnerable. Maitland CHC had a more stable situation with fewer resignations, vacancies and secondments and less change in management. Perhaps more importantly it remained an entity for a decade before being divided to form new CHCs. By this time its sub-centres had become secure established entities in their own right. An outcome of ongoing change was that CHCs, having raised expectations amongst local communities and other services providers that certain services would be provided, had to either take on the work of others or renege. Practitioners had created workloads by 1976 and these had grown thereafter. While various disciplines were employed at CHCs most practitioners were nurses.

Mostly Nurses but not Really a ‘Nursing Service’ Most of the practitioners employed at each CHC were nurses, with some being specialists but the majority generalists. As indicated, each CHC commenced with a doctor, two to three allied health practitioners and five or more nurses. All had specialist psychiatric/mental health nurses, one to three psychologists (some completing clinical masters at Newcastle University with Regional Office support) and a speech therapist.

163 Social workers, occupational therapists or health education officer/s were rare. Windale consistently had a social worker and Maitland usually had a health education officer. From 1978 Westlakes CHC had an Aboriginal Health Worker for two or three years. In 1984 Newcastle West gained ethnic health workers. In the early 1980s Maitland’s complement of specialists (sexual assault worker, drug and alcohol counsellor, women’s health nurse) increased. Community physicians gradually disappeared to be replaced by non- medical ‘team leaders’. By 1984 only Westlakes had a medical manager, and his title had been changed to Team Leader. In 1986, reflecting Commonwealth concerns, funding was provided to employ a new category of community nurse, Home and Community Care (HACC). All CHCs gained such nurses (Maitland 5, Westlakes 4, Newcastle West 3, Eastlakes 2). The strategies used to obtain practitioners for CHCs had long term effects. Maitland CHC, had more new recruits, more seconded from specialist services, and more GCNs than other centres. Practitioner numbers increased over time. Few CHCs achieved a full allied health establishment. Mental health nurse numbers remained static. Practitioner numbers increased as hospital bed numbers declined and early discharge and community care became the norm for general as well as psychiatric hospitals. The greatest increase was amongst generalists.

Large Catchment Areas Concerns about the escalating cost of implementing the CHP policy in NSW, and state policy changes, discussed in Chapter 8, resulted in five, rather than eight, generalist CHCs being funded in 1973. There was little option. Vickers established five CHCs with large catchment areas, his view being that the size of these areas could be reduced when funding was provided for more CHCs. CHC catchment areas and resident populations varied. The larger the catchment area the smaller the population. • 1975 Maitland CHC catchment 4603 sq kms, population 77,900 • 1975 Windale CHC catchment 748 square kms, population 131,000 • 1976 Newcastle CHC catchment 213 sq kms, population, 138,700

The size of a catchment area is reflected in the time practitioners required to travel across them. Distance, time of day, topography, poor roads, narrow one-lane highways, and in Newcastle City traffic lights, traffic and railway crossings affected the time required to travel from a sub-centre to a CHC. Within Newcastle fifteen to forty five minutes was common. In other areas travelling to a CHC from a sub-centre could take up to two hours. Clearly smaller catchments were required to reduce the need for travel. CHCs' catchments were reduced using natural (eg. a lake or mountain range) or political (Local Government Areas) boundaries. Whether this occurred depended on three factors: the number of practitioners employed at a CHC and whether there were enough to divide into two or more viable groups; whether funding was available to employ new managers; and whether suitable managers could be obtained.

164 Reducing the Size of Catchments Areas This process began in 1978 and ceased in 1985. The following year Area Health Boards were formed. Windale CHC's area, divided naturally by a large lake, was an obvious first choice. The community physician lived in Toronto, and a new community physician had been recruited to the region. Creating two CHCs, Eastlakes (300 sq kms) and Westlakes (448 sq kms), reduced catchments by half. Newcastle CHC, with the smallest and most densely populated catchment area, was next in 1984. Newcastle East (under 100 sq kms) and West (113 sq kms) had small catchment areas. In 1985 Newcastle West increased slightly with the addition of two suburbs from Westlakes CHC. Maitland CHC had the largest and most diverse catchment area with three or four Local Government Areas (LGAs), two Cities, Maitland ( 396 sq kms, population 46,130) and Cessnock (1962 sq kms, population 43,170), and one or two Shires, Dungog (2245 sq kms, population 6880) and Singleton (4810 sq kms). This CHC's catchment changed more often and more radically than others as the Hunter Health Region’s boundaries were adjusted to include or exclude specific townships. Singleton, for example, was to oscillate in and out of its catchment until 1985 when three CHCs were created: Maitland, Northumberland (Cessnock City), and Upper Hunter (Singleton Shire). By 1989 there were more CHCs in the Region, catchment areas were smaller, practitioner numbers had increased and most operated from new, purpose-built CHCs. There were two exceptions. A newly formed Northumberland CHC had been located in a large building in the grounds of Cessnock District Hospital while Westlakes CHC, the most inadequate of all, continued operating from its annex. Policy implementation is a difficult task. It is made more difficult when resources, buildings and personnel are difficult to obtain or funding to obtain them is lacking. CHC facilities were generally poor and often grossly inadequate. Practitioner numbers increased over time but CHCs lacked the stability enjoyed by local hospitals. Their preparedness for CHC work was also limited. Only those nurses employed prior to 1976 were provided with an orientation. The intricacies of working at CHCs that were part of a large bureaucracy, as explored in Chapters 8 and 9, imposed constraints on service development and provision yet a rich mix of services evolved with most provided away from CHCs, in communities, by nurses.

Services, Centre Based and Outreach The issue of relevance has to be considered. As the previous Chapter illustrated, between 1974 and 1989 the Hunter population made greater use of in-patient hospital services and less use of primary medical care then the NSW population. Intra- regional differences were consistent. When CHCs were established general hospitals were the most visible service providers. Accessibility varied with proximity to Newcastle City. Inpatient care was readily accessible in more rural areas. Access to ambulatory care via casualty, outpatient clinics, domiciliary nurses and GPs, was more varied. Access to domiciliary nursing services was restricted in city areas by the need to obtain a specialist medical referral. Royal Newcastle Hospital restricted care to patients referred by a staff geriatrician. This created a gap in care which many expected CHCs to fill.

165 The CHP policy aimed to provide accessible, locally relevant generalist services the focus of which was preventive rather than curative. Early studies found CHC practitioners offered services which were more similar than different to those offered by mainstream services (ACHA 1986). If, however, the services provided by CHCs in the Hunter are compared with those offered by those services originally operating when they were established, differences become evident. Seven aspects of CHC services provide a basis for comparison: location and time; access; clients, purpose, provider/s; continuity and indirect care.

Location and Time, Away from CHCs at All Hours Most mainstream services were offered at a single facility for example at a hospital, GP surgery or office. Home visits were rarely offered. Practitioners provided some services at CHCs, sub-centres, and BHCs. However, the majority of practitioners were generalist nurses and they spent most of their time away from CHCs providing services in people's homes, at hostels, schools, work-places, church and community halls, bowling and other clubs and even general hospitals. Like most CHC practitioners they relied on Commission cars, which they took home, to travel across the Region to provide services. Being in the ‘field’ most of the time meant they provided services where, or close to where, people lived or worked. Space limitations at sub-centres CHCs, and BHCs, limited their use of these facilities. Effectively most practitioners were forced to use community facilities to provide services which involved larger numbers of people. Most of the services provided at centres involved individuals or families seeing a practitioner, attending a clinic or dropping-in. Clients were generally seen during business hours. However some appointments were made during the evening (e.g. counselling, family therapy), and education programs were conducted at this time. More rarely, and more commonly at some CHCs, long term clients were seen at weekends or on an on-call basis even late at night, if appropriate for therapeutic reasons. During the early 1970s, for a period of three or more months, GCNs also provided an on-call week-end service for local hospitals and GPs (NSWNA CNHB 1976).

Access, Near Universal Access to mainstream services was restricted by purpose, opening hours and costs. Individuals could seek assistance but an organisation’s purpose determined if a response was provided. For example, hospitals and GPs would attend to a ‘condition’ but not necessarily to social problems. Cost limited access to some services as did time. During the 1970s mainstream services tended to operate on a first come, first served basis, emergencies being the exception. People waited their turn. CHCs offered free services and few restrictions on the types of problems addressed. One service had limits imposed. Maitland CHC offered a podiatry service in the early 1970s but restricted it to elderly and disabled persons, in-patients of hospitals or nursing homes, or people living alone in their own home. This was because one practitioner covered the whole catchment area and some private services were available. Practitioners also assisted people to access relevant services through referral to other services.

166 Clients of CHCs: Who Sought Assistance? The clients of CHCs, as of mainstream services, consisted of those seeking services and those referring others. People sought assistance from mainstream services because they were ill or thought they were ill or because they needed assistance with problems associated with aging, chronic illness or psycho-social or economic problems (Dewdney 1972; Sax 1972a). Specific information, as was illustrated in Chapter 6, was limited by the data collection systems used. General hospitals collected data regarding primary disease and length of stay when patients were discharged. Psychiatric hospitals kept a few more details. Information remained limited into the 1970s (Palmer 1971; Sax 1972a,b). For the first twelve years, until 1986, no systematic data collection occurred about CHC clients (HHSU 1988). Information was therefore limited to what was recorded in client files and CHC team records. Central Office started collecting monthly data on number of clients, age, sex, purpose and location in 1976 but use of imprecise categorisation rendered the data collected meaningless and collection ceased. BHC and school medical services reported contacts, client age and sex, problems, referrals and where services were provided (BHC, home, hospital or school) to Regional Office. However the profile of CHC clients in this Region seem to be similar to those of CHCs in other areas of NSW, children, adults, elderly persons and women of child bearing age (Duckett et al 1980). CHCs outside Newcastle City with similar numbers of practitioners had more clients and more contact with them. Between January and June 1978, for example, Maitland had more client contacts (19,193) than Eastlakes (13,061), Newcastle (12,181), or Westlakes (10,0607) CHC (HCNSW 1982). The CHC with the largest catchment area (4603 sq kms) and lowest population density (77,900) had more clients. This CHC also had the highest practitioner to population ratio. Windale CHC, catchment 748 sq kms and population 131,000, and Newcastle CHC, catchment 213 sq kms and population 138,700, had a similar number of practitioners. This trend continued. Statistics collected by the Hunter Health Statistics Unit in 1986 and 1987 illustrate that CHC clients were mostly Australian-born, female, working age adults, who sought assistance with coping with normal life events, parenting, relationships and personal problems, and problems associated with acute, chronic or terminal illnesses, and aging. Most clients were individuals, fewer were families or groups. Certain groups were over-represented (Thwaites et al 1980). Increasingly clients sought assistance due to referrals from GPs, hospitals, and schools. Referrals from GPs increased most.

Purpose, Improving People's Circumstances Most of the services provided had one purpose, to improve people's circumstances. Few had a single focus such as preventing a particular problem occurring. People sought assistance out of concern even if they responded to advertisements for a group program offering information. A central purpose was preventing further unnecessary problems arising. For example, psychiatric nurses mostly provided services to people with a diagnosed psychiatric illness. Their aim was to prevent further admissions to

167 hospital by helping people cope with normal problems of living which, in the absence of support, might precipitate an acute psychiatric episode. Even at CHCs lacking a health education officer, practitioners developed and offered a diverse range of education programs for population groups- parents, couples, school children and people experiencing specific life circumstances. Some were single session, others ran from four to ten weeks. Programs were conducted to inform, educate or develop skills and enable people to make informed decisions and/or gain greater control over their circumstances. Differences between CHCs were most evident amongst these programs.

Provider/s, One or Many Most services were provided by single practitioners. For example counselling of individuals experiencing personal or relationships problems, and the ‘worried well’, usually involved one person. Occasionally two practitioners saw a family. Services involving two or more practitioners were more often educative, that is they involved groups and were directed at a specific issue, for example ‘ living with toddlers’, pre-natal, parenting, menopause, or self-help programs aimed at weight control. Some programs were innovative. For example many GCNs tried to encourage Schools to sell healthy food, rather than ‘junk’ food, to reduce the number of overweight children. GCNs from Newcastle CHC worked with Family Planning Educators to conduct personal development seminars for apprentices in local industries (eg. BHP) focussed on relationships and safe sex practices. These programs tended to involve practitioners from different disciplines working together, that is nurses, psychologists, health education officers, and even doctors. The same pattern was evident in South Australia where preventive programs involved one or more practitioners (SCHRU 1987).

Some Continuity of Provider Generally clients saw the same practitioner thus some continuity of provider occurred. Other studies had found continuity lacking (ACHA 1986). Referrals to colleagues within centres occurred but were limited. Most were from generalist to specialists for mental health problems. The reason for this is discussed in Chapter 9.

Indirect Services, Finding Someone Else To Help CHCs offered services that were usually universally accessible. Exclusions were rare as there was no need to ‘fit’ specific criteria. Anyone could seek assistance. Practitioners provided direct services, however they also provided what could be described as indirect services as they made contact with other service providers, at CHCs and other organisations, to seek assistance or gain access to care for a client. For example they might communicate with a colleague or a GP to gain or share information relevant to the problem at hand. This was done sometimes with and sometimes without the client but always with client consent. Much of the work undertaken by practitioners was like this i.e. indirect and on behalf of clients.

168 Differences between CHCs All practitioners worked with geographically defined communities. The demography of these areas and their death and illness rates varied as the previous Chapter illustrated. All provided the types of services proposed by the H&HSC in 1973 which included: health information, assistance, treatment, rehabilitation, counselling and preventative services. Yet there were quantitative and qualitative differences between CHCs and practitioner groups when the various health education, health promotion and community development projects undertaken were compared. Regional data (HHSU 1988) reveal that Newcastle West CHC, for example, had more clients who were elderly and female than other CHCs. It received fewer referrals from GPs than other CHCs and more from general hospitals. Fewer clients had problems associated with frail aging. More required post hospital care for acute, self-limiting problems. Practitioners here also leaned towards developing health education and health promotion programs aimed at preventing specific diseases such as skin cancer and heart disease. By contrast those at Maitland and Eastlakes CHCs emphasised the psycho-social aspects of health and skill development. There were other differences. Generalists working in the Lakes areas traditionally received more referrals from GPs and a greater proportion of their clients had terminal illnesses. Generalists working in this area thus had more clients requiring lengthy periods of home nursing including palliative care. Some services were well received in some areas but failed in others. For example preparation for parenthood classes were established in Maitland, and later taken over by hospitals, but attempts to establish them in the Westlakes CHC area such as Edgeworth failed.

Differences between Disciplines Earlier studies of CHCs found CHCs offered similar services to similar populations. Mention was rarely made about differences in the services provided by different disciplines (SCHRU 1985, 1987). Where comparisons were made community nurses were found to be more involved in providing preventive services and working with other disciplines. Studies of community nurses’ work similarly found generalist nurses engaged in preventive work with individual clients, groups and population (Archer 1976; Hurworth 1976; Dowling et al 1983; Katz et al 1976; Round & Sellick 1984). It was the same in the Hunter. Different disciplines provided similar services at each CHC with few exceptions amongst nurses. For example, from 1975 mothercraft qualified generalist nurses at Windale CHC ran baby health clinics. Generalists at Maitland CHC provided school medical services where at Newcastle and the Lakes CHCs this service was provided by specialist school medical nurses until the 1980s at which time GCNs became involved. Psychiatric nurses mostly worked with clients who had psychiatric conditions while psychologists mostly worked with people experiencing family or interpersonal problems. A few nurses worked with families and what administrators often referred to as the ‘worried well’.

169 Generalist Nurses initiated most preventive programs Team records, and practitioners recollections, illustrate that most projects were initiated and conducted by generalist nurses, at times in conjunction with other nurses and allied health practitioners. Over time differences emerged. Generalists at Maitland remained involved in health education, health promotion and community development projects unlike those at East Lakes. By the mid-1980s practitioners at Eastlakes and Westlakes CHCs were providing more occasions of service to clients than those at other CHCs. Generalist and HACC nurses spent most of their time providing care for frail aged, disabled and terminally ill persons.

In Summary In a region of recognised social and health needs and ill distributed, uncoordinated health services, CHCs were established at appropriately needy centres. From the start financial constraints placed limitations on buildings for CHCs and on staff employed. Over time there was a lack of stability in administrative and financial arrangements which was unhelpful to the fledgling CHP program, and as resources were scarce the preparation given to practitioners decreased and selectivity also decreased as full-time positions were limited. Despite such constraints the CHC teams of concern to this study established and provided a broad range of new services for populations living within their centres geographically defined catchment area. Over time team size increased, catchment area size declined along with that of resident populations, and the buildings from which practitioners worked improved with all but one operating from purpose-built CHCs by 1988. Most CHCs were managed initially by doctors and, within eighteen months, senior nurses. Allied health practitioners were appointed as team leaders as doctors resigned. These managers, regardless of discipline, had difficulties obtaining and replacing practitioners from 1975. From 1975 positions remained vacant for extended periods due to fiscal problems. CHC teams offered similar services. Differences were evident, however, when the work of different disciplines groups, at different CHCs, were compared. In the Hunter, as elsewhere, GCNs provided the greatest proportion of preventive and educative services. Early in the period under study difficulties in administration developed at Regional level. Some of these had their source in divergent understanding of the CHP. There were as well conflicting views on the relative priorities of the existing hospital system, stressed by the establishment of a new medical school, and the preventative and public health perspective’s of the CHP policy which were not always well understood or favoured by Regional Directors.

170 CHAPTER 8 THE APPROACH OF ADMINISTRATORS − DOING WHAT YOU CAN ON THE SMELL OF AN OILY RAG Those who promoted community health concepts were interested in finding ways of addressing changing needs, particularly among mentally and physically disabled persons and the socially disadvantaged, and at the same time they sought to exploit opportunities for counselling about health and for preventing sickness and disability. They spoke about giving people, especially those who were old and disabled, opportunities to choose between institutional and appropriate arrays of community services. Most of them had not considered the political implications of what they were doing, and would have been surprised to read, that for the doctors, the prospect of an extensive network of government health centres presented a ‘more potent long term threat’ than the ‘more free enterprise’ health insurance scheme (Sax 1984 p.141).

Introduction The previous Chapter discussed CHCs’ location, the discipline mix of teams, and the types of services offered to populations. It illustrated that within two years of being established CHC teams had developed a diverse mix of new services. Thus far I have demonstrated that in implementing the CHP policy, CHC practitioners established new services which broadened primary care and reduced barriers to access, location and cost, and provided an alternative to hospital care for some populations. Contrasting with the findings of earlier studies of CHCs most of the services offered were shown to be preventive. What was achieved reflected H&HSC expectations, and developments occurring internationally illustrated in Chapter 5. As shown in that Chapter the CHP policy complemented directions advocated by senior members of the NSW Health Commission and this is why the state government initially took a vigorous approach to its implementation. Health department officials, some medically qualified, drove this policy because, like many other health department officials internationally, they believed that if various organisations cooperated, shared resources, and operated as part of an integrated, interdependent system that included CHCs, health care could be provided more effectively. CHCs were considered central to changing how health systems operated and practitioners practised and how populations used health services. The purpose of this Chapter is to explore how government bureaucrats approached the process of implementing the CHP policy and the mechanisms they used to direct and support its evolution over time. It focuses mostly on the actions of administrators involved in implementing this policy in the Hunter Region. It reveals how various stakeholder groups reacted to CHCs and to a new, more autonomous, category of community nurse, a generalist. History shows many stakeholders, including hospitals and GPs, were often opposed to the concept of CHCs even when it was evident populations needed access to services such centres could provide (Alford 1975; Church 1993; Hall et al 1975). The Australian CHP literature, discussed in Chapter 3, focused on practitioners whilst almost ignoring the circumstances in which they worked. This is particularly so for NSW where, for over a decade, practitioners worked for an overly large state public service beset by administrative and budgetary problems (Alaba 1994; Chaples, Nelson & Turner 1985; Wilenski 1985). Unlike their contemporaries in most other states practitioners in

171 NSW were employed by large government bureaucracies governed by rules, regulations and procedures which even street level practitioners were required to follow. As this Chapter reveals the NSW Health Commission and state government determined how the CHP policy was implemented and how well or how poorly it was resourced. It further highlights the commitment of many but also the deficiencies in administrative processes and leadership at critical junctures in time.

A Window of Opportunity The CHP policy presented the NSW government with an unprecedented opportunity and budget to act on its own plans. By 1973 NSW had plans to regionalise health care, rationalise general hospitals and establish primary care centres in collaboration with public, non-government and private organisations (DHNSW 1972; Eglington 1968; Meyers 1966; Starr 1969; NSWDHSRP 1971; NSW Parliament 1972). The CHP policy provided NSW with the funds, and thus the means, to action plans until then constrained by budgetary problems and autonomous general hospital boards. It was also timely. A NSW Health Department and Hospitals Commission had been disestablished to create a Health Commission whose goal was to improve the health of the population of NSW. The CHP policy would aid administrators achieve this purpose, or so they thought. The Health Commission was responsible for funding all health services and oversighting departments involved in policy formation and planning. The Commission’s responsibilities were broad, as Figure 8.1 shows, and this should have made implementing the CHP policy easier.

Figure 8.1 NSW Health Commission Responsibilities in 1974 Environment and Special Health Services, health education, dental, forensic medicine, occupational health, immunisation, diagnostic and laboratory services, Acts of Parliament relating to pure foods, sanitation, therapeutic goods and local government;

Personal Health Services, health care, hospitals and the CHP;

Manpower and Management, staffing establishments, staff development, manpower planning and industrial matters and computing services;

Finance and Physical Resources, determining Commission subsidies to public hospitals, hospital development and the CHP.

Oversight Division of Health Services Research, Division of Epidemiology, Division of Nursing. Source: NSW State Government 1976

The Commission Act enabled Regional Offices to be established with delegated authority to administer health services and implement the CHP policy. Responsibilities were split between divisions, decisions concerning the CHP policy involving numerous groups. Gaining approval for Regional CHP projects was cumbersome as the Hausfeld Report (1982), Report to the Minister for Health Community Health Interim Evaluation illustrated. Submissions were forwarded:

172 • To the Central Coordinating Committee for vetting, • To the Public Service Board to create positions, • To the Treasury for approval, • To the national H&HSC for consideration and funding approval. Opportunities for delay or refusal were numerous. The speed with which the CHP policy was implemented in NSW, how it developed, which projects were supported, were controllable. As the government applied for and was granted block funding it controlled distribution. It had the flexibility to move monies between projects or to withhold funds. As official reports illustrate the government exercised its prerogative. From 1973 until early 1975 growth was rapid. By mid-1975, as the Hunter Region's Regional Director, John Krister, informed senior officers, the Public Service Board and Treasury had decided the NSW CHP was ‘overdeveloped’ (SOC May 1975). Implementation of the CHP policy was slowed and growth contained by underspending federal allocations, lowering establishment ceilings and imposing freezes on the recruitment and appointment of practitioners to CHCs. The Hausfeld Report (1982) reveals the extent to which state administration influenced the growth of the CHP. Decisions were taken not to spend all federal monies received from 1973 to 1976. In the 1974/1975 financial year NSW received 16.6 million dollars and expended 3.2 million dollars by June 1976 and for 1976 it received 29.6 million dollars and expended 18 million dollars with unspent monies being returned to the federal government (Hausfeld, Boleyn & Stevenson 1982). This Report reveals that between 1976 and 1982 NSW had 2296 established positions jointly funded by federal and state governments. During 1978 a ceiling of 1,940 positions was imposed − staff freezes were imposed to prevent vacancies being filled. By 1982 some 1,736 of these 2,296 positions were occupied − 560 remained vacant (Hausfeld et al 1982). This level of vacancies was significant for a small program. These decisions, as was shown in Chapter 7, left positions vacant at CHCs in the Hunter Region for varying lengths of time. The reason these decisions were taken was probably due to Treasury's concerns about the large size of the public service (Alaba 1994). It is also likely that the government's increasing responsibility for provision of direct care gave rise to concern. However, such concerns were not evident as Commission officers from the old Health Department began preparing the Hunter Region for implementation of the CHP policy.

Spreading the Word with Missionary Zeal Commission officers visited regions to explain the CHP policy and the need for regional health systems and rationalisation of public hospitals. Their intent was to prepare stakeholder groups for the systemic changes proposed. In the Hunter Region these proposals ‘went down like a lead balloon’ (Administrative Officer Interview 48). Official reports and newspaper coverage of a workshop and conference support this observation. Maybe because opposition was anticipated central office descended in force for the planning events held in February and November 1974. The significance attributed to these events, and the CHP

173 policy, is reflected in the speakers co-opted to participate. As Table 8.1 reveals, support was garnered from academics, GPs, hospitals, the education department, and non-government organisations. The first event can be seen as an attempt to gain support for the CHP policy by getting stakeholder groups to identify local needs and strategies to resolve them.

Table 8.1. Speakers, Topics, Health Commission of NSW Conference, Rankin Park Hospital, February 26-28, 1974. Name Position Topic Dr Krister Regional Director, Hunter Region Planning for a Region Mr Derwent Director, Institute of Management, Strategies for Attaining Planned University of New South Wales Goals Mr Boylan Commissioner for Finances and Physical Financial Resources Management of Health Services Dr Adams Director, Division of Research and The Place of Research in Health Planning Planning Mr Della- Chief Executive Officer, Benevolent The Future Role of Voluntary Bosca Society of New South Wales Agencies in Health Care Mr Newall Regional Administrative Officer, North Regional Thinking by Hospitals. Coast and New England Region, Health Commission Source: NSW Health Commission, Planning for a Region, 1974a.

Policy implementation is a complex and difficult process (Dunn 1994; Field 1989; Hall et al 1975; Davis et al 1988). It is particularly difficult when those involved lack a shared vision and entrenched philosophical positions limit dialogue as occurred in the Hunter Region. Official reports of the first event indicate that the Regional Director, John Krister, invited representatives of public, private and non-government organisations to attend. The fifty who attended were invited because of the: ..contribution they could make to health planning in view of their special interest in research, consumer representation, community development and education, local government and hospital planning (NSWHC 1974a, p.1).

The arguments presented on this occasion make clear that rational planning, based on an analysis of local needs, was required. Planners needed to conduct ‘qualitative and quantitative assessment of health needs’ using ‘geographical, social and demographic facts’ to assist them in ‘determining the location and type of facilities to be developed’ (HCNSW 1974a, p.2). Attendees were invited to identify local needs. As the summary in Table 8.2 illustrates needs were identified for more ‘primary care, health education, rehabilitation, supportive and counselling services’, ‘domiciliary nursing services, especially to the chronically sick and aged’ and ‘continuity of care’ between episodes of illness (p.2). Strategies to resolve problems likely to arise from regionalisation and rationalising hospitals were also identified: research, sharing resources, moving services from hospitals to communities, increasing interaction between government, non-government and volunteer organisations, and encouraging GPs to use CHC practitioners from allied health and nursing. Areas of conflict quickly became obvious. Some stakeholders reached consensus that the likely outcomes of regionalisation, rationalisation, and the CHP policy, would be a threat to their autonomy.

174 Expectations of the CHP policy and CHCs were diverse (HCNSW 1974a; NH February 28.1974, p.2). The extent of these differences was revealed by a report in the Newcastle Herald.

Table 8.2. NSW Conference February 26-28, 1974. Summary of participants’ suggestions for solving problems arising from regionalisation, rationalization of hospitals and emphasis on prevention and provision of domiciliary nursing. Service Proposed role Hospitals Using small hospitals as CHCs; Encouraging hospital boards to provide preventative and rehabilitative services; Varying nurses' hours of work; Rationalising hospital services. Prevention Using CHCs to educate the public; Training community health staff to act as health educators; Publicising the importance of early consultation for people with physical and mental illnesses; Training BHC nurses to provide counselling for disturbed families to prevent development of serious family problems; Having CHC staff talk to students; Making educational institutions aware of health services. Domiciliary Deploying more nursing and paramedical staff to primary care to support general nursing practitioners; Offering nursing home staff opportunities to train in re-motivation and rehabilitation; Encouraging private nursing homes to establish day centres; Involving voluntary agencies in providing services for chronically ill and aged persons living at home; Using existing buildings for mixed sex day centres; Rationalizing transport for aged and handicapped persons and providing an evening service; Involving local groups in day programs at nursing homes. Source: New South Wales Health Commission, Planning for a Region, 1974.a

A schism was evident between various stakeholder groups. Representatives of non-government and non- health organisations viewed CHCs as an addition to the Region's health care system. They were organisations to assist communities and health service providers resolve issues of access and continuity of care. In focusing on prevention, on psycho-social problems, and offering counselling and education CHCs would ‘take the strain off hospitals and provide a better standard of care’ (NH 28.2.1974 p.2). Importantly CHCs could offer new services and involve communities in deciding what they needed. The Chair of Royal Newcastle Hospital Board saw it differently: CHCs would duplicate outpatient departments. From this perspective CHCs immediately became competitors. The official report raised another source of potential conflict, the regional adviser on geriatrics, Dr Richard Gibson, opposed the idea of GCNs working independently, i.e. without medical control. The official report said it all when observing local politics would ‘likely’ hinder implementation of the CHP (HCNSW 1974a, p.4). Industrial workers were not the only groups to take a confrontational approach to problems! By November 1974 when the next planning event was held, hostility had grown. There were also indications that the government and the Commission had become concerned at the rapid growth of the CHP and public hospitals and GPs' opposition to CHCs. The Newcastle Herald reported the forth-coming

175 conference as an opportunity for delegates from ‘health services, industry, consumer groups, community organisations and trade unions to express opinions’ (NH 15.11.1974, p.6). It was observed the ‘community needs identified in February had ‘been developed into tentative plans for improving hospital and community services’ (NH 15.11.1974, p.6). As Table 8.3 illustrates the formal program of the second planning event would not have offered the eighty stakeholders, health service administrators, medical specialists and GPs, who attended, any real opportunities to express their views. Animosity and hostility were palpable (Administrative Officers Interviews 14, 48). The Newcastle Herald reported the first day of this event positively by quoting Krister whose view was that it had 'helped many delegates to be less parochial in their attitude to community health' (NH 28.11.1974 p.15). He expected it to ‘encourage hospitals and other institutions to look more broadly at the health needs of the community’ (p.15). Official reports and the reflections of administrators suggest otherwise. The proposals advanced by speakers including Mr Slough, Deputy Chairman, who opened proceedings seem to have been rejected. Importantly GPs opposed the proposal to extend community nurses' responsibilities. Official records demonstrate that Vickers explained how extending generalist nurses' responsibilities to include coordination to improve services would help GPs reduce their workload and improve ‘the quality of health care for the patient’ as they could refer to them. He pointed out that ...the basic role of nurses is evolving into the role of a community health worker with emphasis on case finding, colleague finding, preventative health care, supportive, therapeutic and rehabilitative care. The community health worker should be able to act as a point of contact for referral to other health and welfare agencies, or as a co-ordinator of community efforts in achieving local health care objectives (Vickers, Health Commission NSW 1974b, p.3). Local doctors were not convinced by his argument (HCNSW 1974b). A sharp division became obvious between Vickers' view, which reflected that of the Commission, and that of the Regional Adviser on Geriatrics and Rehabilitation, Dick Gibson. Gibson opposed the idea that nurses could coordinate care, a role he attributed to medical specialists and assessment teams, except in country areas where nurses could do it (HCNSW 1974a). There was support for Vickers' position from GPs outside the Region. Canberra GPs, for example, observed they had improved quality of care and gained more 'clinical' time, by referring patients to nurses and allied health personnel. This appears to have had little effect. Local GPs were not convinced. How they responded to an academic psychologist's suggestion that they use informal opinion leaders (community workers, school teachers) to disseminate ‘health propaganda’ and gain community participation to decide what services CHCs should offer was not reported (HCNSW 1974b). These would have been somewhat radical ideas for a conservative Region like the Hunter and the very conservative views of the Hunter Medical Association (Personal Recollection). The Hunter’s Regional administrators had a problem from November 1974. Clearly they needed the support of hospital administrators, salaried medical specialists and GPs to implement the CHP policy and make headway on achieving the Commission’s objectives. These included encouraging GPs to use CHC services and reducing admissions to general hospitals, as Chapter 5 illustrated. CHP funding had begun

176 to arrive. A small Coordination Team of five people was operating, some advisers were in place, recruitment had begun, some appointments had been made, cars had been purchased and advice was expected as to how many CHC teams could proceed. By 1974 a CHC was almost complete at Nelson Bay (NSW Parliament 1974-1975, 30.6.1974, p.91) and building was due to start on Windale CHC (NH 26.11.1974, p.3). The problem for regional administrators, in particular Vickers, who was responsible for implementing the CHP policy was that these planning events had fuelled tensions and raised fears rather than fostered cooperation. Table 8.3. Speakers, ‘Planned Health Care for the Hunter’, Stockton Hospital, 27-28.11.1974. Speakers Position Topic Dr Barclay Director of Psychiatric Services Opportunities, Rewards and Problems of Regionalisation Panel, Rationalisation of Hospital Prof. Maddison Professor of Medicine, Chair, Head Office rep. Services Dr King Hunter Medical Association (GP?) Mr Miller Assistant Regional Director, Finance Dr Currow Superintendent, Royal Newcastle Hospital Miss Punton Matron, Wallsend District Hospital Mr Talty Chair, Mater Misericordia Hospital Dr Darcy Medical Superintendent, Morisset Hospital. Panel, Planning of Community Dr Staines Professor, Department of Psychology, University of Health Care Newcastle, Chair. Dr Vickers Ass. Regional Director, Hunter, Community Health, Mr Beard Regional Director of Education Dr Gibson Regional Geriatrician, RNH Mr McIntyre Psychologist, Morisset Hospital Sr Chesworth Baby Health Centre Nurse Dr Renshaw General Practitioner Dr Toohey Director, Medical Services, Royal Newcastle Hospital. Prof. Staines Professor of Psychology Ensuring Community Participation Dr Adams Director, Division, Research and Planning Regional Planning, State Wide Panel General Practitioners Family Medicine in the Drs Hampson Chair Future Dorrsett, Marples, Rowlands, Fitt & Mrs Kern Dr Ambrose Community Physician, Aerial Health Service Aerial Health Services Dr Danger Occupational Health Occupational Health In the Region Professor Chair, Hunter District Water Board The Progress and Problems Carmichael in Planning a Healthy Environment and Pure Food and Health Source: HCNSW, Planned Health Care for the Hunter, Stockton Hospital, November 27-28th, 1974. If unstated the position of speakers was determined from other sources.

177 Hospital administrators had reason to feel angry as by now they would have been aware that the proposed new medical school would not attract additional resources to their hospitals as had occurred elsewhere (Olsen Interview 1994; Administrative Officer Interview 14). Their hospitals would remain in dire need of capital works and the development of ward infrastructure. Further, as the official report illustrates, Miller, the Assistant Regional Director for Finance, was explicit − regionalisation would limit the autonomy of hospitals and medical specialists (HCNSW 1974b). Other officers were similarly blunt, public hospital growth was to be constrained while CHCs needed flexibility to grow and adapt ‘to the particular needs of the community’ (HCNSW 1974b, p.2). Only one person ‘openly objected’ to the positions advanced by the speakers at this planning meeting but ‘passive opposition’ was observed and attributed to rejection or misunderstanding of Commission policies. It was both. Some hospital CEOs and GPs failed to grasp what was being proposed or why change was necessary and so they rejected the policies. These planning events had two positive outcomes. They provided the local media with an opportunity to discuss the importance of non-medical, non-inpatient health services and exposed different views on CHCs and the role of nurses. Further they provided a forum for bringing together people from different organisations from which was formed a working party with ‘confidence in the Commission's policies’ to advise the Regional Director on planning matters. While the membership of this working party has been forgotten those involved suggest it likely included the Region's adviser on geriatrics, representatives of the Hunter Medical Association, hospital administrators and members of the medical faculty (Administrative Officer Interview 14). It is unlikely support for CHCs, GCNs, or systemic change would have been high amongst these stakeholders. The strongest advocates for change, and for CHCs, were medically qualified Commission officers, as their presentations illustrated. These officers could be considered visionaries, they were ahead of their time. The Commissioner for Personal Services, Bill Barclay, was one of the strongest and most outspoken advocates of change. In his presentation he argued the need for research ‘into health advisory and management techniques’ as in his view this focus had greater potential for promoting health than research into acute disorders (HCNSW 1974b, p.4). Krister advanced the view that ’concentration on further preventative methods’ and collaboration might lead to ‘slackening of demand for the cure-methods of medicine’ and prevent illness in the general sector as it had in public health as councils, private enterprise and public health worked together (p.4). Vickers argued that regionalisation and CHCs offered a means to improve people's access to preventative services and redress the Region's maldistribution of domiciliary nursing and specialist medical care. Representatives of the Commission's central office, recognising that there were differences between Regions, assured the Hunter Region it would be accorded autonomy to decide what it required. The Director, Division of Health Services Research and Planning, Tony Adams, made this clear in his presentation, arguing regional solutions did not have to ‘fit’ into centralist guidelines (HCNSW 1974b). The Region was expected to establish an organisational structure with lines of accountability that would facilitate regional planning and successful implementation of the CHP policy. In reality senior officers did not perform as expected.

178 Unreasonable Demands on Senior Officers Earlier studies suggest bureaucratic competence was not an issue and that CHCs failed to achieve the goals of the CHP policy because practitioners continued to work as if in hospitals (Gibson 1980). In the Hunter Region, as Chapter 7 illustrated, practitioners established a range of new services and they achieved this by taking a different approach to work to that learnt in hospitals. The same cannot be said for some senior officers. Records supported by the recollections of participants, illustrate that a planning deficit occurred at a regional level in the Hunter as elsewhere. By mid-1975 the Commission Chairman, Roderick McEwin, was displeased with the progress being made. Regional Directors were left in no doubt of the source of the problem, senior officers. The Chairman was informed about regional progress through Senior Officers' Conferences, monthly meetings for Regional Directors. By mid-1975 McEwin was instructing them to seek ‘better performance’, ‘quality’ and ‘planning’ from senior officers and to have ‘no hesitation in taking action against poor quality officers’. McEwin expected these officers to contribute to policy development, assess needs and liaise with local hospitals and doctors to promote the CHP policy. Regional and team records make little mention of senior officers engaging in such activities. Krister, for example, observed the lack of senior officer involvement in implementing and evaluating health promotion programs of ‘long term importance’, for over-weight children, promoting physical exercise in the elderly, preventing coronary disease and stress management (SOC 9.6.1975). In the Hunter Regional advisers and specialist team leaders seem to have been more preoccupied with clinical work and service delivery than planning. Krister responded to the Chairman’s concerns by asking the Assistant Director Community Health, Vickers, to provide a confidential report on each senior officer. These officers were likely regional advisers and planners, community physicians and the team leaders of specialist teams. Giving Regions autonomy had not worked. By mid-1975 the Chairman and the Public Service Board were seeking greater control. They did this by proposing that Regions establish similar administrative structures to enable comparability and that they develop Statements of Duties for all CHC practitioners. By this time the Regional Director, Krister, had become concerned about how policy implementation was proceeding in the Hunter.

Communities Unaware of CHCs By mid-1975 Krister was expressing concern that communities remained unaware of the purpose of CHC teams. His major concern, as minutes of senior officers' meetings indicate, was Windale CHC, a new centre located on a large public housing estate where the population was known to be experiencing health and socio-economic problems as discussed in Chapter 6. Vickers, maybe due to overseas experience, was more inclined to accept that time was needed for people to accept and use new services. As he reported to a June meeting, he had been talking with community and professional groups since 1974. He was scheduled to speak to the Windale Progress Association in 1975 and to the Institute of Hospital Administrators in April 1976 (SOC 9.6.1975). The latter, it would seem, were not too anxious to hear what

179 he had to say. Krister considered it essential that communities be aware of the services CHCs could offer while for Vickers an ‘uninformed’ community was ‘possibly one of those things we just have to live with’. It was not that Vickers was apathetic, he was just realistic. In an attempt to raise public awareness of CHCs he had talked with local groups and arranged for a psychologist from Nelson Bay CHC to speak with groups at Maitland and Charlestown. Krister had asked the same officer to write a report on ‘community service’ as he ‘so well conceptualised’ them in his talks. The area's newly appointed community physicians were not, it would seem, being asked undertake this activity. Few senior officers, including community physicians, seem to have been confident enough to promote CHCs by giving public talks. Maybe these new appointees, who lacked an orientation, had yet to understand the purpose of the CHP policy and what it was that they were expected to do. Yet such a high level of concern seems to have been premature when the Windale CHC team, with fewer than ten practitioners, had been operating for less then six months and the community physician from England had yet to take up his appointment. It is highly unlikely that hospitals and GPs were promoting CHCs. Krister’s concern was likely fuelled by the series of visits planned to the Region between mid-June and August. The Chairman, Roderick McEwin, was due to visit on June 17-18 for what Krister described as an opportunity for senior officers to engage with him in ‘free and frank discussion’ (SOC 9.6.1975). On June 25 members of a Commission and Cabinet Committee on Social Development were scheduled to visit the Region and the 'community nurse training' program and Addiction Unit. The purpose of their visit was to investigate overlaps in service provision created by CHCs duplicating existing services. Presumably this was a state-wide concern. The Opposition Spokesperson on Health, Mr Kevin Stewart, was also scheduled to visit the Region to inspect local health facilities. The Cabinet Committee's views were not reported in the local media. However Stewart's visit to Windale CHC was reported positively with him quoted as saying it was ‘staffed by obviously dedicated people devoted to their jobs’ (NH Herald 27.8.1975, p.4). Windale CHC had been open for six weeks at this time. These visits can be viewed as interest in or concern about how the CHP policy was being implemented. Commission reports and records illustrate that by mid-1975, within six months of funding for CHCs arriving in the Region, senior commission officers had begun scrutinising how the CHP policy was being implemented at regional level. The Bureau of Personal Services had begun urging Regions to adopt uniform administrative structures and duty statements. This was less an issue for the Hunter which had already adopted a generalist-specialist model which was similar to that being proposed (Appendix 8.1). However on June 11,1975, before the Chairman’s visit, Krister circulated the proposed structure and duty statements to senior officers, noting the need for comparability of Regions and its being listed for discussion on July 14 1975 at the senior officers' conference. Initially Regions were encouraged to act autonomously, to make their own decisions but by mid-1975 central office wanted uniformity of administrative structure and duties for discipline groups at CHCs. This was a reasonable request. The structure proposed included a co-ordination team, professional Regional advisers, multidisciplinary teams for 50,000 people managed by community physicians/ area coordinators, district

180 level satellite centres (shop front/primary care centres) offering first contact care (primary medical and nursing), counselling (mental health, drug and alcohol) and specialist centres with team leaders providing ‘back-up’ for generalist teams and seeing clients on a referral basis. Lines of responsibility were not delineated as this was considered a Regional matter. This proposal was similar to that selected for the Hunter. By mid-1975 the Public Service Board, professional (paramedical/allied health) and general (nursing) branches, had developed duty statements for all practitioners which identified families and communities as their primary focus. Expectations varied as to administration, management, evaluation, research, education and service provision as Table 8. 4 shows. Area physicians were expected to develop services.

Table 8.4. Responsibilities by positions as identified in Duty Statements prepared by the Bureau of Personal Services, June 1975. Staff Member Responsibilities Area physician plan, develop, co-ordinate and directs all community health services in the area Regional geriatrician develop and co-ordinate all geriatric services within the Region Regional medical officer promote, protect, maintain the physical and mental health and social child adjustment of children and their families in a defined area Community nurses family and community nursing services relating to the maintenance protection and promotion of the physical, mental and social health of the family and the community. Community psychologists provide psychological services for a defined Area which is part of the total comprehensive health service Social worker provide social work and welfare services that are part of the overall community based comprehensive health service for a defined geographical area. Speech therapist initiate and implement a speech therapy service for the whole or a particular section of a community as part of an overall community based comprehensive health service to a geographical area. Source: Statements of duties, Bureau of Personal Services, 1975. RCP, Regional community physician, RG, Regional geriatrician, CHMO, child health medical officer, CP, community psychologist, SW, social worker, SP, speech pathologist, and GCN, generalist community nurse.

Doctors would administer and manage teams, provide leadership, develop health services based on empirical data and consult and liaise with private doctors. In child health doctors would provide preventative services and write annual reports. Allied health professionals would provide services, educate and consult. Community psychologists would conduct evaluation and research. Social workers would evaluate services and work with volunteers. Speech therapists were expected to work with groups. Nurses would maintain, protect, and promote the physical, mental and social health of families and communities by offering services, liaison, consultation, and community development. Three responsibilities identified in early H&HSC (1973) reports and the November 1974 conference were omitted: co-ordination, management of services and prevention. On May 15 the prepared Statements of Duties were referred to the Manpower and Management Services and Community Health Services Branch so possible industrial implications could be identified, however no action had been taken by June when Regional Directors discussed the matter at a Senior Officers' Conference (CC/CAM 711).

181 Administrators in the Hunter Region adopted Statements of Duties for one group only, GCNs. None of the original statements could be traced. However, a Statement for GCNs holding psychiatric qualifications offers an indication of the scope of their responsibilities. They were to provide school medical, follow-up of people with infectious diseases, provide domiciliary nursing and work with people with a mental illness (Appendix 8.2). As a community physician observed to me in 1975 it was an enormous amount of work. There was no mention of first contact services, counselling, coordination or management. GCNs in the Hunter, as elsewhere, objected as the duties listed conflicted with the information provided at selection interviews. The differences between what nurses were told they would be doing and duty statements issued by mid-1975 suggest the Commission's expectations of GCNs changed very quickly. Public Service Board and Treasury officials remained concerned about senior officers’ ability to achieve what they expected. Guidance was provided two years after policy implementation began. On August 6-8 1975 a two day seminar was conducted for senior officers, senior medical officers, assistant directors and advisers (HCNSW 1975a). Records of attendance reveal that Assistant Regional Director, Wes Vickers, and a senior administrative coordinator, David Henville, attended from the Hunter Region. None of the Region's community physicians or regional advisers attended. Their perspectives might have changed if they had. The Hunter’s representatives were already converts. Participants engaged in group planning exercises and were given guidelines for planning and organising community health services. Papers were presented on: CHP philosophy and concepts, objective and subjective measures of health, community participation, statistics, evaluation and organising community health services. Robin Stevenson, an area social worker with Western Metropolitan Region, discussed organising community health services. The Chairman of Gosford Hospital where a pilot project operated, discussed if hospitals should administer CHCs and whether community health services ought to be hospital-based (HCNSW 1975a). Within two years the administrative ability of the Commission officers responsible for regional planning was being questioned and the activities of CHC practitioners scrutinised. Attention seems to have shifted away from scrutinising the costs of general hospitals.

Declining Support for CHP Policy and CHCs By September 1975 CHC teams were under intense scrutiny from Regional administration who were required to examine how buildings and cars were being used, time spent on neighbourly as distinct from health activities, feedback from communities, and how practitioners were working with communities. McEwin was expressing his disappointment that Regions were providing so little comment and feedback on centrally prepared working documents leaving the Commission with 'too little advice of innovative programs' for policy formation (SOC, September). Regional Directors were also directed to halt advisory committees. The Hunter, as one of the few Regions with one, was asked to report on its experience. What this report contained is now forgotten. Administrative officers recall ongoing animosity on the part of local GPs, general hospitals (CEOs, matrons) and the Hunter Medical Association (Administrative Officer, Interviews 1.13, 14, 42, 44, 46, 48, 58). Concerns raised at this time about CHCs can be seen as part of a

182 broader concern arising within government about the performance of the Health Commission. This concern was likely fuelled by ongoing criticism from influential stakeholders loyal to general hospitals. It needs to be remembered that some Commission officers, as earlier discussion illustrated, viewed CHCs unfavourably. In October 1975, prior to the Whitlam Government’s dismissal, a Committee was established to examine the CHP's costs and benefits. Bill Barclay, the Commissioner responsible for CHP's rapid implementation in NSW, was appointed chair (NSW Parliament 1976-1977, p.7). The report, Regulation and Management Structure of the Health Commission of NSW, submitted to the Public Service Board in late 1975 raised questions concerning the administration of the Health Commission. In June 1976 Barclay resigned as Director, Bureau of Personal Health Services (NSW Parliament 1976-1977, p.7). With Barclay gone support for regionalisation, rationalising hospitals and implementing the CHP policy seemed to decline. In the Hunter support for the CHP also policy began to decline around this time. A coalescence of circumstances prompted change. Krister resigned in late 1975, his successor was the Deputy Regional Director, Bernie Geraghty, a supporter of hospitals. Vickers was promoted to Deputy Regional Director. It was an important administrative change. Relations between Geraghty and Vickers and the Regional Nursing Officer, Jean Johnson, were hostile (Administrative Officers Interviews 1.13, 14, 42, 46, 68; Allied Health Interview 5), mainly as their views on hospitals, CHCs and GCNs diverged and fuelled dissent. Geraghty would state his position forcefully much later, in 1978, in a paper presented to an Australian Hospitals National Conference (Geraghty 1978). Like Gibson, Geraghty viewed CHCs and GCNs as duplicating services already provided by hospitals, in particular Royal Newcastle, a hospital both men considered to have traditionally shown concern for the health of communities. He argued that CHC staff should be transferred to hospitals to offer preventive programs (e.g. anti-smoking) to inpatients. Geraghty had one major concern − improving the state of the Region's general hospitals. There is no question that they needed improving. Most were antiquated and in poor condition as Chapter 6 illustrated. This concern was shared with newly appointed members of the medical faculty at Newcastle University who also, with few exceptions, saw little value in CHCs. Their concerns lay with developing specialist medical services. The foundation Dean, David Maddison, a psychiatrist and former Dean of Medicine at the University of Sydney, wanted to develop a new, innovative medical program (Maddison 1976). His also wanted to improve the Region's hospitals, establish a chair in psychiatry and a program for trainee psychiatrists. In a Region with antiquated hospital facilities, limited mental health services and few psychiatrists, as Chapter 6 illustrated, these were appropriate goals. The consequence of this preoccupation with hospitals and medical education was that only one member of the medical faculty expressed any interest in or concern for CHCs, namely the Foundation Professor of Community Medicine, Stephen Leeder. Geraghty asked Leeder to review the Region's CHP in late 1976. It is unlikely that Leeder’s report provided the analysis he expected, for Leeder (1977a,b) found CHCs had too few resources, too few staff, especially nurses. It was disregarded in the sense that it was not acted upon. The reason for the lack of resources evident by early

183 1976 can be tracked to the way implementation of the CHP policy commenced in this Region in late 1974 and the effect of decisions made by the government.

Planning Underestimated Local Needs The Region's first Regional Director, John Krister, and Assistant Regional Director Community Health, Wes Vickers, as discussed earlier, chose to establish a generalist/specialist model similar to that proposed by the Bureau of Personal Services as a way of overcoming a shortage of specialist services. This model, as Figure 8.1 shows, included specialist teams, Regional advisers (psychology, social work, geriatrics) and CHCs in addition to traditional maternal and child health and mental health services. By 1973 the Region had plans, as Commission Reports to Parliament show, to use baby health centres as CHCs, transfer school medical teams (a doctor and two nurses) to baby health centres and use GCNs to redress the Region's shortage of BHC nurses (NSW, Parliament 1973). Negotiations with councils had begun to enable baby health centres to be used as CHCs. By 1974 the Regional Director had committed the Region to a generalist/ specialist administrative model and submission was made for a: coordination team; specialist teams; information services; staff education unit; eight generalist CHC teams (East and West Lakes, West Metropolitan and Inner City, Lower and Upper Hunter, Manning and Great Lakes and Port Stephens); women's health centre; community medicine teaching unit; Regional health education unit with five specialist sections (mental health, drug education, alcohol and addiction, general health education, information and publication, graphic and visual aids); and 30 establishment positions for a Regional nursing service. The model established included Regional advisers for psychology, social work and geriatrics. The role of these advisers was to participate in planning and service development. They had no line responsibility for CHC practitioners although allied health advisers acted as professional advisers for specific disciplines. What Vickers expected of CHC teams can be inferred from correspondence to other senior officers in which he explains his reason for making a submission for funds to establish a health education unit. He wanted the unit to ‘train field personnel and community volunteers’, ‘employees of other governmental authorities’ and to conduct health education programs on immunisation, health service organisation, and hygiene in schools, homes and factories for the public (Vickers, Correspondence, 9.12.1974). Its purpose was to assist CHC teams to develop health education programs. Similarly specialist teams were expected to provide backup for generalist CHC teams. By mid-1975 funding had been approved for three, rather than the six, generalist CHC teams for the Local Government Areas of Newcastle and Lake Macquarie and the Cities of Cessnock and Maitland in the Lower Hunter. As Leeder pointed out in his 1977 report on the regions health needs, the Region's submissions for CHP funding were conservative yet most were either partially funded or refused (1977a, p.8). This had an enormous impact on policy implementation. The original plan had been to develop generalist CHC teams slowly over a minimum of five years as community and health problems were identified so later submissions were based on identified needs (Leeder 1977a, p.8). This strategy, as was illustrated in

184 Chapter 5, was consistent with H&HSC guidelines. The problem, as Leeder pointed out in his report, was that the ratios used to calculate staff needs were below those suggested by reports to the state government. These reports, as discussed in Chapter 5, proposed a ratio of one GCN to 5000 or 6000 people. A degree of naivety appears to have influenced the decisions made in 1974 and 1975. It appears Krister and Vickers assumed that ‘more nurses, aides and others who would occupy a predominantly service role in later years’ could be added later (Leeder 1977a, p.9). By 1975 a regional planning group comprised of administrative officers, some advisers and CHC team leaders were involved in planning and developing submissions for funding. Their plan was to increase the number of generalist teams and locate them in areas with identified needs for services. By 1976 six areas had been identified, Newcastle City, Lake Macquarie Shire, Port Stephens Shire, Lower Hunter, Upper Hunter and Northern Sector. They had also identified rural communities with inadequate support systems, areas of rapid growth, and areas with the highest proportion of very young, young mothers, adolescents and elderly persons as needing services (Leeder, 1977a, p.12). By the 1980s this group expected area teams to provide directly or by referral geriatric assessment, day care, physiotherapy, child health, school dental, maternal and infant, family planning, health education, community nursing domiciliary care and mental health (p.12). Teams were expected to interact with and assist non-government organisations and encourage Lifeline, Red Cross, Alcoholics Anonymous and the Marriage Guidance Council to use CHCs (p.13). Leeder found CHCs had achieved something unique. However if one considers what the regional planning group hoped to achieve and what practitioners managed to provide, discussed in Chapter 7, it is evident that these plans were not fulfilled. Regional and state administrators influenced what was achieved.

Bad Timing and Slow Decision-Making As the previous discussion illustrates, the Region's problems date from 1974. Decisions taken outside the Region in 1974 and 1975 thwarted Regional administrators' earliest plans to expand and divide generalist CHC teams. Four objectives set in November 1974 for 1975/1976 financial year constrained growth (SOC, Summary of Decisions, 11.1974). Growth was to be limited. First, the Hunter, Illawarra and country areas were able to expand but Metropolitan areas had to consolidate existing programs. Second, new developments were limited to ‘areas of health resource scarcity'. Third, hospital and community services were to be integrated and coordinated to promote ‘better utilisation’ of ‘supportive services by doctors’. Fourth, health education and preventative services were to be Regionalised 'to the community clinic level'. Central Office had made these decision before the November 1974 Regional planning conference was held. These decisions had implications for the Hunter Region as did slow decision-making by the H&HSC and the Commission. The Commission made decisions slowly. The Region had to wait. For example, Krister advised senior officers he 'hoped' funding would be allocated for four or five major generalist teams which could later be expanded to create sub-teams (SOC 9.12.1974) weeks before the November conference was held. It was

185 February 1975 before it was clear the Region could proceed to establish CHCs (SOC 10.2.1975). Decisions had to be made quickly. With funding refused for a health education unit Vickers decided to locate health education officers at CHCs and equip them with an audio-visual kit, space to store pamphlets and equipment, funds to rent rooms for meetings, and a part-time service officer, (SOC 10.2.1975). Vehicles for the staff it expected to appoint were sitting in parking lots in Newcastle and at Stockton Hospital (Administrative Officer 14, 52). Despite its submissions being only partly filled Regional Office would have given the impression of having abundant resources. What it had was cars, car parks full of them, but the state's budget problems meant staff appointments were delayed in 1976. As was illustrated in Chapter 7, by 1977 each CHC had a team of around 30 members. By then the Region had five health education officers based at CHCs and a senior health education officer, Dan Krister, at Regional Office. After he resigned in early 1978 this position remained vacant and health education officer numbers declined. The problem, as one administrative officer observed, was that the ‘money started to dry up after three or so years’, when the Region was 'probably about 30 percent to 40 percent into the program' and after that it 'more or less trod water' (Administrative Officer Interview 14).

Regional Autonomy and a Cult Of Personalities Why the Region's submissions were partially funded or refused from 1976 is unclear. The Region had high death and illness rates compared with NSW, there were service gaps, services were maldistributed and hospitals over-used as Chapter 6 illustrated. Nor can refusal be attributed merely to the state's fiscal problems and the imposition of staff ceilings and freezes which limited the growth of the Region's CHC teams. An administrative officer working at Central Office in the later 1970s argued the Region was slow making submissions for funds (Administrative Officer Interview 8). This was not so prior to 1976. The Region was well prepared in 1973 with a Regional Director, John Krister, from Central Office aware of the CHP policy. Submissions were made early. According to Dr Geoffrey Olsen, Deputy Regional Director, Inner Metropolitan Region in 1975, and Regional Director of the Hunter from 1982, from 1976 the Region got less than its fair share. Problems appeared from late 1975 after the new Regional Director, Bernard Geraghty, was appointed. Olsen suggests, and other administrative officers agree (Interview 14), that the Region did poorly because of a conflict of personalities. The Regional Director’s relationship with the Commission Chairman was poor. With projects selected and priorities determined ‘by federal and state officials’ (Sax 1984, p143) good relationships were required between those seeking funding and those with the authority to allocate funds. The poor relationship could have been because Geraghty wanted funds for the Region's hospitals. He oversighted the building of two medical science buildings, New Med I and New Med II, both costly exercises offering the medical faculty clinical resources. A further difficulty, which created intra-regional problems, concerned communication. For the Region to make submissions senior officers had to know what opportunities were likely to arise. Under Krister senior officers were well informed about Commission decisions. This enabled Vickers to provide community physicians and team leaders with information gleaned from reports from Regional

186 Directors' meetings. Krister had held monthly meetings with senior officers to discuss policy issues and problems. He provided a summary of Commission decisions. All changed once Geraghty was appointed Regional Director. The senior officers' conference was replaced by a Regional meeting involving senior officers, advisers and specialist team leaders but excluding generalist team leaders and the Regional nursing officer, Jean Johnson. A less collegial approach was evident. For example, on one occasion officers were advised to collect their meeting papers from the secretary 'before departing from the office on Friday afternoon'. A 'list of meetings for all community health groups was urgently required from Vickers' (Agenda, SOC 8.3.1976). This meeting was cancelled on the day, rescheduled for March 11, cancelled again and rescheduled. When held on March 29,1976 it was acrimonious. Specialist team leaders and the Regional Adviser on geriatrics attended along with Vickers and Miller, Assistant Regional Director, Finance. Most of their proposals were rejected. Vickers asked for Johnson to be included due to her involvement with private hospitals, nursing homes, and nurse administrators. This proposal was rejected on the basis that ... if he included Sister Johnson he would have to include other senior members of the Regional office staff such as .....The group would become too cumbersome (Geraghty, SOC 29.3.1976). Geraghty was selective. He invited newly appointed advisers on psychology and social work, and the Medical Superintendent of Newcastle Psychiatric Centre (SOC 29.3.1976). Specialist team leaders attended unwillingly. Minutes, near verbatim, suggest meetings were unstructured and lacked an agenda. One attendee proposed that future meetings have agendas, notices of motions, and submissions circulated in advance. These were not, however, formal meetings but rather, according to one unhappy attendee, a venue used to identify the failings of specialist and CHC teams and senior staff. Attendance tapered off over time. Animosity between Geraghty and Vickers continued. In the ‘Rainbow Books’ (HCNSW 1977a,b,c,d,e,f) the authors describe the role of specialists as consultants whose role was to assist generalists to provide services as Figure 8.4 Illustrates. Geraghty wanted specialist teams to provide direct rather than consultative services. In his view, taking time to decide what services were needed was unnecessary. He further opposed the team leaders' decision to delay advertising of the Child Development Unit until all team members had been appointed, a process hindered by a staff freeze. Controlling specialist team leaders, mainly doctors, was to become an issue. To achieve this the Regional Director required team leaders to attend meetings and report on their movements over the past and forthcoming week. One can only assume that complaints were being made to the Regional Director about specialist services. During 1976 and 1977 Geraghty, in his capacity as Regional Director, requested reports on four aspects of the Region's health services: 1) on community health services from the Professor of Community Medicine; 2) on psychology services from the Regional Adviser on Psychology; 3) on mental health from a working party he established; and 4) on health promotion by the Professor of Occupational Health. Each report argued that community health services required more resources and commented

187 favourably on the services provided. No resources were forthcoming, however other services were extended from early 1976. Between 1976 and mid-1977 feedback to Regional administrators from Regional Directors' conferences declined. This hindered planning as it left Geraghty's deputy with insufficient information about the Commission's activities, plans, expectations and funding. Some one must have complained for in 1977 Mr Eagleton, the Secretary of the Health Commission, wrote to Geraghty. Dated July 20, 1977, the letter noted a lapse in protocol by some Regional Directors who were failing to provide senior officers with feedback from Regional Directors' Conferences. It advised that only confidential matters were to be kept confidential. This had an effect as an agenda was prepared for the September 12,1977 meeting listing the activities of the medical school, drug and alcohol services, office moves and the Regional Directors' Conference. Some fruitful discussion and Regional planning continued to occur at meetings Vickers held with generalist and specialist team leaders and Health Education Officers. Meetings were structured with agendas and minutes although issues more appropriately discussed elsewhere were also raised. These meetings continued during 1978, as those attending tried to plan amidst chaos and staff shortages.

Conflict over Resources and Populations The Commission expected CHCs to provide first contact primary care services after identifying gaps in local services. This expectation was similar to with that of CHCs overseas (see Chapter 3 & 5). In 1974 Regional administrators and community physicians were advised to implement the Commission's policies aggressively by advising hospitals what services Regions required, ‘what their contribution ought to be and how they should plan for it’ and by changing GPs' referral practices (SOC 9.12.1974). This position was outlined in Monitoring Community Health Services (1976) and later in the 'Rainbow Books' (HCNSW 1977a-f). For public hospital boards and their executive officers, who were used to asking for and gaining resources, this would have been a difficult situation. The Commission’s expectation of CHC practitioners, especially nurses, also differed. GCNs were to be given autonomy. Newcastle Hospital seems to have expected CHP funding and thus control over more practitioners. Barclay, Commissioner, Bureau for Personal Services, however, considered it inappropriate for large hospitals to act as CHCs or provide community health services (HCNSW 1974a,b). One concern, shared by Kirster, Vickers and Leeder, was that public hospitals might misuse CHP funds. Some administrators thought this unlikely (Administrative Officer Interview 14). Leeder, however, was not so sure, noting some chief executive officers and hospital boards planned to use CHP funds to upgrade hospital facilities for staff (one administrator at a conference had suggested building a tennis court for nurses) or patients (Olsen Interview 1994). A bigger concern was how hospitals might use CHC team members.

188 Advisers or Opponents By 1975 conflict was evident over who should control CHC teams, Regional administrators, Regional advisers, hospital administrators, hospital boards, or CHC team leaders. Relations had soured between Regional Office and local hospitals. Krister proposed appointing community physicians to hospitals as visiting medical officers (only relevant for medical specialists) and the Staff Development Unit running workshops for public hospital and community members interested in health care (SOC 22.7.1975). Neither occurred. To facilitate communication he maintained a diary of community health staff/hospital meeting (SOC 22.7.1975). The root of hospitals' discontent was control of GCNs. This matter was discussed at a meeting of hospital executives held on April 2 1976, by hospital boards, and Lower and Upper Hunter Advisory Committee chaired by Ken Miller, Assistant Regional Director for Finance. The Regional Adviser on Geriatrics and Rehabilitation, Dr Dick Gibson, kept this issue on the agenda arguing for hospital control of all services for elderly and chronically ill persons. By March 1976 Gibson advised senior officers that he had established a regional equipment pool with Newcastle Hospital purchasing equipment. He also requested that GCNs in the Lake Macquarie LGA be ‘withdrawn from domiciliary nursing as the service was proving quite unsatisfactory’. As this was a major policy issue Miller proposed that Gibson prepare a paper on the matter (SOC 29.3.1976). On April 5, 1976 Gibson tabled a paper given to the NSW College of Nursing in February 1975 ‘Home Care Programmes for the Chronic Invalid − should they be Hospital or Community based’. The paper argued that: cities required specialist hospital based nursing services and generalists were appropriate for rural areas; community care disadvantaged elderly people who required hospital care such as that provided by Royal Newcastle Hospital; and geriatric teams should assess all persons requiring care (SOC 5.4.1976). His position differed from that of the Commission and H&HSC (1973) which advocated for community care provided by GPs and generalist nurses. This issue did not die. Gibson sought the support of advisory committees and found an advocate for his ideas in Ken Kingsford, Chief Exective Officer of Kurri Kurri Hospital, Secretary of the Lower Hunter Regional Health Advisory Committee. On February 21, 1977 Kingsford wrote to the Regional Director to inform him that on February 11 the committee had discussed the ‘chronic invalid’ and identified ‘considerable gaps and overlaps’ between services supplied by ‘the local Hospital and the Community Care Team’. It agreed, in principle, that this population should be the responsibility of District Hospitals and requested the Commission to develop a policy on this matter. On March 3 Geraghty forwarded this letter to Gibson requesting a paper for senior officers. His brief paper dated May 2 and a letter dated May 4 predictably recommended that ... responsibility of the Community Care of the Chronic Invalid be withdrawn from the Community Care Generalist Teams whenever possible and given over to the District Nursing Staff of appropriate District Hospitals. The increase in staff the hospital will need to do this could be by secondment from existing Community Nursing establishment (Gibson to Geraghty May 4th, 1977).

189 This matter and his 1975 paper were listed for discussion on May 14, 1977. Again no action was taken. Gibson raised this matter again in a letter to Geraghty dated February 3, 1978. No action was taken. CHCs continued to control resources that the hospitals wanted. Not surprisingly by 1977 Leeder was describing relations between public hospitals and CHCs as 'delicate' and 'tenuous' (1977a p.10). Minutes of the senior officers' conference for March 1976 offer some insight into the reason hospitals kept asking for GCNs. The Region's public hospitals were apparently being ‘clogged’ with elderly patients awaiting nursing home placement with some admitted to Newcastle Psychiatric Centre where Thwaites, medical superintendent observed, they interfered with ‘therapy’ (SOC 29.3.1976). Gibson’s solution was to build a special unit for this client group at the hospital. Surprisingly hospital administrators failed to understand that control of GCNs would not resolve their problems or ensure appropriate timely services were provided for this population. Debate focused on resources not on how they were used once obtained.

Delicate Relations By 1977 Leeder, who supported continued separation of CHCs and hospitals, argued the ... level of sophistication of much of the debate upon the need to put the community health programme "under the control of the hospitals" is so low, and so frequently lacking in any perception of the contribution which could be made through community health programmes in helping to prevent the diseases which are costing society so much, that relations with hospitals remain tentative (Leeder 1977b, p.10). Representatives of hospitals made regular pleas for staff and monies to be diverted from community health as they sought to maintain their own autonomy while challenging that of CHC teams. Leeder did not doubt the administrative ability of hospital administrators but he doubted their ability to meet and respond to community needs as ... despite the vulnerability of the Community Health Programme, its relative economic and managerial fragility, the problems which has faced and still blight it, the ambiguity of its relationship with the hospitals and the private medical sector, there is a growing appreciation, particularly at the Federal political level, that when we deal with the Community Health programme we may be dealing with something worthwhile and very good for the health of the nation (Leeder 1977b, p.18). Leeder supported separation of CHCs and public hospitals to prevent teams being 'swamped with casework' and neglecting 'more general preventative and community development work' (1977b, p.9). He described CHC teams in 1977 as having extended domiciliary care and developed insights into health education and prevention. For these reasons he found it ‘hard to see how hospitals could be put in charge of community health services without a serious loss of these unique perspectives’ (Leeder 1977b, p.18). Relations between some CHCs and GPs remained poor over immunisation. Geraghty had discussed this matter with the Hunter Medical Liaison Committee on April 5 1976 but it also remained unresolved. By the late 1970s, Leeder argued, CHCs had developed a different perspective to existing organisations and provided services appropriate to the community. The Deputy Regional Director of Nursing, R. McMellon, shared Leeder's view, observing that CHCs provided a different service, however, as she found

190 when appointed to her position, this service was not reported or recorded in a way that made their work visible (McMellon 8.3.1979). Despite Leeder’s perception that the Region's CHCs had developed a different perspective and added to the its mix of services the Regional Director continued to see CHCs as unnecessary and to remain unsupportive of their endeavours. The situation for CHC teams became worse between 1978 and 1982 as ceilings were again lower and freezes were again imposed on appointments.

Nothing Much Left to Cut The CHP in the Hunter grew from 1975 but still had fewer people employed than Regions of similar size such as Illawarra. For example by 1977 it had 125 in generalist CHCs, specialist, coordinating teams and staff development (H&HSC 1976b; HCNSW 1977). Staffing was unstable. In 1975 official reports state it had 155 state-funded positions out of a total of 296 positions. The Illawarra Region had 198 jointly funded Commonwealth and state positions and 110 state-funded, a total of 308 positions. Part of the problem concerned how appointments were made. Those involved from 1974 recall recruitment and appointment as a stop-start process occurring between telexes (Administrative Officers Interviews 14, 48, 52). Permission to recruit and appoint were given and rescinded within weeks, days, and even hours. Growth was limited. The imposition of ceilings and freezes meant the number of established positions administrators could fill fluctuated. According to Leeder generalist CHC teams were too small. In his report to Geraghty in 1977 he argued that '50% more nursing and aide staff' were required to meet the health needs identified by a local planning committee in 1974 (1977b p.11). As Vickers pointed out to a Joint Consultative Committee in 1978, the Region had fewer ‘paramedical, community and domiciliary nursing staff’ than Metropolitan Sydney and required more GCNs and baby health nurses (JCC 4.4.1978). The loss of three baby health relief positions in 1973 contributed to the Region’s difficulty and submissions for two nurses for each centre had been unsuccessful (JCC 4.4.1978). Staff ceilings and freezes meant there were too few staff and this created industrial problems amongst nurses. Nurses formed a Hunter Community Nurses Branch of the NSW Nurses’ Association in 1975 because of such problems (NSWNA CNHB 26.4 1978). Minutes of their monthly meetings were forwarded to CHCs and the Nurses Association. Minutes reveal that by mid-1978 the Region had thirty-three nurses employed as temporary employees under Section 44 of the PSB Act (NSWNA CNHB 25.7.1978). Positions of leadership were lost, for example that of Assistant Regional Director Community Health. Positions remained vacant for extended periods of time or were filled by appointees acting at a higher grade for extended periods. The Deputy Regional Nursing Officer (DRNO) position created in early 1978 was vacant for nine months (NSWNA Archives 29.8.1978). In October the government imposed across the board cuts to the state health system. Community health and Schedule 5 hospitals were affected most. The 6.6% cut imposed on the Hunter Region required a loss of 165 positions, 28 from community health and Regional Office and the rest from Schedule 5 hospitals.

191 Vickers wrote to the Commission on October 28,1978. He argued blanket cuts failed to consider needs or priorities and that these cuts were in 'direct' conflict with Commission policy to provide 'preventative services and services for minority groups'. He proposed that rather than responding to 'parish-pump pressures', changes should be made 'in line with long term plans rather than short term expediency' (Vickers, 28.10. 1978 NSWNA Archives p.1). The position he took was that community health should be exempted from cuts. He argued for approving more private nursing homes, reducing beds at two hospitals, Kurri Kurri and Cessnock, and regazetting Morisset Hospital and Newcastle Psychiatric Centre as one institution. Vickers suggested cutting medical and allied health positions but keeping senior community nurse positions. Vacancies increased. During 1978 the state government fiscal position worsened. Practitioners and supporters began a ‘save community health campaign’ a rally scheduled for Sydney on December 13 and Newcastle on December 16. Team leaders were planning a conference to resolve problems. Before this was arranged the Regional Director announced a meeting at Stockton Hospital on October 19 which all community health staff, administrative, specialist and generalists teams were to attend. All services were to be closed. It occurred as the federal government established a Commission of Inquiry into the Efficiency and Administration of Hospitals chaired by Mr Jamison. Geraghty was concerned this Commission might propose tying funding to population size rather than mortality as anticipated. If this occurred Regional funding would decline. The agenda for this meeting, reflecting the concerns of team leaders and the Commission, listed relations between community health and the faculty of medicine, planning and development of community health services, relations between community health and Regional office, problems associated with achieving consensus between community health staff. Records are limited. Those who attended recall little detail. Some saw it as a fiasco. The lingering impression was one of hostility directed at the Regional Director who spoke about the Region's poor financial position and the Commission's concerns about the CHP. Aware team leaders were planning a conference he acted decisively, setting a meeting date, chairing the meeting, usurping their plans and changing the agenda. It is unclear what it achieved. Resources remained limited. By November 1979 Vickers was hoping hospitals would reclassify positions to domiciliary nursing to reduce generalist's workloads (TLM 16.11.1979). Staff ceilings for jointly funded positions were 120, 20 below the previous level. The Region had 50-60% of the staff it required according to Vickers. A further review of staff establishments was undertaken in 1981. There were losses (TLM 13.2.1981). The problem was that the Region had too few staff well before cuts began. Events occurring in 1981 while creating a great deal of upheaval proved to be positive for the Region if not for CHCs although practitioners gained some validation for their long held view that they had too few resources. The Region's CHP was in a state as fragile as the budget.

192 Media Reports Precipitated Change The Region's attempts to implement the CHP policy by establishing a system of CHCs that worked with other stakeholders, hospitals and GPs were hindered from 1974 by resource issues and intra-Regional conflict. The former limited growth of the CHP while the latter hindered cooperative relations forming between Regional Office and hospitals. Staff freezes and fluctuating authorised staff establishments hindered growth of CHC teams despite teams having achieved what was expected of them, GPs were referring and admissions to hospitals had declined. The new medical school’s need for adequate clinical facilities created further problems. Attempts to develop a Regional health system were marred by competition for resources and animosity between specialist and generalist teams, hospitals and CHC teams. CHCs received consistent support from 1975 to 1981 from one administrator Wes Vickers, by this time the Deputy Regional Director. This was a turbulent year. In December 1980 the Commonwealth Government had released the Jamison Report (1980a,1980b), the Report of the Commission of Inquiry into the Efficiency and Administration of Hospitals. By January 1981 Hospital CEOs in the Hunter were aware of the implications of this Report for the Region. On January 28 Mills (1981) wrote an article in the Herald entitled 'Jamison Report will ring the hospital changes'. It was the beginning of what would be a difficult year for the Region's community health services. The first sign of something unusual brewing occurred in February 1981 when meetings between CHC team leaders and Vickers were abruptly terminated. This occurred as some CHC services were being withdrawn. Then Geraghty announced that he would meet with team leaders on the fourth Friday of each month between 2 and 4.30pm followed by afternoon tea at a cost of $2.00 per person. Between January and August the Newcastle Herald ran a series of editorials and articles raising questions about the adequacy of the Region's health services, hospital and community health. Gradually these reports began expressing criticism of the Regional Director, Geraghty, then suggesting that he and the Minister for Health, Kevin Stuart, had misused local resources. Disgruntled senior staff, many being medical specialists, and some nurses began to speak out, and journalists such as Faye Lowe and Greg Rae listened and reported their concerns. It was compelling reading for those interested in health services, especially community health services. Gilchrist (NH 5.1.1981, p.5) began the onslaught in an article written in January 'Study reveals overloaded services'. Further critical reports followed between February and April. Rae (14. 2.1981, pp.1,3) reported on a fiasco involving Dr Peter Wells, a psychiatrist, bought from England to establish an adolescent psychiatry unit but who had to return home because funds were not available to house him. Leeder (25.2.1981a, p.2) wrote an article critical of the poor care offered to terminally ill persons. Lowe reported on proposed cuts to community health including baby health (Lowe 21.2.1981, p.1; 12.3.1981 p.1; 24.6.1981, p.7). Then she reported various senior officers' views. The Director of the Diabetic Unit at Royal Newcastle Hospital, Paul Moffett, expressed concerns about staff freezes (Lowe 13.3.1981, p.2). Leeder’s view of the Region's CHP as ‘chaotic and confused’ was quoted (Lowe 14.3.1981, p.2). Editorials were written identifying the most needy as most likely to be affected by funding

193 cuts (17.3.1981, p.3). The CHP was described by the Professor of Paediatrics, John Bolton, as a 'poor relation' (28.3.1981, p.3). By April 1981 funding for CHP services had become a public issue (Lowe 27.4.1981, p.2). By late May Geraghty and Stewart were accused of inappropriate use of government property, a launch, for fishing trips (NH, 23.5.1981, p.1, NH 29.5.1981, pp.1,3). By June questions were being raised about the administration of the Region's health services (NH 4.6.1981, p.2). One June 26 an editorial reported what they referred to as an ‘intriguing shuffle’ − the abrupt transfer of the Region's Deputy Director, Wes Vickers, to Illawarra and the Assistant Regional Office for Finance, Ken Miller, to Wodonga (NH 26.6. 1981, p.1-2). A few days latter Lowe reported a $16 million budget deficit affecting all local hospitals (30.6.1981 p.1). Community health staff responded by petitioning the Commission to keep Vickers in the Region (Allied Health Interview 66; Administrative Officer Interview 2; Personal Recollection). Speculation over the cause of this reshuffle was rife. The Newcastle Herald reported that: ... it is believed that Dr Vickers was not entirely happy about aspects of the Health Commission's administration of the Hunter Region. He has said nothing publicly (NH 26.6.1981, p.1). It was common knowledge that relations between Vickers and Geraghty were strained at best. Their views about the CHP, CHCs and health services varied and this hindered communication. Geraghty’s concern was general hospitals. Vickers, like the Chairmen of the NSW Health Commission, McEwin, and H&HSC, Sax, considered hospitals part of a comprehensive Regional health system. He supported extending the responsibilities of non-medical staff. Official reports and minutes of meetings reveal that he supported a different model of nursing service to that offered by Newcastle Hospital while being cognisant of the Region’s need for specialist services, including a nursing service. Vickers and Miller were respected by CHC team members (Administrative Officers Interviews 2, 42, 46, 68).

A Beneficial Upheaval The shuffle which occurred followed months of criticism by the local media. Speculation was rife as to who the informant, the whistleblower, was. A confidential report, prepared for the State government, that identified the Region's community health services as deficient was crucial (Gilchrist 22.7.1981 p.1). Internal criticism of Regional office to central office prompted this report. Once these transfers had occurred change followed. First the CEO of Stockton Hospital was seconded to Regional Office to replace Miller until August (NH 8.8.1981). Then on August 8 the team leader of Westlakes CHC, Thom Boleyn, was appointed Acting Deputy Regional Director (NH 15.8.1981). The Herald reported 'high' hopes for this Deputy. In October the Minister for Health, Kevin Stewart, was transferred to another portfolio. These administrative changes had enormous implications for the Region's health services. When a new Minister for Health, Laurie Brereton was appointed in December 1981 he acted swiftly. He appointed the Regional Director of New England Region, Dr Geoffrey Olsen, as the Hunter's Project Manager. Olsen’s brief was to develop the Region's first strategic plan. Within eight months, January to August 1982, Olsen and the Region's planning division had completed seven major reports. In March

194 1982, eight months after Vickers and Miller had been transferred to other Regions, Geraghty was given twenty four hours notice of his transfer to a newly created position, CEO of a Committee investigating the state's ambulance services (NH 24.3.1982). Geraghty’s appeal failed and in October 1982 he retired (Maitland Mercury 13.10.1982). CHC practitioners were unmoved by his retirement. Olsen was appointed Acting Regional Director and then Regional Director. His appointment was warmly regarded by many. As one allied health practitioner observed, he won respect by treating people with respect and listening (Allied Health Interview 5). The position of Deputy Regional Director was advertised three times with no appointment being made. Boleyn remained Acting Deputy until late 1982 when he returned to Westlakes CHC as team leader before being seconded to a working party chaired by Hausfeld, to conduct an Interim Evaluation of Community Health (Hausfeld Report 1982). Olsen’s reports concerned local hospitals and how to rationalise them, but all had implications for generalist CHC teams in the Hunter Region.

Generalist Teams Unsustainable Olsen’s first report proposed restructuring hospital and community services and integrating hospitals and CHCs. This was a direction the government perused from the early 1980s as is illustrated by the terms of reference established for the Interim Evaluation Report (Hausfeld et al 1982) and a Review of Community Health Services (McHarg et al 1983). By 1982 the process of implementing the CHP policy had struck difficulties. There were twelve generalist teams, four located in the LGAs of Lake Macquarie and Newcastle and the Cities of Maitland and Cessnock, and six specialist teams, Diabetic Education and Stabilisation, Child Development, Hunter Drug Advisory, Developmental Disabilities, Geriatric and Rehabilitation, and Child and Family Psychiatry. All offered direct services. None of these teams met the criteria for specialist services described in the ‘Rainbow Books’, the booklets issued by the NSW Health Commission as a guide to CHC teams, discussed earlier (NSW HC 1977a-f). As Project Manager, Olsen, having taken account of the Hunter Region's demography, service utilisation and health needs, recommended distinguishing hospital as referral, district or community. It was noted that while CHC teams provided a wide range of services, including preventive services, limited recruitment had prevented them offering a comprehensive range of services. Like others (Leeder 1977b; Thwaites et al 1979) Olsen found insufficient health education and research occurring while Regional data were inadequate for developing priorities and programs (1982b, p.36-37). As discussed earlier, in 1975 the Hunter Region was one of two given permission to continue expanding CHP services when other areas were considered 'overdeveloped'. Growth was, however, hindered by regional planners' conservative estimates (Leeder 1977b). In 1982 Olsen found the Hunter Region CHPs under-resourced compared with other areas of NSW. He also found, as Leeder had earlier, outreach domiciliary nursing care deficient, with the Region being 90 positions under the weighted average for the State. The size of the Region's CHP led Olsen to conclude it was no longer viable as an independent identity (Olsen 1982b, p.64). He proposed linking generalist and Regional specialist teams to public hospitals for two reasons. First as hospitals operated 24 hours a day this association would legitimise the CHP.

195 Second, this linking would help hospitals integrate the CHP concepts − self-help, prevention, area and self responsibility − necessary to reduce the pressure on the ‘traditional system’. He recognised safeguards had to be inbuilt to maintain the autonomy of the CHP. Olsen proposed linking Eastlakes with Belmont Hospital, Westlakes with Wallsend Hospital, Newcastle with Newcastle Hospital and Lower Hunter with Maitland Hospital (p.65). Specialist teams were to be linked with the hospital designated responsible for their speciality. He further proposed appointing a psycho-geriatrician, establishing a child and adolescent psychiatry unit, building a new hospital at Rankin Park, developing acute psychiatric units at public hospitals, using Morisset Hospital as a long term unit and coordinating services for drug dependent persons (p.67). Olsen, unlike his predecessor Geraghty, proposed allocating more Regional resources to CHCs to expand their services. He also proposed offering hospitals incentives to divert funds to community health services (p.74). Where the Mental Health Working Party Report had proposed recruiting more allied health staff, Olsen, like the Hausfeld Report (1982) and Community Nurses Hunter Branch of the NSW Nurses’ Association, proposed appointing more nurses (1981). The Mental Health Working Party, discussed earlier, had proposed expanding mental health services. Olsen’s concern, like Leeder and Vickers earlier, was to developing a comprehensive Regional health service rather than focusing on specialist services. The Hunter Region had a Planning Unit. Until Olsen began developing a strategic plan this Unit had focused almost totally on hospital beds, who occupied them, for what reason and who had referred them to gain data to support an argument that the Region's high death and illness rates meant more funding was required. Olsen was critical of hospitals’ 'disproportionately high admission rates and retention rates of older people in hospitals' (Olsen & Renwick 1982a, p.39). In his view this trend reflected a failure to understand aged persons' needs and develop a full range of services (aged, acute and community) (p.39). A later report outlined an integrated Regional service. The release of ‘Proposals for the Development of Public Hospital Services in the Greater Newcastle Area requiring Predominantly Capital Works Solutions’ in May 1982 proposed changes be made that ... will bring about an arrangement of services which is unique within Australia. It will be the first time that a major community is serviced by an effective network of services, many located on separate sites, but all requiring (sic) to function as an integrated whole to supply the proper services to the population it serves (1982c, p.30).

Educative and Preventive Services Needed Olsen proposed establishing a network of services administered by a participatory community board comprised of hospital executives and practising medical representatives from Greater Newcastle area (1982c, p.30). In his view the unique geographical configuration of the Region and the presence of a university medical faculty made dividing the Region inappropriate (p.31). A Newcastle Hospitals and Health Board was suggested to administer all public health services and advise Schedule 3 and 5 hospitals and community health. This board, a new Schedule 2 organisation, would alter the public service status of some staff (p.32). He assumed, flagging the shift of Nursing Education to Colleges of Advanced

196 Education in NSW, that hospitals would 'have no relationship to nurse training by the time this is implemented' (p.34). This proposal also flagged a Regional administrative structure for all health services, nurse education moving away from hospitals, participatory management and program budgeting (p.36). Some 4000 submissions were made in response to this report. The second report, Proposals for the Development of Public Hospital Services in the Hunter Region (excluding the Greater Newcastle Area), was released in July 1982. This report delineated hospitals' responsibilities and recommended hospitals provide extended care programs and community health activities including 'preventative services' (1982d, p.3). Key issues identified were accessibility of services and community nursing being provided by 'properly trained nursing staff (with appropriate back-up from other health professionals)' (1982d, p.42). Aged, disabled persons, families, babies and young children were identified as having unmet needs. Prevention and health education were identified as integral to community health services. The population’s health problems and over-use of hospital beds were raised as causes for concern. It was noted that psychiatrically disabled people required advocacy and community based rehabilitation, developmentally disabled persons required education, and alcohol dependent persons needed access to main-streamed services in general hospitals. Aged persons needed assistance to retain independence and with psycho-social problems. Instead of admission to hospitals they needed community care, multidisciplinary assessment upon admission to hospital, continuity of care and community support networks. Olsen described hospitalisation as causing a sequence of events more harmful than the original problem leading service providers to 'win the battle, but lose the war' (1982d, p.5). Aged, chronically ill and disabled persons, it was suggested, required a greater number of more diverse services, advocacy, prevention and health education. The report was critical of the tendency of existing services to focus on the presenting problems of clients instead of their 'needs'. Funding was low and effort was directed at developing a funding formula that would not disadvantage the Region. A statistician, Greg Hardes, and Olsen wrote Allocation of General Operating Funds in the Hunter Region (A Method) (Hardes & Olsen 1982) which defined hospitals as teaching and non-teaching, urban and rural and acute or long stay. They argued that need, determined by area health requirements, for example, socio-demographic indices, age, sex and morbidity patterns and availability of private services, should determine funding. On these criteria Greater Newcastle, Newcastle and Lake Macquarie, were underfunded and rural areas over-funded (p.2). The Minister for Health requested that Olsen conduct a major review of the Hunter Region's health care system. This exercise was personally costly for all involved. Shortly after these reports were submitted Olsen was on extended leave. The first report (1982a) proposed a restructuring of hospital and community services which ultimately led to CHCs and hospitals integrating in 1985. The CHP in the Hunter Region had been affected by the actions of the Commission, internal divisions, and a lack of administrative support within the Region between 1976 and 1982.

197 A Strategic Plan for ‘a Chaotic and Confused’ CHP As Project Manager Olsen developed a strategic plan. In 1983, as Regional Director, he appointed Regional coordinators for community health. The appointees, a social worker, Margaret Stevenson, and a speech therapist, Margaret Hutchinson, were well qualified to assess community health services and develop a five year plan. In late 1983 they submitted a two volume report, A Community Health Programme for the Hunter, containing 274 recommendations. There were few surprises. They recommended keeping a generalist/specialist model, integrating community health services, allocating budgets to sector and specialist teams, establishing an administrative system for CHCs and having CHCs administered by hospitals. Two district hospitals, Wallsend and Maitland (p.105-106), were identified as appropriate organisations to administer CHCs. So CHCs could remain autonomous they proposed establishing a Community Health Coordinating Committee for two years comprised of the Deputy Regional Director, Area Coordinators, a hospital CEO and an Assistant Secretary. A generalist CHC population to staff ratio was proposed and the additional staff required by each CHC were specified. They proposed that generalist programs offer entry into services at district or local level and that specialist programs, defined by anatomical or pathological categories, focus on target groups, problems or a mode of intervention (p.15). CHP funded projects (Lifeline, Mercy Community Care, and the Mayfield Working Women's Centre) were counted as community health services. Stevenson and Hutchinson proposed delineating areas (populations of 100,000 to 3000,000), sectors (populations of 30,000 to 100,000) and districts (populations of 5,000 to10,000). Spatial orientation, rural or metropolitan, was considered. They identified three CHCs, Windale, Toronto and Newcastle West, as metropolitan and Maitland, including Cessnock, as rural (p.21). Rural areas, it was argued, required their own specialist services. GCNs had already been allocated geographic areas in CHC catchment areas. They proposed allocating GCNs districts, based on an amalgam of census collectors' districts defined by a community or cluster of communities corresponding to primary school catchment areas, other community divisions, and boundaries of other agencies. Dividing Lower Hunter and Newcastle into two sectors was supported. The 'pivotal unit' for planning, delivering, managing and monitoring community health services and developing consultative committees was identified as the centres (p.23). Generalist and project grant funds were to be used to fund district and sector services with project and hospital outreach program funds used for specialist area and Regional services (p.25). The report recommended allocating a district to generalist staff so they could develop an understanding of resources, and provide continuity of care. Stability was considered essential to ensure that these generalists could develop collaborative relationships with other workers and become known to those in need of services, as: Knowing the core generalist worker in their district should be the access they need to help them define their need, and get assistance in finding a way of meeting the need. Identification of how to access the system is enhanced by having stable high profile core generalists (Stevenson and Hutchinson 1983, p.26). They argued that generalist services should be more accessible at district level while more specialised services should be accessible at sector level. A new term was coined, 'resource generalists', these being

198 staff with knowledge and skills related to particular aspects of illness, problem or disability management, early detection, health promotion or community development, who could act as consultants for several districts depending on sector need (p.26). The term ‘activities’ was used to include planning, management, service provision, and such goal-directed activities as illness, problem and disability management, health promotion and community development. They identified aspects of community health work previously ignored. Stevenson et al argued for community health services to provide; care for persons with health problems, health promotion and community development. Service providers were identified as needing Regional support with planning, review, program evaluation, research, management, coordination, administration, monitoring and education (p.28). Health promotion was interpreted as health education and assisting people to gain access to health promoting options or removing health damaging conditions. It was therefore more than providing information. Community development was interpreted as assisting people develop knowledge, skills, opportunities and resources to act on their own behalf (p.29). Generalist staff were to plan and review, analyse the resources, issues and needs of an area, devise goals, priorities and strategies, and revise them. Specialists were to focus on utilising data and analysing the nature, frequency and causal factors significant for physical and mental health to inform planning and goal setting for Regional specialist programs. Evaluation and research were processes to establish the effectiveness and efficiency of programs or projects while management and coordination were desribed as important activities for developing and maintaining functional teams (p.30). A long term management goal was to transfer a Regional CHP, in its entity, to an Area Board (p.102). The weakest part of the program was considered to be administration, without which ... all the plans and goodwill in the world will come to naught. It also recognises the almost insurmountable odds against which team leaders and Administrative staff have struggled to operate an efficient service (p.102). Team leaders remained unclear of their delegated responsibilities for documentation, budget control, and lacked control and involvement in decision making by 1983 (p.103). For this reason, amongst others, Stevenson and Hutchinson identified education as a priority for team leaders and senior community nurses along with educating and orientating GCNs so they understood their responsibilities, which included developing effective teams and a home nursing service (p.115).

Generalist Nurses' Inadequate Preparation While Stevenson et al envisaged GCNs providing a full range of generalist services at a district level it was noted they had neither the training nor the inclination to undertake this role (vol 2 p.6). Their rationale for proposing development of a home nursing service was that the 'Metropolitan Area must have one of the most disjointed and elusive sets of Home Nursing services in the State' (Volume 2, p.8). A working party, consisting of representatives of hospitals and all home nursing services, was proposed to facilitate the coordination of hospital and community health services along with locating discharge planners, initially for

199 three years, in metropolitan hospitals (Volume 2, p.10). They expected the role of the senior nurse to alter as the program altered. Community health staff gave this report a favourable reception, mainly because it offered direction. It also confirmed practitioners' views that CHC teams were too small and supported directions CHC teams had tried to take. As indicated, by the time this report was handed down Olsen was on extended leave. The Acting Regional Director, Ken Miller, who had returned from Wodonga, wrote the foreword to this report. He acknowledged community health as a vital part of the Region's health services but cautioned that the '… proposed increase in resourcing ... may not be possible in exactly the same sequence of time or schedule listed in the report' (Miller, in Stevenson et al 1983). Again there was no money for community health. With Olsen and Stevenson on extended leave the political will required to carry through these recommendations was missing.

Integration Prior to Change By 1982 the NSW government had well-advanced plans to establish Area Health Boards and transfer nursing education to Colleges of Advanced Education. Numerous reports were written between 1984 and 1989 to forward these plans. Structures and time lines for transferring the CHP to an Area Board were outlined. The first report concerned management of community health and contained 57 recommendations and proposed a six stage program for integration with hospitals (Stevenson et al 1985a,b). The second by Sutherland, Beavis, Robinson and Quinlan (Regional Office administrative staff for community health) and Hutchinson (rural Area Coordinator) addressed procedures for administering a CHP. This report outlined public service employees' conditions (including study leave, time in lieu, annual leave and cars) which had to be maintained for existing public servants. The final report outlined how to establish a domiciliary nursing service. Administration of the Region's CHP was problematic. Stevenson argued no area was large enough to support a ‘fully fledged’ generalist program. Like Olsen Stevenson argued the population was too small, significant resources were inadequate, and personnel were inappropriately trained. Major staffing deficits were identified in Greater Newcastle (1985 p.9). Information systems were also inadequate. Stevenson proposed adopting a structure consistent with basic principles of management, community health organisation and practice so as not to create further industrial problems (1985, p.11). She proposed creating a Regional Coordinator Community Health (by reclassifying community physician Metropolitan); area coordinators (instead of team leaders) and making incumbents responsible for CHC budgets for the first time; and requiring hospital outreach services to develop reporting systems.

200 Table 8.5 Regional Reports concerning the CHP between 1984 and 1989 Year Month Author Report Title 1985 April Stevenson Community Health Management Hunter Region Morisset Hospital Review of Morisset Hospital Review Team July Sutherland et al Community Health Administration Hunter Region September Strategic Planning Strategic Overview of Health Service Development in Committee the Hunter Region October Management Planning Services for the Hunter Region Consultancy Group Health Promotion Unit First Annual Report 1986 July Strategic Planning Strategic Plan for the Provision of Health Services in Committee the Greater Newcastle Area up to the year 2000 October Working Party Psychiatric Rehabilitation Services Working Party Report November Management Hunter Region Program Objectives 1987 Consultancy Group 1987 November Management Review of Community Health services Consultancy Group Department of Health, Summary of Community Health client registrations and Hunter Region Occasions of Service in the Hunter Region, 1st July 1987 to 31st December 1987. 1989 McMellon Development of a Community Nursing Service Source: Regional Reports By 1985 the Region had a Community Health Management Committee. Team leaders and Area Coordinators (rural and metropolitan) met to exchange information (TLM 10.1.1985). Service Development Groups were operating to plan child health, mental health, and community health services. In 1986 they were disbanded after public hospital boards were disestablished to form four Area Health Boards. In early 1989 they reformed (Westlakes Team Meeting, 15.3.1989). By mid-1985 a new Regional Director, Owen James, an anaesthetist from Royal Newcastle Hospital had been appointed. A Strategic Planning Committee had been formed the membership of which included: Richmond, Secretary, Department of Health, Chair, Owen James, Regional Director, Ken Miller, Deputy Regional Director, Geoff Olsen, now a Special Adviser (until June 10th 1985 when he resigned), Greg Hardes, Acting Senior Planner for the Hunter, John Hamilton, Dean, Faculty of Medicine, Margaret Hutchinson, Acting Regional Community Health Coordinator (appointed August 1st 1985) and three representatives from the Department of Health with expertise in planning, research and policy development. The project officer for a new public hospital being built at Rankin Park assisted. The purpose of this Committee was to develop a framework for service development under an Area Board Structure. They delineated hospital responsibilities and proposed services for aged, psychiatrically ill, developmentally disabled persons, consolidating specialist services and increasing generalist teams CHC teams from five to six. Nine specialist teams, four hospital outreach programs and services provided by non-government organisations were considered to be community services. A major deficit in services was identified as lack of a regional nursing service. As Stevenson (1985, p.22) pointed out the Region still had a shortfall of 60 nurses. This was not as low as the 90 Olsen had identified in 1982 (Appendix 8.3).

201

Restricting Nursing Practice In 1988 regional administrators decided to create a regional nursing service to cater for aged and disabled persons living in Lake Macquarie and Newcastle. From 1986, as the federal Home and Community Care Act (HACC) made funds available for the care of frail aged, disabled and chronically ill persons, the number of CHC nurses providing care for this group increased. Too few nurses provided services for this population, with needs being greatest in Greater Newcastle, Newcastle and Lake Macquarie. In 1989 the Director of Community Services, Sue Fardy, commissioned the past Regional Director of Nursing, Robyn McMellon, to write a report on how such a nursing service could be established. McMellon proposed disestablishing generalist CHC teams in Greater Newcastle and re-locating district nurses employed by Royal Newcastle Hospital, based at Rankin Park, to Newcastle West CHC where generalists and hospital district nurses had been integrated in 1984. In late 1989 a Director of Community Health Nursing, Lee Hughes, previously Director of Nursing, William Lynne Hospital, part of the Royal Newcastle Hospital geriatric service was appointed.

In Summary Regional administrators, guided by central office, commenced implementing the national CHP policy consistent with H&HSC (1973) guidelines and expectations in late 1974. Regional needs were identified and plans made to meet these needs. Contrary to experiences elsewhere as delineated in the literature this Chapter reveals that senior Health Commission officers influenced how the CHP policy was implemented via decisions made within and outside this Region. Resource levels for CHC teams were affected. Many stakeholders, angered by the confrontational approach taken by Commission officers, opposed CHCs. Hospital administrators, medical specialists, and GPs remained hostile to CHCs and to the expanded role proposed for GCNs. Implementation was rapid and this in itself generated anxiety, and the intertwining of the CHP policy with one directed at regionalising health care and rationalising hospitals ensured resistance continued. When hospitals and community health services were transferred to Area Boards in 1986 a slower pace of policy implementation meant stakeholders became involved. Administrative structures were established gradually and leadership and guidance were given to senior hospital administrators. By contrast implementation of the CHP policy had prepared some practitioners, GCNs, Health Education Officers, and senior Commission officers, but neglected CHC managers and hospital administrators. The approach of practitioners when establishing services is now discussed.

202 CHAPTER 9 PRACTITIONERS' APPROACH TO ESTABLISHING CHC SERVICES: FLYING BY THE SEAT OF THEIR PANTS − UNTIL CONSTRAINED ... on the first of April 1975 half a dozen of us were given a car, given a bag, shown how to change a tyre, given a map, and told "that's your area, go and do it". By this time we had done our community training – the twelve week one (GCN, Interview 42).

Introduction The previous chapter explored how administrators implemented the CHP policy in the Hunter Region. It illustrated that political support for its implementation declined at a state and regional level and that the process progressed by lurching from one administrative and fiscal crisis to another. The Region had too little funding to achieve the initial vision. With a new Regional Director the vision changed and the funds were more restricted. Eventually a small Community Health Program (CHCs, specialist teams) was transferred to selected hospitals prior to Area Boards being established. This chapter explores how CHC practitioners implemented the CHP policy in what was for them a volatile administrative context. It illustrates that initially poorly prepared practitioners practised differently in this new environment because they had to, and they were encouraged to. They had to use their initiative and learn to work together. Significantly, practitioners alerted to the CHP policy at orientation were managed in teams which included members not so oriented and led by Community Physicians who also lacked such orientation. Over time, changes in practice were stifled at some CHCs by Regional Administrators and CHC managers seeking to control and monitor practitioners' activities, especially those of generalist community nurses. This Chapter adds further to our understanding of Regional context and illustrates how differential workloads and lack of leadership underpinned the intra-team conflict which arose between nurses and some centre managers. It begins by exploring how practitioners, street level bureaucrats, were prepared to implement the CHP policy and work at CHCs.

So Many Needs and Service Gaps As Chapter 8 illustrated Regional Administrators responsible for implementing the CHP policy had little difficulty deciding where to locate CHCs and GCNs. The Region was a ‘barren field’ in need of services (Administrative Officer Interview 1.13). Although needs were suspected they had to be officially determined. Administrators expected CHC practitioners, especially generalist nurses, to uncover and address needs or else encourage other organisations to do so (Administrative Officer Interviews 1.13, 46, 48). Practitioners appointed to CHCs in 1975 consisted of two distinct groups: experienced nurses educated to work in general hospitals and allied health practitioners mostly new graduates. Their reasons for working at CHCs varied. Many, like myself, thought the work would be interesting (Allied Health Interview 30; Psychiatric Nurse Interviews 2, 44; GCN Interviews 40, 46, 63). For some it was an opportunity to leave the constraining atmosphere of hospitals (Administrative Officer Interview 41; Allied

203 Health Interviews 30, 68). With the assimilation of baby health, school medical and community mental health staff, another group of experienced practitioners joined CHC teams. After freezes were imposed on recruitment yet another group of nurses were attracted to CHCs, those immediately available for short but usually indeterminate periods of employment. This group was generally less professionally experienced and lacking the benefit of having been orientated to the population health concerns motivating the framers of the CHP policy and the purpose of a Health Commission. Nurses who commenced as temporary or casual employees often sought permanent positions, gaining them years later (Psychiatric Nurse Interviews 37, 44; GCN Interviews 6, 63). Most practitioners appointed to CHCs were willing recruits to a new work environment but most were educationally unprepared for their roles as generalists, especially nurses.

A New Perspective was Presented Teamwork arising from a shared understanding of purpose, responsibilities and skills (Payne 1982; Rubin et al 1975; Rotem 1981, 1984; WHO 1988a, 1993a) is essential if a health care system is to focus on health and offer people timely access to relevant health care during times of need (H&HSC 1973). Australia’s health care system consisted of a plethora of services operating in isolation (H&HSC 1974). Some Health Commission officers saw the CHP policy as a way to refocus health care systems, but powerful stakeholders, happy with the status quo, rejected this view. Practitioners expected to form CHC teams came to their new positions steeped in the cultures and traditions of the types of organisations discussed in Chapter 6. Most knew nothing about ‘health’ but lots about ‘disease’ and ‘treatment’. The CHP policy and NSW Health Commission were concerned with improving people's health (H&HSC 1973; HCNSW 1979f, 1981a; NSW Parliament 1972, 1973), so an orientation to the policy practitioners were expected to implement was appropriate. Two disciplines, nurses and health education officers, were orientated to the intentions of the Commission employing them, and to the CHP policy. The mix of disciplines allotted to each CHC between 1974 and 1976 meant that most practitioners then appointed were orientated to the CHP policy as interpreted by Commission Officers.

Orientation to CHP Policy and Health for CHC Recruits – Missed Opportunities The earliest recruits to CHCs were receptive to, and excited by, the new ideas presented to them during selection interviews and orientations. The challenge was that it was up to them to work out how to translate ideas into practice. Orientations were conducted to inform practitioners of the new Health Commission (its purpose, rules, regulations, policies, procedures, employee entitlements) and to develop skills relevant to community work (HCNSW 1975b; HD 1974b; SOC 10.2.1975). Health education officers, mostly university graduates, learnt to develop and conduct health education programs and work with communities (Health Education Officer Interview 66). New skills were practised during fieldwork they conducted as part of their orientation. For this group, usually untainted by the traditions of general

204 hospitals, orientations were conducted in Sydney by employees of Central Office, experienced health education officers. Returning to the Region after their 13- week orientation, they had the support of a senior Regional Health Education Officer (until 1978) and Regional Administrators. Due to funding issues they were allocated to CHC teams rather than a Specialist Health Education Unit. Nurses attended orientations in Sydney (1973–1976) and, following establishment of a new Regional Staff Development Unit, in the Hunter Region (1974-1976) (HCNSW 1974b, 1975b; Kershaw 1977). Most GCNs, like health education officers, attended orientations before taking up positions at CHCs. Following a one-off part-time orientation these programs were conducted full-time, over 12 weeks, and coordinated by an experienced health visitor (UK) and school medical nurse, Ruth Kershaw. This program, like community nursing courses elsewhere, focussed on assessment (CH Nursing Course Notes 1975; GCN Interviews 44, 63; Administrative Officer Interview 1.5; Kershaw 1977; Personal Recollection; Waring & Mclennan 1979). Nurses learnt about problem based client records and strategies to assess communities, families and individuals (including those with drug addictions and chronic illnesses) and to offer counselling, including to bereaved persons. Fieldwork included placements with new CHP funded services (Diabetic Education Centre, Aged Care Assessment Team) and assessment of a community in their area, identifying actual and likely needs for services. Newly appointed health education officers continued to attend orientations until late 1979. By early 1976 nurses' orientations had been reduced first to six and then to two weeks, before ceasing. By the end they were limited to lectures. Thereafter nurses learnt about the CHP policy via their contact with peers like allied health practitioners and centre managers. For nurses, opportunities to study community nursing were limited. Cumberland College offered a full-time Diploma in Nursing, with Community Health Nursing major (Cumberland College of Health Sciences 1977). I enrolled in the Diploma in Nursing Education offered by Armidale College of Advanced Education as it offered distance mode. From 1976 until 1982, newly appointed nurses, like their allied health colleagues, were oriented to the activities of a CHC team rather than to the CHP policy. This changed following a review of the Region's health services (Stevenson & Hutchinson 1983a,b). A two-week generic orientation to community health services was offered to incoming community health workers and employees of hospitals (medical, allied health, administrative and clerical staff), how long for is unclear (Staff Development Unit Community Health Orientation Program 1983). The last orientation conducted in the Region was in 1986 for Home and Community Care (HACC) nurses, a new category of community nurse (Administrative Officer Interview 41). This two week course was conducted by the senior nurse from Newcastle West CHCs, Eileen Cook (HACC Nurse Interview 9). For nurses, as for other practitioners, Regional Administrators supported a learn-on-the job policy, depriving them of an opportunity to gain a new perspective on practice and a raised awareness of possibilities.

205 Nurses Enlightened to Possibilities – Centre Managers Missed Out The most important feature of orientations was that they offered practitioners a different perspective and led many to change their views about health and health care. Exposed to new ideas they started to see possibilities and consider new ways of practising. Domiciliary nurses benefited while noting they could not apply what they had learnt in their current positions (HCNSW 1975b). An allied health practitioner, employed in another Region at the time, described their orientation as ‘wonderful’ for opening up new ways of thinking about issues (Allied Health Interview 30). Experienced nurses gained new skills (Psychiatric Nurse Interview 44). I remember learning to conduct a ‘windscreen1’ survey while driving and observing. Most practitioners found orientations useful and enlightening, although one felt hers was useless as 'no one could tell her' what she had to do (GCN Interview 7) and another resented being lectured on bereavement (GCN Interview 39). However, they were required to assess a community and submit a report containing a demographic profile of the population, details about health and welfare services and an analysis of the services required. Evaluations of these courses found nurses' attitudes towards community nursing changed. Nurses identified a need for ongoing education, follow-up seminars, and more input on counselling. Those attending the August 1975 course expressed confusion over their new duty statements, as they conflicted with expectations gained at interview and during their orientation (HCNSW 1975b). Once orientations ceased GCNs, increasingly temporary employees, joined teams with no theoretical input regarding how to assess groups, families, communities or individuals, children, aged or chronically ill persons, or how to provide services with a preventative orientation. The significance of this form of orientation is illustrated by a HACC nurse, with experience overseas and as a GCN, who described her orientation as having offered her a new perspective on nursing (HACC Nurse Interviews 9). Orientations provided a vision of what could be done, with direction on how to do it supposedly coming from teams guided by team leaders once local needs were assessed and decisions made. The problem, as one administrative officer (Interview 52) pointed out, was that Community Physicians were not oriented to the CHP policy or the intentions of the Health Commission, as were the majority of the original practitioners, GCNs and HEOs. This set up a situation whereby practitioners’ interpretations of their responsibilities differed from those of team leaders. Herein lay seeds of difficulties that ensued for CHC teams as they began implementing the CHP policy.

Expected to Swim with Minimal Assistance As Chapter 8 illustrated, implementation of the CHP policy in the Hunter Region shuffled along with little leadership from Regional Administrators until 1983. As Chapter 7 revealed, practitioners began identifying local needs and responded by providing or helping establish new services as the architects to the CHP policy had intended. Those oriented to the policy knew that they were expected to 'swim'. The nurses who were employed without the benefit of an additional professional orientation, commenced with different

1 A technique for conducting a preliminary, rudimentary, community assessment.

206 concerns, and more importantly an antiquated view of community nursing as nurses who ‘just’ do home nursing. This difference in understanding of professional responsibilities laid the foundations for intra- professional conflict which arose over time, culminating by the mid-1980s in specialisation. From late 1976 team leaders and senior nurses tried to ensure new team members were orientated to their CHC and its catchment area. Different strategies were pursued to achieve this aim. New GCNs were usually ‘buddied’ with another GCN for one to three days to gain some idea what was expected of them. Those employed urgently, for undetermined periods, were often thrown in − handed a diary, car keys, a list of client names and addresses and then it was ‘on your way’ (GCN Interview 6; Psychiatric Nurse Interview 37). They had to pick up where the other practitioner had left off. A newly qualified baby health nurse employed as a reliever was in this position. She was so uninformed she did not know ... where the main centre was ... and when the team leader came at the end of two weeks and said "Well how did you manage?" I didn't know who he was ... and I said … I wouldn't have a clue". And he said "Oh well if you liked it you can come round for twelve months to Maitland" (Baby Health/GCN Interview 35). It was the same for all disciplines. Being thrown in was confronting. Little wonder that many of the practitioners appointed from late1976 focused on clients rather than seeing the possibilities open to them to focus on ‘health’ and take the opportunities available to respond more appropriately to the needs of local populations. Some practitioners had a different experience. An allied health practitioner, for example, recalled feeling really supported by a team leader advising them to take time to get a ‘feel’ for the area (Interview 28). A GCN given the same advice recalled her irritation and only later realised its importance (Interview 23). Practitioners appointed to recently vacated positions or to relieve, when funds became available, had to pick up their predecessor's workload. It was different for those appointed to new positions or those left vacant for months. For example, when I transferred from Newcastle CHC I took a position vacated six months earlier. I had to begin again. Trust had been lost in the community, amongst GPs.

Nurses' and Managers' Expectations Diverged One problem arising from the way practitioners were appointed to CHC teams relates to the expectation that they would take on new responsibilities, identify needs and establish new services relevant to their discipline and consistent with expectations outlined by the Division of Personal Services discussed in Chapter 8. Clearly Commission Officers, Regional Administrators, had expectations of CHC practitioners and team leaders. Orientations provided those involved in them with ideas about these expectations about what they could do, along with relevant skills. A major flaw in the implementation process in the Hunter was that the disciplines from which team leaders were drawn (community physicians, allied health) were not orientated to CHP policy, as Regional Administrators did not consider it necessary (Administrative Officer Interview 48; Allied Health Interview Allied Health 30). Nor were they provided with opportunities to gain the skills required to manage growing teams with increasingly fluid membership amongst whom tensions arose regarding differing workloads and the centre's purpose. The architects of the CHP along with Regional Administrators apparently

207 expected community physicians, and team leaders, to share their enthusiasm for developing population orientated services and changing how the current health care delivery system worked. They also expected them to build multi-disciplinary teams, identify area needs and create new services, a notoriously difficult process (Axelrod 1997; Baker & Schulberg 1967; Gwynne & Young 1979; Parsloe 1981; Wellard 1992; WHO 1988a). One outcome of this situation was that practitioners orientated to the CHP policy and exposed to new ideas found themselves working with team managers and, increasingly, with temporary employees whose understanding of the purpose of the CHP policy and the new responsibilities envisioned for GCNs was at best limited. This situation created tensions at some CHCs within and between disciplines, between nurses, senior nurses and team leaders. Before such problems arose, GCNs, allied health practitioners and psychiatric nurses, oversighted by Regional Administrators were accorded an unprecedented degree of freedom, which they used effectively.

Nurses’ Roles Redefined, a Unique Freeing Experience As envisaged by the CHP policy, professional roles began to develop free of the hierarchical constraints of the traditional hospital model. While poorly prepared for their new responsibilities the first practitioners appointed to CHCs had a rare luxury time which they used to learn about their area and identify local needs. For many nurses used to being busy and directed, it was difficult to adjust, and realisation dawned when it was too late and opportunities had been lost, never to be regained. For, as earlier chapters illustrated, CHC practitioners were expected to determine needs by focusing on communities, families and population groups. The first appointees were concerned with making sense of their new circumstances, working out what they could do, and identifying a niche they could fill. In hospitals everyone knew their place and what was expected of them (H&HSC 1974; Russell 1990). Few understood their place at CHCs, or for that matter what was expected of them even following orientation. It was a uniquely unsettling experience. Vickers and Johnson provided some guidance from Regional Office. Generalists were advised to stay in their areas instead of returning daily to CHCs (Appendix 9.1; Administrative Officer Interview 44; GCN Interview 63; Personal Recollection). The message to these nurses was to work alone in the field, from a base or car, and learn about an area. Johnson and Vickers wanted GCNs to ‘do something’ but not necessarily the same thing. It depended on need. Both however expected baby health and school medical nurses to continue providing traditional services and to develop new services as appropriate. Vickers clearly expected allied health team members to offer relevant discipline-specific services. He expected psychologists, social workers and psychiatric nurses to compensate for the Region's shortage of psychiatrists by offering counselling and support to persons with psychiatric and mental health problems. Prior to most practitioners offering services they had to become known, learn about their area and promote the CHC to other service providers, especially GPs and general hospitals, the two groups the Commission expected to refer clients to CHCs to improve the quality of care offered their clients.

208 GCNs Reached Out to Learn about their Areas Practitioners began the daunting and difficult task of learning about their area. As Chapters 6 and 7 illustrated, CHC catchment areas became smaller over time, as did the still large areas allocated to individual practitioners, especially GCNs. Significantly, despite desirable population to practitioner ratios being specified by various authors, such standards were not applied (Eglington 1968; Meyer 1972; Stevenson & Hutchinson 1983a,b; Winslow 1920, 1938). Practitioners were allocated areas, and populations, of disparate size and variable health status with differential access to health and welfare services. This had implications for all CHC teams and all practitioners. The population to practitioner ratio was usually lower in rural areas (especially those with swinging political seats like Maitland) but they exceeded desirable rates specified by the Division of Personal Services in all areas (Appendix 9.2). Newly appointed practitioners had a difficult task. They, especially GCNs, started collecting and filing information, assessing their areas and the needs for services. One practitioner who benefited from this activity recalled finding a file containing a ‘significant amount of data… about the people of Lake Macquarie and local GPs' collated by ‘2 or 3' GCNs (Allied Health Practitioner Interview 54). GCNs collected information about their areas and ... every nurse knew what resources were actually in the community, what groups ... what organisations were around, what voluntary groups …. nurses kept that, because it changed. Organisations moved and closed ... you kept them in your diary from year to year, you crossed it out and noted it ... then you passed all that information ... to the next nurse (GCN Interview 7). Daily diaries were a resource passed to a successor or, for nurses, a reliever when on leave. Nurses started assessing their communities while being orientated and continued this practice. They sought to learn about their area, become known and trusted, and promote their CHC. Like other practitioners they started this process by visiting other service providers to find out what they did and explain what they and the CHC could offer.

Knocking on Doors to Learn about Service Gaps and Raise Awareness How could new services, meeting discovered needs and involving community participation, develop? Visiting, door knocking, was the way they began. Practitioners began visiting government organisations, schools, the Department of Youth and Community Services; non-government organisations, welfare organisations, charities and self-help groups; GPs and hospitals. Nurses explained that they visited ‘doctors and all the different groups around, churches, you name it’ (GCN Interview 39). Another remembers spending three to four months visiting ‘Centre Care and Life Line, Marriage Guidance and family GPs’ (Psychiatric Nurse Interview 2). New team members revisited, guided by their predecessors' files or their diaries. Driving around was an integral part of nurses' efforts to gain in-depth knowledge of their area and of local needs. Information was collected daily, informally and over time. Formal surveys were rarely undertaken and when they were the purpose was to learn about residents' perceptions of need (Allied Health Interviews 54; Clarke et al 1990; Psychiatric Nurse Interview 2), clients' problems and area of residence (Hewson undated 1982?) or what residents knew about CHC services

209 (Kerkoff & Green 1982). Formal studies confirmed what practitioners were learning via contact with other service providers and clients, that psychosocial issues were a major concern (Clarke et al 1990; Leeder 1977a; Vinson & Homell 1976; Vinson, Homell & Bonney 1976). Finding gaps and identifying needs was relatively easy for as one practitioner observed There just wasn't anything. There were no community support groups at that time ... there was the Department of Community Services, or whatever their title was then and the Department of Health. That was it … (Allied Health Practitioner, Interview 30). Two major gaps were identified: counselling services (Allied Health Interviews 28, 30, 54; Psychiatric Nurse 2, 33, 37) and home nursing for elderly, disabled and terminally ill persons especially in Lake Macquarie where few services operated (Administrative Officer 42; GCN Interviews 6, 7, 39, 63; HACC Nurse Interviews 1.5, 9). As CHP policy intended, needs were being ascertained in order to develop appropriate responses (Appendix 9.3).

Relationships and Links By knocking on doors, often unannounced, practitioners began to establish relationships with other services and form loose links. Most services operated independently of other services (Dewdney 1972; Lewis 2003; Sax 1972a, 1972b). In the Hunter, for example, general hospitals operated separately from other services including GPs except at a district level where some GPs had admitting rights. Separation hindered access and continuity of care (H&HSC 1974). As Chapter 5 illustrated some governments, policy analysts and GPs considered CHCs an organisational form capable of linking services and levels of care. But they could also operate in isolation (ACHA 1986; Gibson 1980; Raymer 1980). In the Hunter CHC practitioners saw reaching out to various stakeholders an essential part of practice and the only way to become known and create work. Meeting people was interesting but most wanted to do something. Responses to their overtures varied as they had at the Regional Planning Meetings held in 1974.

CHCs, A Welcome Addition or An Interloper Local stakeholder groups' responses to CHC practitioners varied and reflected attitudes displayed at local planning meetings (HC 1974a, NH 28.2.1974; NH 15.11.1974). Employees of non-health government and non-government organisations responded positively and links were readily established. Overburdened district officers, employees of the Department of Youth and Community Services, and school counsellors were receptive to the overtures made by CHC practitioners. District Officers, already ‘dropping in’ or telephoning some baby health nurses to discuss a child or a family causing concern, also began asking GCNs to assist families experiencing problems with parenting, hygiene and nutrition (Baby Health Nurse Interview 12; GCN Interview s 1.6, 42). School counsellors began referring children and families to psychologists, social workers and speech therapists (Allied Health Interviews 28, 30, 54; Personal Recollection). According to one allied health professional they referred because they were often ‘desperate for help’ and professional support (Allied Health Practitioner Interview 28; Psychiatric Nurse

210 Interview 2). Some of the children referred had complex behavioural problems, some associated with physical and sexual abuse. Opportunistic contact became more formal amongst practitioners working in the Cities of Maitland and Cessnock City where district officers, school counsellors and some CHC practitioners met each month to discuss local needs and coordinate approaches to clients-in-common whose problems were often complex. Collaboration and inter-agency referrals became common. By the late 1970s, representatives of CHCs and such agencies as Centre Care, Family Support, Information Centres, Lifeline, Marriage and Family, Youth and Community Services, school counsellors and local councils were holding formal Inter-agency Meetings in all LGAs with minutes of meetings circulated to all participants.

Liaison Leads to Representation Outreach and liaison were integral to CHC practice and over time led to invitations to community meetings and offers of positions on management committees. Team leaders, acting team leaders and senior nurses commonly represented their CHC. GCNs were also involved in committee work usually relating to services they had established or were trying to establish: carers groups, farm safety projects, meals-on-wheels, mobile library, palliative care and play groups (Administrative Officer Interview 46; Allied Health interviews 30, 36; GCN Interview 29; Senior Community Nurse 42, 45; Personal Recollections). GCNs called public meetings to form committees. Committee work usually involved services for families and children2. One psychiatric nurse worked as a co-therapist with Marriage Guidance (Psychiatric Nurse Interview 2). CHC team members were invited to work with other organisations.

Opportunities Open Out for Health Promotion in Schools Schools' contact with CHCs was usually via GCNs who, depending on their location, visited schools to conduct school screenings, immunisations and/or ‘brush-ins’ (applying fluoride to teeth). Preparatory visits were often used as opportunities to offer to talk to children about health issues which was how the various talks to infants and high school children, discussed in Chapter 7, came about. One nurse recalled talking with children about hospitalisation and giving them bedpans, gowns, masks and stethoscopes to play with. Teachers ‘seemed to like it’ (GCN Interview 63). Importantly spending time at schools enabled GCNs to become known and form relationships with teachers who started raising health issues with them. This led to work, to their making home visits, or referrals to CHC psychologists or speech therapists. This was how structured educational programs evolved, like the personal development program conducted at one primary school. This collaborative project, which involved the Education Department, parents, GCNs and a health education officer, evolved from a recurrent head lice problem (McKenzie 1982). Concern over speech problems led speech therapists to show teachers, volunteers and GCNs in schools how to use

2 For example I was a member of various management committees, Jenny’s Place, Newcastle Family Support Scheme, Regional After Schools Programs, Wickham Community Group. Numerous organisations were represented on these committees.

211 screening tools and exercises they had developed (Allied Health Interview 28; GCN Interview 63). CHC practitioners were used as a resource. School resources and a principal's willingness to work with other organisations influenced what GCNs were able to do. Contact with schools, school children and parents raised GCNs', and so their team's, awareness of local concerns and problems such as behavioural and parenting problems.

Acceptance of CHCs was Related to Need Health Commission Officers wanted GPs and general hospitals to refer to CHCs, and as Chapter 7 showed, this occurred. Acceptance was slow in some areas. CHC teams visited GPs and kept them informed of health promotion activities (pre-natal, parenting, relaxation) by letters, telephone calls and distribution of promotional material to their surgeries along with local shops and baby health centres. They also reported on their patients' progress, with permission, regardless of whether they had referred or the client had self-referred. By the mid 1980s practitioners felt they had developed ‘good’ working relationships with GPs. Initially responses varied. In East Lake Macquarie with its large newly established public and private housing estates, high unemployment rates amongst men and women, and a high proportion of young families, single parents, and few services, GPs began referring within months. The people they referred had alcohol, behavioural and mental health problems (Allied Health Practitioner Interview 54). GPs in Newcastle referred patients who were ‘worried but well’ or had long term psychiatric conditions, learning that it was possible to keep ‘difficult people... out of their surgeries’ except for ‘medication’ (Psychiatric Nurse Interview 2). Outside metropolitan areas GPs were more reluctant to refer, sensing possible competition. In West Lake Macquarie, Maitland and Cessnock, for example, they took ‘quite a few years’ to refer to GCNs (GCN Interviews 42, 64; Personal Recollection). Some appeared fearful that CHCs would take ‘their people’, ‘their bread and butter’ away (GCN Interview 42). Their reluctance to refer made it ‘very hard’ for GCNs to ‘get clients’ (GCN Interview 64). Referrals were so slow by 1978 that Vickers, Deputy Regional Director, approached a Community Physician, Ron Setchell, also an after-hours GP, to discuss this matter informally with the President of the Hunter Medical Association (TLM 19.4.1978). The circumstances in which these GPs worked varied. Those working in East Lake Macquarie were finding it difficult to have elderly patients admitted to Royal Newcastle Hospital, so the services offered by GCNs would likely have been welcomed. By contrast those working on West Lake Macquarie, Maitland, Cessnock and other more rural areas had admitting rights to District Hospitals and ready access to hospital beds and domiciliary nurses. The initially passive-aggressive response of some was overcome in time. I recall, for example, the rudeness of GPs who kept me waiting in their surgeries for over an hour when I called to inform them what I had done for patients referred by their locums. Gaining trust took time. I felt accepted when a local GP referred his mother to me for assessment and assistance.

212 Sources of Resistance and Hostility NSW Health Commission officers wanted CHC practitioners to work co-operatively with general hospitals as well as GPs. Referrals to GCNs were expected to prevent or delay admissions and facilitate early discharge. Treasury expected community care to reduce costs (Sax Interview 1991). In the Hunter relations between CHCs and psychiatric hospitals were positive, psychiatric nurses ran clinics with psychiatrists, attended discharge meetings, and followed-up patients after discharge (Psychiatric Nurse Interviews 33, 37, 44; Stevenson & Hutchinson 1982; Thwaites et al 1980). Some psychiatric nurses also established cordial relations with staff at general hospitals where they sometimes ran clinics and even assisted accident and emergency staff to assess a person for discharge after a suicide attempt (Psychiatric Nurse Interview 37). Baby health nurses had contact with obstetric units and some therapists assisted their hospital based peers (Administrative Officer Interviews 42, 45; Allied Health Interview 28). Contact was spasmodic and dependent on personal contact between individual practitioners. In general CHC teams and general hospitals, as organisations, had little real contact or interaction for almost a decade except in rural areas. Practitioners reached out to hospitals the administrators and staff of general hospitals although they mostly remained indifferent or hostile (Administrative Officer Interviews 14, 46, 52; GCN Interviews 24, 25; CNS 26). A ‘them and us’ mentality evolved. It was rare for Matrons, who met with the Regional Nursing Officer and were kept informed of all new appointments, to establish positive relationships with GCNs (Administrative Officers Interviews 1.13, 46). One outcome was some GCNs felt they ‘were battling GPs and the hospital organisation’ (GCN Interview 64). The Matron at Wallsend District Hospital, Narelle Punton, was helpful seeming not to see control of GCNs as an issue (Personal Recollection; Senior Nurses Interviews 2, 42). Aside from lending or providing equipment she organised for hospital-employed domiciliary nurses to care for GCNs' clients on weekends and public holidays. Contact between this hospital and CHCs increased with the opening of a Geriatric Assessment Unit oversighted by a new Medical Superintendent, previously a Community Physician. The CEO of Kurri Kurri District Hospital was also helpful to the extent that he agreed to hospital facilities being used for parenting and prenatal programs (Administrative Officer interview 46; Personal Recollection). He was less receptive to later requests for fathers to be allowed into the delivery suite when their partners were giving birth (Personal Recollection). General hospital administrators' hostility to CHCs arose from the CHP policy since it, and the introduction of GCNs, ended all hopes of their expanding or establishing domiciliary nursing services (Administrative Officer Interviews 1.6, 14, 52).

Restructuring Forced Interaction between CHCs and General Hospitals At an organisational level, CHC teams and general hospitals operated in isolation until reviews of the Region's health services, discussed in Chapter 8, recommended transferring administrative responsibility for CHCs to general hospitals. Managers of CHC teams started meeting with the executive officers of general hospitals located within their CHC's catchment areas. Minutes suggest that meetings between the

213 managers of Newcastle East, Eastlakes CHCs and Matrons of Royal Newcastle and Belmont Hospitals achieved little. In 1984 Newcastle West CHC team was established in premises owned by and close to Wallsend District Hospital. The Sector Coordinator, Dr Dick Armstrong, was appointed as a hospital employee and member of the hospital executive. This arrangement created a situation where the Sector Coordinator, Senior Nurse, and the hospital's executive members, Chief Executive Officer, and Director of Nursing, worked together and with the Hospital Board. Armstrong and the Senior Nurse, Eileen Cook, attended Board Meetings where planning, resource allocation, quality assurance and financial matters were discussed (Sub-team Meetings 1984-1986). Cook became responsible for educational programs for both organisations. A clash of cultures led to tensions and conflicts but correspondence indicates they were resolved through ongoing contact and focusing on issues as they arose. In 1985 Regional Office transferred administrative responsibility for all CHCs to this hospital and Maitland District Hospital. This administrative structure saw team leaders' and senior nurses' responsibilities increased to include budgets and staffing. Team leader positions were reclassified to Sector Coordinator and Senior Nurses, reflecting changing career paths for nurses, were soon reclassified as Nurse Unit Managers. Budgets were allocated to CHCs under this administrative structure which placed them in a formal relationship with a Hospital Board. Regional Office administrative officers monitored this arrangement and administrative processes became more bureaucratic. This restructure saw the groundwork laid for the introduction of Area Health Boards in 1986 and Hunter Area Board in 1987 (Administrative Officer Interview 52; Stevenson 1985; Sutherland et al 1985). The structures and processes established by CHCs in the decade prior to 1985 served them well in a new administrative context.

Democratic Administrative Structures and Processes Traditionally general hospitals evolved as inward looking organisations concerned with their patients, staff, traditions and practices (Davies 1979; Dewdney 1972; H&HSC 1974; Hamm 1980; Meyers 1970; Sax 1972). Internally they were hierarchical, information flowed down, registered nurses had little control over their practice and decision-making was the function of Boards, CEOs and Medical Superintendents (H&HSC 1974). Matrons, the most senior nursing officer, had limited influence over nurses’ practice3. Hospital routines which revolved around medical rounds, and doctors' preferences dictated the care provided. CHCs began and continued with a flat organisational structure, in which processes, routines and norms had to be established. With a community physician as sole CHC manager until 1976 when senior nurses were appointed, practitioners started working independently. For nurses used to a Matron, deputy and assistant matrons monitoring their workloads and to whom they referred problems, it was a strange situation. They had to decide what to do and how to do it. Regional Administrators, Vickers and Johnson, advised and expected nurses to ‘go and do it’ and to stay in their areas, giving them permission to make

3 Matrons controlled rostering and the behaviour of nurses but it was senior medical specialists who dictated what care was provided.

214 decisions. Practitioners interpreted this advice to mean that they had to develop, offer and establish new services as Chapter 7 illustrated. Community physicians offered less guidance, but began holding meetings where decisions could be made and information shared. Meetings were a central feature of CHC work, part of the normal routine. What began as informal affairs became more structured over time with minutes reporting decisions, outcomes of action and attributing responsibility for action. They began and remained a forum to discuss team purpose, establish norms and processes, plan activities, and resolve conflict. For many practitioners they were an entirely new mode of professional interaction.

Team Meetings Fostered A Sense of Belonging Within two years of being appointed to or assimilated into a CHC many practitioners saw themselves as members of a team (Leeder 1977b; Thwaites et al 1980). Meetings were central to this shift in perception. Practitioners met fortnightly, at different times, on different days, and for varied lengths of time at each CHC (Appendix 9.4). Meeting procedure was followed, minutes were kept (the receptionist took them initially) and attendance, apologies, correspondence and business arising were recorded. Starting with a simple format of reports and a monthly education session, meeting format became more structured and formal over time. As Chapter 8 illustrated the Assistant Regional Director, Community Health, met monthly with team leaders to inform them of the Commission's most recent decisions, policy changes, Regional developments and what practitioners were doing. At meetings team leaders reported on these team leader meetings and other activities. Practitioners similarly reported on their activities, what they had done, who they had visited. Reporting became routine. By the early 1980s minutes and agendas circulated in advance, time frames for action were being specified and the persons responsible for taking action were recorded. Over time practitioners' participation in conducting meetings increased. By 1984 teams at Newcastle West and Maitland were rotating responsibility for chairing meetings, taking minutes, preparing agendas, and arranging speakers for their monthly education session. By 1987 Eastlakes and Westlakes CHC teams were doing the same. Attendance at CHC meetings provided practitioners with a forum to obtain and discuss information reported by their team members and vast amounts of correspondence.

Correspondence Overload For most nurses team meetings were a new experience. Prior to working at CHCs, ‘hand over’ at the beginning or end of a shift was the closest they came to meetings. Psychiatric nurses had experience attending multi-disciplinary meetings to discuss patient progress and plan their discharge. CHC meetings were different in that they provided practitioners with access to information directly concerning their teams, as well as Regional developments, and state and national issues. The diversity of the correspondence received by CHC teams and tabled at meetings is illustrated by Figure 9.1. They learnt what was happening and what was being planned. Correspondence into CHCs increased over time as more organisations saw fit to inform them of their activities, current and future.

215 Figure 9.1 Types of Correspondence Received by CHC Teams 1975 – 1989

• Letters of thanks from grateful clients and/or relatives; • Letters from organisations requesting or providing information; • Minutes of meetings held by non-government organisations and/or community groups; • Commission and state government circulars; • State and regional reports; • Notices of seminars, conferences and workshops, past and pending; • Reports from other CHCs; • Vacancies in various government departments; • Minutes of meetings held by the community health nurses Hunter Branch of the NSW Nurses Association (from 1977); • Reports from Regional Working Parties and Committees (during the 1980s); • From 1985, reports from a newly established Health Promotion Unit; • Notice of community and professional bodies' activities.

Source: Minutes of CHC Team Meetings 1975 -1989.

The correspondence tabled referred to past, current, and future activities. The administrative changes from 1984 had no effect on the flow of information. By 1984 new practices had become what Yin (1979) would describe as 'routinized'.

Opportunities to Respond Reports were tabled at meetings for information but some requested a submission outlining a CHC team's views. In 1977, for example, the Professor of Community Medicine, Stephen Leeder, invited practitioners to complete a survey. Later they were invited to respond to his report on the Region's CHP and the CHC services needed in each area (Leeder 1977a). In 1982 Hardes and Olsen (1982) and Olsen (1982 a,b,c,d,e): invited responses to a Strategic Plan for the Region's health services; a proposal to transfer administrative responsibility for CHCs to hospitals, and to disestablish hospital boards to form Area Boards. Between 1987 and 1989 comments were requested on proposals to restructure community health services (1987), separate mental health and generalist services (1988), and disestablish generalist teams in the Greater Newcastle Area to form a nursing service (1989). Teams responded to some proposals and reports, usually via managers, to raise implications for CHC clients and practitioners. The Westlakes CHC team, for example, raised their concerns about program budgets which they saw as ignoring psychosocial and environmental influences on health. They also identified the need for research into this area, the contribution of allied health practitioners and the effect of streaming services for specific populations. They additionally questioned practitioner preparedness to act as consultants in the highly specialised areas proposed. How other CHC teams responded is unknown.

216 Reports of Change and Problems Team leaders' reports to practitioners were influenced by the administrative structure under which CHCs were operating and by issues then dominant. Between 1975 and the early 1980s team leaders' reports kept practitioners informed of Commission decisions and policies. Fiscal problems dominated their concerns during this volatile period when establishment ceilings were lowered, freezes were imposed on recruitment, and practitioners participated in a ‘Save Community Health Program’. Until 1982 team leaders reported on their monthly meetings with Vickers, thereafter they reported on the infrequent meetings with the Regional Director. From 1983, following the appointment of a new Regional Director and Coordinators of Community Health, they reported on meetings with rural or urban coordinators. In 1983 they reported on meetings with representatives of Schedule 2 hospitals and a Community Health Coordinating Committee’s efforts to plan community services. In 1984 the Newcastle West CHC team was informed about decisions made by the executive and Board of Wallsend District Hospital relevant to them. In 1985 Team leaders reported on the work of: Community Health Management Committees to set service priorities, goals for integrating services and strategies to encourage and facilitate research; and Community Health Service Development Groups established in response to the Report of the Standing Committee for Policy and Evaluation of Community Health Services. By 1987, following the establishment of the Hunter Area Board they reported on their meetings with the Acting Director of Community Health.

Anxiety Provoked Not Reduced Team leaders kept CHC teams informed of the volatile and changing administrative context in which they worked. Some ensured they were also aware of the political wrangling occurring in Newcastle. Their reports to teams dealt with resources, funding, staff establishments, staff freezes, cars, policies, GCNs' responsibilities, the activities of specialist teams and discussions with officers responsible for community health at different times. Their reports reflected their lack of control over resources available to teams and their dependence initially on Regional Office Administrators, and the Commission, for approval to recruit and to obtain equipment or attend to maintenance. From late 1975 practitioners' awareness of the difficulties team leaders were experiencing varied. Some team leaders ensured practitioners were kept informed about organisational and political problems. During the turbulent period between late 1975 and early 1983 practitioners at some CHCs were better informed about the Health Commission's fiscal difficulties and their effect on the Region's CHP than were others. The team leader at Maitland CHC, for example, an experienced English GP, kept the team informed while filtering out information concerning issues likely to cause anxiety, but which they could not influence (Allied Health Interview 30; Administrative Officer Interview 46). Practitioners at Windale CHC received less information than any other team. This led members of the NSW Nurses Association Community Nurses Hunter Branch to forward relevant information to their colleagues concerning, for example, the ‘Save Community Health’ campaign which commenced in late 1978 and then again in 1979.

217 Senior nurses, consistent with their responsibilities, reported on internal team matters and practice issues. From 1979 they began reporting on meetings with a new Regional Nursing Officer, Robyn McMellon, a former GCN and senior nurse. They also reported on their meetings with local Matrons, later Directors of Nursing. Their reports focussed on professional and policy issues, relief for nurses, workloads and cars. From 1986, following the appointment of HACC nurses, they started addressing practice issues specific to nurses. By 1987 GCNs and HACC nurses were holding fortnightly nurses’ meetings at which they discussed nursing issues, new techniques, treatments, department and team policies, procedures, work-loads and industrial issues. Who instigated this development is unclear from the records.

CHC Team Meetings Present Needs and Solutions Individuals planned and managed their own work. They worked as autonomous professionals. However, they also began planning as a team and this process also occurred at meetings where they reported to on their activities, their plans for their areas, and client loads. When practitioners began working at CHC they were used to planning their day. As members of a CHC team they had to plan their day, week, month and year, due to their responsibilities. For example GCNs in some areas conducted school medical screening for all the schools in their area, saw clients, and developed and conducted health promotion programs. There were few restrictions on their activities other than their ability to fit them into their schedule. An allied health practitioner explained how she would ... go to a team meeting and I will say ‘There is this need. I just want to inform the team, to see if anyone has any objections’. How they feel about it would be a case of, 'Well can you fit it in?' If I can fit it in, are the resources available? Can I get a car? the same old story can you get a car? Well that is fine. (There is)... much more sharing as a team ... you are a part of team (Interview 28). The process was similar for all practitioners including nurses. As one baby health nurse explained she would present an idea others would say ‘Yeah, terrific idea’, some might offer to help, but usually it was ‘off you go and do it’ (Baby Health Nurse Interview 22). The process was the same at all CHCs until the early 1980s when planning became such a preoccupation that it inhibited action. All nurses, with one exception, psychiatric nurses, became increasingly concerned with managing growing client loads. Team leaders' and practitioners' reports to teams served three purposes. First, practitioners gained an overview of their colleagues' responsibilities and activities. Second, opportunities arose to participate in activities initiated by others. Third, managers were informed what practitioners were doing and needs they were identifying. Some practitioners, usually nurses, wrote monthly and or annual reports. For example, during 1975 and 1976 the team leader requested GCNs at Maitland CHC write annual reports outlining their plans and time-lines for the following year (Personal Recollection). These records could not be found. During 1985 and 1986 GCNs and HACC nurses at Westlakes CHC wrote monthly reports detailing clients' problems, client numbers and their concerns and difficulties. All practitioners reported on contact with clients as occasions of service in 1976 and from 1986.

218 Growing Dissatisfaction with CHC Team Meetings Meetings served multiple purposes depending on how practitioners interpreted their responsibilities. By the late 1970s practitioners were viewing meetings differently. Some viewed them as opportunities for professional interaction which fostered teamwork and a venue for planning services. Others considered them an unnecessary waste of time better spent with clients (GCN Interviews 6, 64). Such a difference reflected the differences discussed earlier between those oriented to the CHP policy with its emphasis on health and population needs, and those denied such a vision but well versed in a traditional episodic treatment-focused practice. Problems were evident from 1975 when employees of different services were first brought together to form CHC teams. For some team members dissatisfaction with meetings grew over time as resources remained static and they found themselves spending increasing amounts of time with clients. Some practitioners attended meetings because it was compulsory. Non-attendance was acceptable for emergencies, clinics, illness, leave or attendance at a course. These criteria meant the nurses and doctors providing maternal and child health services who were assimilated into teams from 1976 were able to avoid most meetings because they had a clinic to run or school children to screen. When they did attend some remained unengaged in the proceedings. One school medical nurse remained famous for knitting her way through meetings (Psychiatric Nurse Interview 2). The part-time allied health practitioners employed at some CHCs could also avoid meetings, having clients to see. By 1977 many practitioners were attending unwillingly. Practitioners' reasons for dissatisfaction were multiple: the distances some had to travel to attend, the time of day, physical discomfort, how meetings were run and finally workloads. These concerns were valid given the context in which practitioners worked. The sheer size of CHC catchment areas meant travel to and from meetings could take up to two hours. Morning meetings interfered with home visiting or clinic appointments, afternoon meetings extended the working day of some who had to travel back to their area, which is where most lived. Directives from Central Office at times made travel more of a problem. For example, a decision taken in 1976 to garage cars at local hospitals meant practitioners wasted time backtracking to collect or return cars (Administrative Officer Interview 46). While this decision was finally rescinded because of cost it created difficulties for the practitioners affected. I chose to transfer to a CHC closer to my home because of this decision. As Chapter 7 illustrated, teams increased in size but CHC buildings did not. Most CHCs were established in rented premises. Purpose-built centres came later. The original CHC buildings were small. There were not enough chairs. Attending a meeting could mean driving for an hour in a car without air conditioning and sitting on the floor for up to three hours. Westlakes CHC, a demountable building, was too small to hold all members by the early 1980s. Some practitioners considered meetings irrelevant and others found the atmosphere discomforting because of the way they were conducted. By mid-1978 members of the Windale CHC team had begun asking if attendance was ‘compulsory or obligatory’ (WTM 27.7.1978). At Westlakes CHC one practitioner observed ‘people moaned and groaned’ about meetings (GCN Interview 6). Changing meeting times,

219 from mornings which were ‘fairly disruptive to the nurses’ to afternoons, made it easier (GCN Interview 6). The problem, according to a member of the Maitland CHC team, was that the team leader 'waffled on and on’ (GCN Interview 64). From this nurse's perspective the information provided by the community physician was irrelevant to her, to her work. Later she changed her mind. However, when first employed her concern was coping with clients. Some non-GCNs felt this group's concerns dominated meetings. If they did, minutes of meetings do not reflect this. Debate was often spirited as practitioners discussed what direction teams should take, what needed to be done, which services CHCs should offer and industrial issues. Strong personalities and more confident members enjoyed differences of opinion and ‘the conflict’ that ensued (Allied Health Interview 30). Others found the situation intimidating and rarely spoke ‘you tended to get participation from the same people, very often the ones who had an axe to grind’ (GCN Interview 64). Tensions ran high during the early 1980s as practitioners continued to try and identify and set priorities while experiencing problems maintaining the services they had established. As well as physical discomforts, logistical difficulties and personal differences, these tensions reflect the underlying differences of orientation to the CHP ideals and policy. By the mid- to late-1980s meetings at Westlakes CHC had become ‘difficult’. One new GCN found them ‘horrendous’ with practitioners being obstructive and unsupportive of a team leader who left them to make their own decisions (HACC Nurse Interview 11). Direction, it seems, was lacking. Another GCN viewed it differently: it was a ‘good team’ that made decisions and planned (GCN Interview 6). This team, she argued, had a: ... reputation of being difficult or stirrers, but looking at the team members, I don't think that's so. I just think that we had a voice...we have quite a number of very strong characters who said what they thought, and challenged. There's nothing wrong with that (GCN Interview 6). However, minutes of meetings indicate that here, more than in any other team, conflict arose over the changing nature of GCNs’ work, the work of HACC nurses and leadership. The conflict that arose in teams, here as at other CHCs, concerned workloads, in particular GCNs' workloads. As workloads increased and as more temporary employees joined teams, planning future activities was viewed as irrelevant. Some were barely able to manage the client loads they were allocated when they began working at the CHC. Resource scarcity made it difficult to focus on ideals and identify emerging local needs, population health issues, in face of sometimes urgent, but always growing, individual client needs.

GCNs' Work with Clients Just Grew The scope of GCNs' work was affected by a Region-wide deficit of baby health and domiciliary nurses, dental therapists and public health doctors. Deficits were greatest in the Region's population growth area, East Lake Macquarie from 1975. From early 1976, following the appointment of senior nurses, GCNs in this area were continually being asked to take on responsibilities that ought to have been carried out by baby health nurses, dental therapists and doctors. Regional Administrators gave tacit agreement to GCNs

220 replacing baby health nurses. As they explained to a Joint Consultative Committee comprised of representatives of the NSW Nurses Association Community Nurses Hunter Branch, industrial officers and Regional Office, their reasons for concern was a shortage of three nurses unresolved by submissions to the Public Service Board since 1973 (JCC 4.4.1978). This situation fuelled tensions between GCNs, baby health nurses and senior nurses. GCNs resented being asked to defer or cancel their arrangements to open BHCs, a situation which also increased their workloads, while baby health nurses felt devalued by having GCNs take on what they considered specialised work. In 1978 the Deputy Regional Director, having discussed this matter with the New South Wales Nurses Association issued a directive stating that GCNs were only to open BHCs in emergencies. Senior nurses at Windale (Eastlakes) and Westlakes CHCs ignored this directive into the 1980s.

Multi-disciplinary Learning Routine From 1975 meetings included a monthly multi-disciplinary education session. Although started by health education officers teams took over responsibility for this process after the health educators resigned. These sessions were a means of learning about an area, liaising with other organisations, and building a sense of being a team. Local organisations were invited to talk to teams about their organisation and its services. The presenters included lay persons and professionals from different disciplines. The range of topics was relevant to a multidisciplinary team working with a diverse population in a geographically defined area, as those presented at Maitland CHCs during 1986 illustrate: Area coordinators' roles, domestic violence, the Child Development Unit and the Diabetic Education Unit. It was the same at Westlakes CHC where one of the speakers invited in 1986 was the Director of Nursing at CA Brown Nursing Home, who spoke about a new respite service. Some sessions had a lasting impact on practitioners. An early session at Maitland CHC involved the health education officer showing a film. As one practitioner recalled: …. getting in a film doesn't sound anything to-day — but it was getting in resources from a variety of disciplines, so I remember it very clearly, a film called Pege. Which was one on — basically, bereavement. It was one on a person being admitted to a Nursing Home. But it was looking at it from the family's perspectives. And I remember all of us watching that film, which was at a team meeting, but it was immediate challenge to the team! It was ... acknowledging that we're all human, that we all felt it (Allied Health interview 30). This film, which explored a grandson's memories of his grandmother prior to her developing Alzheimer's disease was relevant to all practitioners as bereavement was considered a health issue and courses were being offered at this time. As elsewhere practitioners here found it relevant as they were working with families trying to cope with elderly relatives or chronic and terminal illness of partners and children. I also remember it as powerful and emotive. Multi-disciplinary education sessions continued, occasionally being used to discuss a team project. Baby health nurses, busy with clinics, attended few meetings or education sessions although most managed to attend specialist child development sessions which Dr Geoff Rickerby, a child psychiatrist,

221 and Geoff Hardacre, a paediatrician, conducted from the late 1970s. This kept them apart from their team members. HACC nurses and GCNs began holding separate meetings around 1986. At Westlakes CHC they involved monthly skills sessions and discussion of professional and industrial issues. One meeting was dedicated to preparing a submission to the NSW Nurses Association about wage increases (Westlakes Nurses' Meeting, 27.8.1986). In addition to team-based education practitioners took advantage of Staff Development programs which some attended (Administrative Officer Interview 14). Attendance required an application approved by team leaders and Regional Office Administrators. Those who attended seminars, conferences or other education programs were expected to provide their teams with a report and sometimes to run a course. For example, in 1976, the Professor of Psychiatry, Beverley Raphael, University of Newcastle Medical School, ran a bereavement seminar for health workers. CHC psychologists assisted and then offered workshops for interested GCNs, baby health and psychiatric nurses. Counselling courses were also conducted for GCN and baby health nurses over six to ten weeks in, and out, of work time at different CHCs (Course Notes 1975; Personal Recollection). In the mid-1980s team leaders were encouraged to attend a First Line Management Course by the then Acting Coordinator of Community Health.

Multiple Responsibilities Meant More Planning In hospitals practitioners' responsibilities are usually limited to planning care for those patients allocated to them or in Accident and Emergency to those who walked in. The latter is less controllable than the former. For those working at CHCs it was different. Planning became an essential and complex activity because practitioners' responsibilities were multiple. Nurses worked with other practitioners running clinics, visiting people in their homes, schools and hospitals, and running day centres. GCNs had the most diverse workloads and worked relatively autonomously. As one GCN observed ...this was the good part about it, nobody tells you that you will see Mrs So and So today, you know, Monday and Friday, you choose when you do it, and if you are sensible, you put people who live near together on the same day so you aren't driving all over... you had a certain number of schools that you were responsible for and you knew that you had to get through those schools in that given time, so you planned it accordingly... I tended to start with the same schools at the same time every year... we had to get the immunisation done at a certain time (GCN Interview 6). This nurse juggled her schedule. Like most nurses she tried to visit people as soon as they were referred. In first semester she screened older children and conducted immunisation programs at high schools and then in the second half screened kindergarten children, after they had settled down. GCNs rotated responsibility for coordinating and rostering immunisation programs which they ran with school medical nurses. GCNs negotiated access to school medical officers with school medical nurses. Planning was initially ad hoc and individual. Members of Maitland CHC team had numerous opportunities to plan, as one psychiatric nurse recalls: ... a lot of those things came up at ... staff meetings ... if a subject was sort of brought up, usually ... a sub-group often used to get together, to look at that further ... from what I can recall, I think most people tended to develop things for themselves. There were some joint projects, and certainly some of

222 those joint projects ... the team would discuss that at a meeting and, you know, people were asked to volunteer, so if you volunteered to be involved in it then you were involved in the planning of it and, you know, participating in it ... people doing their own thing and going off and developing in the areas that they felt they had a specific interest in (Psychiatric Nurse Interview 44). Health promotion, health education and community development projects were discussed at meetings. Planning sometimes involved ad hoc working parties reporting back to meetings for decisions. The composition of working parties varied. At Eastlakes and Westlakes CHCs, groups were usually unidisciplinary whereas at Maitland and Newcastle West CHCs they were usually multi-disciplinary groups. Most of projects were planned, proposed and carried out by GCNs. Practitioners from one or more CHC planned some health promotion projects. Planning was devolved to sub-teams at Newcastle West CHC where ideas were presented and discussed at meetings attended by centre managers. At others it became more centralised. A baby health nurse recalls arriving at Maitland CHC to be told ‘Go find out what the needs are, and do something about it,' develop ‘self-help groups or whatever’. Retuning to Eastlakes CHC she recalls receiving ‘quite a shock’ at the limits imposed on her. As she recalls she was ‘blocked’, stopped from doing ‘extra things’ and using skills she had developed as she explained: ... a good example... the centre I was at had no access to cars… there was no pedestrian crossing for the mothers and children to get across the road. It was a very heavily trafficked area ... and I just rang all the council fellows up and asked them to come and have a meeting. Which was okay in the Valley because there were certain council people who were responsible for the different centre and if it needed a paint or a this or a that, you just rang up and said, you know, ‘The blinds need... they're falling apart or something happened’, so I just rang up, and some of them were husbands of the mothers that were coming to the clinics, and they were real happy to come along and see what was needed at the centre, and then I rang down and told them that I'd organised the meeting and did they want to come out. I got rapped over the knuckles, I had to ring up and let them all know that it was off, the meeting was off, cancelled everything, and was told that I was a very naughty girl to do something like that, and they're still waiting for their pedestrian crossing and the other things that the council guys were happy to come along and talk about (Baby Health Nurse Interview 22). This nurse was used to identifying and responding to problems and reporting what she had done at a meeting. She saw the Eastlakes CHC team as having developed a clinical orientation and Maitland CHC team an outward looking orientation. Their approach to planning differed also. At Eastlakes CHC it was a paper exercise where they decided what to do with each age group, what services were needed but nothing happened as she explained: ... after spending twelve months at all these meetings working all this out we ended up at the end of the year with all the paperwork saying what we should do, but in twelve months nothing had happened, and it didn't happen in the following twelve months. … they didn't have a lot of energies and people staff wise to do it anyway, so it was a big exercise of planning… it didn't really need a whole team spending that many sessions planning to get something off the ground, it would have been better with that discipline going and planning this and coming back, there were other ways of doing the planning to be more productive (Baby Health Nurse Interview 22). The difference from her perspective was that at one CHC colleagues expected her to identify and respond to needs and at another, with too few resources, they expected her to plan how needs might be met with more resources. Planning with no resources was a pointless exercise which led to dissatisfaction.

223 The Maitland CHC team planned what to do with their resources and made submission for additional services, for example, employing a women’s health nurse, a sexual assault worker and an addiction worker and developing health promotion projects. In a mixed rural-urban area they were seen to require specialist services. Resources affected what was planned and how it was planned. Planning had become an important part of most team meetings by the late 1970s. The Westlakes CHC team added a planning section to its meetings in 1987. Annual health promotion projects and school medical programs were the limit of this team's planning, maybe as it lacked the resources needed to manage what was being done. Until Area Health Boards were established, there were no CHC budgets. Team leaders had no resources. By 1988 Eastlakes CHC team had thirteen cars, mostly allocated to GCNs travelling 24 to 68 kilometres a day. Services were limited due to insufficient resources. In 1988 this team decided to restrict leave to those who did not require relief, as there were no funds for relief (ELTM 28.7.1988). Practitioners’ workloads increased sufficiently for limits to be imposed on the number of referrals accepted, a solution preventing them from responding to people's expressed needs. This also occurred at Westlakes CHC.

Some Practitioners Juggled Huge Workloads When CHCs were first established practitioners worked autonomously and monitored their own workloads. They accepted referrals and very quickly had clients to whom they provided care. This created a problem, as there was no one to relieve GCNs when they took leave. GCNs dealt with this initially by distributing their clients amongst their peers. The decision taken by some GCNs at Windale CHC to provide 24/7 on- call care for terminal and other clients had taken its toll. By 1976 some were reported to be ‘exhausted’. The community physician reacted by giving them ‘two or three days off’ (Senior Nurse Interview 42). By 1976 it was clear that GCNs needed to be relieved when they were on leave. Lowered establishment ceilings and freezes on employment made this difficult and workloads remained a problem. In 1977 GCNs at this CHC were again instructed to distribute clients amongst their colleagues when taking leave as centre managers refused to employ relievers (NSWNA CNHB 22.11.1977). Relievers were employed at Maitland CHC when GCNs took leave. In late 1978, when Central Office lifted its embargo on staff replacement, the Region's budget precluded full staff replacement (JCC September 22 1978). CHC teams were short of psychologists and baby health nurses. Psychologists at Windale CHC had to provide services at Toronto sub-centre and CHCs in the Upper Hunter and Port Stephens. Baby health nurses at Belmont and Charlestown were seeing large numbers of clients daily until an appointment system was implemented in the 1980s. At Charlestown BHC in the 1970s there ...was only one sister ... it was 40 a day, I can remember going in and asking for more help but it was refused because the Nurse Unit Manager at that time... didn't think it was necessary and they put on a petition actually, I got my wrist slapped because they thought I'd done it, but I hadn't, they had, the mothers had done it, to ask for extra staff. It was refused ... there was very little time for home visiting in that circuit (Baby Health Nurse Interview 12). A mothers' group worked to gain funds for a second nurse at Wallsend CHC. Vickers and Johnson supported two-nurse centres but there were no funds.

224 GCNs Faced Unreasonable Demands Some demands placed on GCNs were self-imposed such as managing to create a client base however, further demands were made by others external to CHCs and being ever-willing most agreed until they realised they could not cope. This problem began in mid-1975. One of the first unreasonable demands put to GCNs by team leaders was at the request of Regional Administrators. The instigator was Dr Dick Gibson, Regional Adviser on Geriatrics and Director, Aged Care Assessment Team, who in June 1975 began expressing concern that ‘family doctors’ were referring ‘Royal Newcastle Hospital patients’ to the Geriatric Assessment Team for further assessment. Gibson interpreted their actions as an indication of dissatisfaction with Royal Newcastle Hospital services or an attempt to gain admission via the ‘back door’ (SOC, 9.6.1975). At the July Conference he requested that GCNs provide an after-hours emergency domiciliary nursing care for ‘chronically ill and handicapped’ people. Krister responded by asking Vickers to convey his request to community physicians (SOCM, 22.7.1975). Community physicians referred this matter to GCNs, as senior nurses had yet to be appointed. Some GCNs were already offering after-hours care to their clients by this time. GCNs from across the Region met, having decided to trial an after-hours regional service. They devised a roster, which they circulated to hospitals and welfare agencies across the Region. I recall being on call one weekend and wondering what I would do with my sons if called to Singleton, a two-hour drive away. After six months, unused, the ‘after hours’ service was terminated but nurses continued providing after-hours care to their clients as needed. For example, my colleagues and I provided weekend care for clients with terminal illnesses for years until we approached Matron Punton at Wallsend District Hospital and she agreed to hospital domiciliary nurses providing this service. No such assistance was forthcoming for GCNs in East Lake Macquarie where, as team records show, many felt overwhelmed by incessant demands for home nursing care. Despite this situation Regional Administrators continued to ask them and others to take on additional time-consuming activities. GCNs at Windale and Newcastle CHCs were asked to conduct ‘brush-ins’ three times a year at infants and primary schools in their area. I recall the training day conducted on the oval at Newcastle Psychiatric Centre in 1977 where we learnt how to apply an unpleasant tasting fluoride paste to the teeth of young children. An attendance list illustrates all GCNs in the Region attended. Then in 1978 GCNs were trained to immunise children without a doctor present. In the late 1980s those at Westlakes CHC were directed to screen high school children for scoliosis. These activities were added to GCNs’ workloads following approaches being made to local Regional Administrators often by medical specialists. By 1978 GCNs in the east Lake Macquarie area were experiencing difficulty coping with their heavy home nursing commitments and brush-ins. In West Lake Macquarie they had difficulty taking accrued time-in-lieu, which they now lost if it exceeded 14 hours. In early 1978 industrial action began. The Acting team leader of Windale CHC agreed ‘brush-ins’ should be provided by dental therapists and advised Vickers that GCNs would no longer provide this service (TLM 15.3.1978). By April 28, following intervention by the NSW Nurses Association, Vickers had agreed that dental therapists would take over. GCNs at Newcastle West CHC continued providing this service but their home nursing loads were smaller.

225 Practitioners’ workloads varied. The availability of other services played a significant part as did the demography of the area. Practitioners’ recollections, Minutes of Joint Consultative Committee and New South Wales Nurses Association Community Nurses Hunter Branch meetings reveal that GCNs' workloads increased from 1975 and that they, like other practitioners, monitored their own workloads. They did not however do this well: they took on too much.

Strategies for Containing Growing Workloads The problem confronting practitioners was that initially, in trying to gain acceptance, they took on clients and virtually whatever other work came along. This was partly because they wanted to ‘do something’ as was expected of them. Monitoring their own workloads led to inequities in workloads within and between disciplines at a CHC and between CHCs. Practitioners began to consider how clients were allocated and how they worked with them. Fundamental differences became evident. Allied health professionals limited their workloads by using a traditional appointment system, one hour one client. Psychiatric nurses took a similar approach. Baby health nurses ran drop-in clinics and so had no control until they introduced an appointment system. Clinics in large centres like Maitland, Wallsend, Belmont and Charlestown were busier than other sites. GCNs accepted all referrals. They had no criteria initially for accepting or rejecting referrals until they made a home visit. One of their difficulties was that people's need for home nursing often increased before it declined. The outcome was that by the late 1970s GCNs working in the LGA of Lake Macquarie were spending most of their time nursing elderly, disabled, chronically or terminally ill persons. While Vickers directed GCNs to limit home nursing to 16 hours a week this edict was ignored by the senior nurses in these areas in the same way they had ignored his edict on opening baby health centres. Some senior nurses advocated for nurses, while some did not.

Tensions between Generalist and Specialist, GCN and HACC Nurses When HACC nurses were appointed to CHC teams CHC managers made different decisions. At Newcastle West CHC they decided to treat HACC nurses as they had treated Wallsend District Hospital domiciliary nurses, as GCNs. District nurses had felt included, if stretched, and while they remained ‘hospital nurses’ for some time (GCN Interview 19), they were encouraged to participate in new activities with more experienced peers. They were included in intake rosters in 1985 as were HACC nurses from late 1986. At Maitland CHC, HACC nurses were allocated a geographically defined area. Only Eastlakes and Westlakes CHCs teams decided HACC nurses would provide a ‘specialist’ service. Here HACC nurses provided care for elderly and disabled persons. In February 1987 GCNs were advised to check their caseloads for frail elderly and disabled clients and discuss their selection with the senior nurse who would then discuss their workload allocation with the Sector Coordinator (WLTM 4.2.87). On appointment HACC nurses were advised they could allocate 20% of their time to non-direct care activities. Some GCNs saw HACC nurses as a ‘revolution’ that gave them more time for health promotion as one explains:

226 …. we had eight generalists, but we also had the four Home and Community Care nurses ... their brief was home nursing five days a week so when the referrals came in, anything that was aged or disabled automatically went to them ... the generalists picked up the younger age group and palliative care... we were actually only required to do 16 hours hands-on nursing a week, whereas their week was five days a week hands-on. It was a lot more than we did. That caused problems, because I think by and large they saw us as bludgers. And they saw themselves as "HACC" they were the old Hack horse. And I think a lot of them thought that the school medical stuff wasn't really work, it's the old tale of nurses being so bloody … isn't it, that you're not a real nurse unless you're out there getting your hands dirty (GCN Interview 6) The HACC nursing program gave GCNs a means to pass over ‘a lot of the patients requiring menial care’ (GCN Interview 23). Viewing ‘hands on’ work as less valuable divided GCNs and HACC nurses, the latter feeling devalued and excluded from team activities. One HACC nurse recalls returning to Westlakes CHC to find the ‘team’ having a Christmas party (HACC Nurse Interview 9). It is likely this was an oversight but it fuelled dissatisfaction amongst HACC nurses who resented their managers for remaining unaware of their workloads (HACC Nurse Interview 9). They began their own education sessions to generate pride in their work. Many GCNs found providing home nursing to individuals with chronic illnesses, disabilities and terminal illnesses rewarding. By the early 1980s those at Westlakes CHC were feeling stressed. Like their peers elsewhere GCNs were driving long distances in cars without air-conditioning, accrued time-in-lieu was harder to take, case loads were growing, and many were overwhelmed by home nursing, so much so that nurses were swapping ... caseloads because sometimes we all have difficult patients and patients who are really demanding. I mean, if you have a patient who does need care for three hours a day, that's a reasonable long amount of time. If they need counselling and that, they can be also mentally draining as well. People were better off to move around, to find staff who don't find that mentally draining, let some other staff do it (GCN Interview 23). GCNs here had been trying to reduce their home nursing responsibilities for some time. It is not, therefore, surprising that some saw HACC nurses as a way to reduce direct client contact. The decision to allocate ‘hands on work’ to HACC nurses, however, reflects managers' interpretation of the HACC nursing program.

A Poor Solution to Inequitable Workloads By the later 1980s this situation had changed with GCNs and HACC nurses being allocated sufficient clients to ensure each provided six hours ‘hands on’ care each day. Psychiatric nurses were not affected, for as one explained ... when referrals were given out it was up to the people to say "Well, I have got time to take that," and once again, in Mental Health as in other ways, there were people who never had time who worked the system to suit themselves. So you would have some Mental Health Workers who would be flat out all day and somebody else who would be saying "I cannot take any more. I have got two visits on this day" (Psychiatric Nurse Interview 44). This, as a mental health nurse with experience working at Windale and Maitland CHCs observed, was because psychiatric services had not developed a measure:

227 ... there has never - and there still isn't a measurement for case load monitoring.... How much can you do? ... It's something that has been in the general - generalist nurses case load - I can remember - can go back many years... there was a chart, you know, and people were able to record ... your client list ... fairly static, and, you know, you'd probably have someone for three months because they had a dressing on their leg, and ... a very clear discharge. With mental health ... how could you put people on a list? One week you've got them, the next week they're gone, the next week back - and they're between areas and, you know, it seemed an impossible sort of a task to try and ... measure, you know, what your case load is. So as a result people just keep building up and building up and building up (Psychiatric Nurse Interview 44). The system then operating required ... a degree of trust. Most people did not abuse the system - there were the odd one or two who did abuse the system, and everybody knew it (2).

Too Many Cars Then too Few By the early 1980s gaining access to a car had become important. In 1975 practitioners were allocated cars to drive to and from CHCs. While private use was prohibited it was expected that they would clean and maintain their vehicles and arrange repairs and registration inspections. In 1976, as mentioned earlier, problems arose from a decree about garaging cars at local hospitals. This decision was rescinded but easy access to cars was lost for allied health and psychiatric nurses and those working mostly at CHCs. Field workers and GCNs were allocated cars which others could use, but were expected to clean them until the NSWNA established that the Commission was responsible for this activity. Team leaders were advised to walk to meetings held under 2 kilometres from the CHC (Psychiatric Nurse Interview 2; Allied Health Interview 68). Practitioners working 50 or more kilometres from their residence had to drive their own cars to work. Team leaders retained cars but few CHCs had sufficient vehicles. HACC nurses' air- conditioned cars were a sore point with GCNs at Westlakes, a hot area in summer. A battle for air conditioning had been fought and lost in 1976 after which seat and steering wheel covers were issued. Some GCNs saw HACC nurses as having a ‘better deal’ because they had ‘air conditioned cars’ an important issue as their cars got hot. As one GCN explained they ... looked at the thermometer in my car one day and the temperature on the dashboard was 51 degrees. And I thought that it wasn't really all that safe to get in a car that was 51 degrees (GCN Interview 23).

Most Practitioners Focussed on Clients Practitioners mostly worked with individual clients. Some community physicians conducted school medical examinations and most non-medical team leaders provided services. Senior nurses focused on managing centres. Those at Eastlakes and Newcastle East CHCs sometimes carried a small client load. Workload problems increased for GCNs especially in Lake Macquarie. Psychiatric nurses also experienced problems, client numbers increased but their numbers did not. Practitioners juggled time. To control their workloads it was necessary to refuse referrals, close their books, or cease participating in health promotion activities. A GCN working in a rural area refused to accept clients needing palliative care as

228 BHC clinics and school medical services precluded her meeting their needs (GCN Interview 29). Instead she referred clients to a private nursing service. GCNs juggled time to participate in health promotion activities, health education and community development. This led them to set priorities in the early 1980s.

Administrative Innovations CHC practitioners worked in defined catchment areas in which the proportion of young, aged and adult persons and their socioeconomic, educational, and cultural backgrounds varied. Different communities within CHC catchment areas had a greater or lesser proportion of advantaged and disadvantaged persons. Their clients included individuals, families and population groups experiencing mainly self- identified problems of a psycho-social, developmental, behavioural, psychiatric and physical nature some of which were amenable to short or long term treatment or support, if not resolvable or curable. Problem Based Records influenced how practitioners conceptualised the purpose of care and focussed their attention on problems. Other mechanisms were introduced to increase access to relevant services and monitor progress, these being case review and then intake. These strategies were innovative, they meant that work with clients was monitored and increased generalist skills.

Concern about Client Needs and Progress Lead to 'Case Review' and 'Intake' CHCs introduced a system of allocating referrals at team meetings in 1975. Referrals, most taken by a receptionist, were taken to the meeting by team leaders and following identification of a person's problem and area of residence allocated to the most appropriate practitioner. Thereafter practitioners monitored the progress of their clients. Concerns were discussed with peers at meetings and in tearooms or on the phone. A more formal system was introduced in 1978. The acting team leader of Windale CHC presented the benefits of a ‘Case Review’ system at a routine team leaders' meeting in early 1978 (TLM 15.3.1978). Team leaders discussed the system with their teams all adopted it. I visited Windale CHC to observe and report back. Case Review had several benefits for CHC teams. It provided a means of monitoring client progress and fostered inter-disciplinary discussion and collaboration. Practitioners wrote information about their clients on a card, which went into the review box, outlining their situation, problem, interventions, progress and when they intended to discharge them. A further benefit was that practitioners could discuss their clients' mental health and physical problems with the whole team. The need for interdisciplinary referrals was reduced by this system. It also enabled issues of dependency to be identified and alternative methods of management to be addressed and tried. New clients were reviewed and the practitioner concerned specified whether they wanted, fortnightly, monthly, three or six monthly reviews. This system promoted the use of time-limited contracts, rather than ongoing open-ended contact. An intake system was introduced in 1986. The aim of this system was to increase people's access to relevant services. All practitioners were rostered to ‘intake’ for half a day per month during which time they

229 responded to requests for assistance from people who dropped in or from telephone referrals to their CHC. No one was excluded from this duty except receptionists. The benefit of this system, as one Area Coordinator argued, was that it provided referring agencies and people seeking assistance with access to a health professional (NWTM, 1.8.1985). Instead of a receptionist's taking information and passing details to a practitioner to make an appointment to assess a potential client, intake enabled a preliminary assessment to be conducted, documented, and any necessary action taken immediately. Access was increased. Practitioners taking referrals could obtain sufficient information to assess if the CHC could assist and if not refer on immediately and make relevant appointments. Newcastle West CHC was the first to adopt this system. Sub-team members at Lambton were resistant to this system, only introducing it after being instructed to have a roster proposal ready by August 19, 1985 (Correspondence Armstrong 1985?). Practitioners at Maitland CHC introduced it in 1986 with seemingly little or no objection. Westlakes CHC team introduced it when the Area Coordinator for Community Health directed them to have an intake roster involving all practitioners for half day a fortnight ready by April (Correspondence 15.4.1987). The problem here concerned GCNs and HACC nurses since introducing this system required a change in the division of their work. Practitioners at Eastlakes CHC also introduced this system in 1987. There was resistance. Some practitioners were opposed to being rostered to the CHC while others felt inadequate and unqualified for the responsibility this system imposed on them. CHC managers viewed intake as staff development activity, a way of increasing practitioners’ telephone counselling skills and also giving opportunity to keep up to date by reading professional journals or completing paperwork between calls. An additional advantage for practitioners mostly based at CHCs was that it freed up cars, now all pooled. Intake, like case review, also offered teams a way of monitoring ‘expressed’ need, requests for assistance, and the activities of practitioners. A further administrative benefit was that practitioners increased their understanding of the reasons people sought assistance from CHCs.

Helping People Help Themselves Initially practitioners assessed clients' needs, offered services, monitored progress and decided when care was no longer required. Many clients had long term contact with practitioners. Some sought to foster independence, self-reliance and an ability to make decisions, yet recognised this was not always possible. One psychiatric nurse, conscious that how she worked with clients had implications for their progress explained that she chose to treat them as ‘competent, as able to do things, rather than as fragile and sick' by working ... very much on a review system monitoring people so that when I think they're at a stage where they can "go it alone" or if the GP's involved I can refer back to that service saying "we're here as a back- up, if you need us - call us if you need us". I think my idea is to try and break down some of those barriers, myths that once you're mentally ill, you're mentally ill forever. I try to get people involved in the general health care system as much as possible with whatever amount of input is needed from us, whether it be minimal or maximum, you know. I don't believe in just visiting someone for the sake of

230 visiting them. Once I think somebody's stabilised and doing well I'm quite happy to say "You call me if you need me" (Psychiatric Nurse Interview 44). Her clients were encouraged to use mainstream services and seek assistance as required to foster independence. Reasons for referral were discussed with clients to see what they thought they needed. The reason, as she pointed out, was that people's circumstances often changed between the time a referral was made and when she saw them and she wanted to understand the client's perspective. Her role, as she saw it, was to assist clients resolve their problems. She saw herself as a resource. As she explained, mental illness impinged on some people’s competence to make decisions some, not all, of the time. Practitioners fostered self-help. One GCN recalled a number of elderly men, all ex-sailors, referred to her for social reasons, they were lonely. As they lived in the same area she decided to encourage them to get together and with their permission she gave them each other's contact details and left them to contact one another (GCN Interview 42). Promoting self-help was how one GCN saw her role. She encouraged people to contact others with similar problems and contact her as required. As she explained ….I get people who are sick and old to help other people. I get them involved. I offer them options ... try and tap into resources. I do a lot of work in choosing people to actually join groups and to help each other. I spend ... energy on that ... I feel we have to be careful ...of them being too dependent (GCN Interview 29). Instead of making regular home visits some practitioners tried to work differently. Nurses took similar approaches with clients whose ability to live independently was hindered. A HACC nurse explained the importance of assessing needs, answering questions, and helping people make decisions. Instead of assuming a client referred for assistance only required what was requested they looked for other problems and involved clients in decision-making. Some described their approach as empowering, others as educative. They learnt to state what they could and could not offer clients. As one nurse explained ‘when I meet up with a client I tell them what I can provide for them’ as an ‘orientation’ so they have ‘a clear picture of who I am’ and my qualifications (Psychiatric Nurse Interview 44). Baby health nurses and allied health practitioners were less explicit in describing their approach, maybe as clients came to them with more focused problems. GCNs and Psychiatric Nurses, on the other hand, often saw people with long term medical and psychiatric problems and associated psychosocial problems. They saw their responsibility as assisting people to learn strategies, techniques to resolve or reduce the impact of their problem on their lives. They promoted self-help, peer support, helped establish self-help groups, and involved families in decision-making. As one nurse explained she learned to look: ... at the whole family as opposed to how we used to work when we just looked at the client. Often you look at a referral and think there could be problems at home. You ask is this person suffering from schizophrenia? How is she or he managing at home? There's are a lot of clients living with families here unlike in town so you do have that family conflict, you do a lot of conflict resolution. You know "What are we going to do, he plays his stereo until 3 am in the morning and we're expected not to say anything because we'll upset him"- so you get every member of a family involved and provide some guidelines on how to resolve this. You do a lot of that. Just seeing the doctor would be the answer for this particular person. You need a team approach. (Psychiatric Nurse Interview 37).

231 They considered clients' relationships with their families. Assisting people with a psychiatric illness gain confidence in their own ability to improve their quality of life was important and could include getting them ‘out of the house’ as: ... sometimes they spend too much time with their relatives, so you look for a bit of respite, family support programs, sometimes you know looking at the overall budgeting skills that they have. That is often a vicious circle which creates problems within the family so we have a budgeting course over at the neighbourhood centre, just working on a support with them, empowering them to do things for themselves. Quite often you hear "Well I've got this illness, I really can't do anything" and they really need to be told, you have to be their advocate, tell them that they can do this and this, but they won't believe that they can, but you work on this sort of thing. It's amazing, they need someone, you need to be there, encouraging them to do it, telling them that they can do that, then you can start to withdraw with a monthly visit or do a follow-up visit. But it's much more intense now, as opposed to how we worked in those early years (Psychiatric Nurse Interview 37). This nurse, like many peers, saw contacts with clients as an opportunity to increase their understanding of their condition, options, resources, and foster their strengths to promote independence. Clients were encouraged to take responsibility for their care. This could involve helping people to learn to mix with other people by attending a day centre or group program, or teaching them to attend to their own or a family member's wound dressings or insulin injections. I recall a psychiatric nurse accompanying a client who had agoraphobia as she tried to leave her home, first into her garden and then the street. Nurses tried to make their clients' experience with CHCs positive, to build on their strengths and foster trust in, and their ability to use, other services. Most considered continuity of provider as a means to foster independence when appropriate.

Continuity and Dependence While some GCNs at Westlakes CHC began swapping areas and clients in the mid to late 1980s this was a new and uncommon practice. Clients of CHCs generally saw the same practitioner. Continuity of carer and care were usual. This raised concerns for some practitioners involved in home visiting. Clients attending clinics could control if and when they saw a practitioner. Those receiving home visits had less control and were thus vulnerable to over-servicing or unwanted services. Practitioners working with elderly, disabled, frail clients with chronic health problems saw them as vulnerable and likely to become dependent on them and the services provided. This was not in the best interest of clients, in the view of most practitioners. The problem, as one GCN pointed out, was that many of the elderly people she visited were isolated. As the only visitor of some clients she felt responsible for their wellbeing and expected them to depend on her. Establishing a trusting relationship in her view was crucial to their care. Her approach was to treat them as friends, not patients, although ….I'm not supposed to, but that's how I treat them. Not actually a friend - I can't explain. I don't treat them as a patient. I treat each one of them as a special person. They're all special, and they all feel special...They know that I've got other people that I see, but each person thinks that ... they're the special one, because they are all special! I try and support them and I'll sit there and listen to them, I won't rush off, I'll just sit there and listen and talk to them and try to help (GCN Interview 39).

232 For this nurse developing a caring relationship was important. Working with people who had long term problems was rewarding and valuable, not menial. She accepted that physically isolated clients might become dependent but tried to use this therapeutically to promote independence. Practitioners recognised that some clients, because of their circumstances, their health or social problems, had a limited capacity to be truly independent of health service providers. Nurses also used knowledge gained from work with individuals to identify population needs.

A Community Perspective Working with individuals over time increased practitioners' understanding of their situations. They began to see patterns and this provided a catalyst for developing new approaches. For example, practitioners began to find schoolteachers, parents and carers seeking assistance with children who had behavioural problems. Instead of seeing individual families they developed a parenting program to help parents learn new ways of interacting with their children. After conducting a pilot program they rewrote it with the …. families who'd been through the program... we also did some unusual things... we had the children present ... the rationale being, that you can tell people lots of things, but unless they're involved in implementing it, they don't understand – they don't... maintain it (Allied Health Interview 30) Conducted initially for residential care workers caring for children with behavioural problems it was extended to parents. This project was taken over by parents. A speech therapist, confronted by high demand for assessments and treatments, trained volunteers to work with children at local schools and developed a tool for GCNs to use during school medical examinations. A recurrent head lice problem was addressed by producing a video and a pamphlet and running a personal development program for year six students (MacKenzie 1982). Another GCN, identifying lack of knowledge about health issues, started a health information stall at an annual small farms day conducted by Tocal Agricultural College. Raising people's awareness of the high proportion of farm accidents involving children led to the development of a farm safety program for farmers and schools (Allied Health Interview 30; GCN Interview 29). A GCN whose clients had Alzheimer's disease, aware of carers’ need for support and respite, established a volunteer visiting and sitting service. Another GCN, finding elderly and disabled people were prevented from visiting doctors and shops through lack of transport, worked with community groups to gain a community bus. Other GCNs, aware of high teenage pregnancy rates worked with family planning educators to develop a personal development program for apprentices in local industry which focused on relationships, safe sex, contraception and sexually transmitted diseases. Practitioners worked with individuals but they developed services in response to problems identified through work with clients.

CHC Work Expands Nurses’ Responsibilities and Awareness Working in multidisciplinary CHC teams helped practitioners develop as professionals and people, as they worked to achieve specific goals and became more aware of people's circumstances. Nurses, especially, found their long held beliefs concerning their professional responsibilities were challenged through close

233 contact with allied health practitioners and ongoing education. Working closely with practitioners from different discipline backgrounds, and long term contact with clients, led practitioners from all disciplines to reflect, looking at themselves and the way they practised. As one psychiatric nurse observed she ‘…changed, so my work practice changed’ she moved from being ‘fairly rigid and concrete’ very ‘black and white’ to seeing ‘a hell of a lot grey’ (Psychiatric Nurse Interview 2). Another GCN explained that they changed from being a ‘very rigid’ and ‘fairly intolerant individual’ who worked in isolation and ‘couldn't really see, for a long time, the benefit of team input, to anything’ (GCN Interview 64). Another reflected that had they continued working in a hospital they would have remained ‘the same narrow person I was’ instead of being able to say ‘I can do this’ (HACC Nurse Interview 9). Another felt working at a CHC allowed them to become their ‘own person, get rid of, work out a lot of inhibitions and stop sitting on the fence’ and start making decisions (GCN Interview 45). Working closely with nurses provided some allied with opportunities to work closely and collaborative with nurses who they came to view as colleagues.

Clients' Expectations Working as case managers, providing personal and other care, for weeks, months and even years pushed practitioners to see their clients' problems from the latters’ perspectives. As one allied health professional explained, they started to take a broader approach and become ‘much more aware of clients and their problems and their difficulties’ and to become more realistic and able to consider a person's circumstances, their family set-up and their ability to even understand what is being asked of them and to question why ... they did not keep their appointments. Maybe what I was asking them to do was unrealistic, maybe there were so many constraints on them that they could not do it anyway, and then there was no method of getting help ... if they did not come to me. (Allied Health Interview 28). Practice issues were considered more broadly along with different approaches and different ways to address problems. Practitioners learnt to enjoy working in generalist teams and regretted the shift to specialist teams as it narrowed their opportunities. One GCN explained ... when Community Health was first set up I think you were given the opportunity to just explode in a way, with your skills if you wanted to, and that is how I saw it and I certainly tried to take some of the opportunities, and I think that is why I kept trying to educate myself to keep up those skills or to broaden them rather than just staying in just strictly a nurse practitioner role (GCN Interview 6). As members of generalist teams, practitioners had opportunities to accept new responsibilities and develop new skills and to draw upon the skills of social workers and other nurses (Baby Health Nurse Interview 12). While women were familiar with baby health clinics people were less aware of services offered by CHCs as one GCN recalls: …I do know that they weren't very informed about the service. That was pretty sad I thought. Sometimes I'd get calls to go to patients who'd say things like "We wish we'd known about you two years ago", and we really rely on their GPs to pass the referrals on to people like us (GCN Interview 7). By co-locating different services women, at least, became aware of CHCs and the services they offered.

234 Teambuilding and Interdisciplinary Collaboration External facilitators were used to assist in team building when baby health and school medical teams were assimilated into Maitland and Windale CHCs teams in 1976. Outcomes varied. The process was seemingly successful at Maitland with practitioners feeling that some team cohesion and trust developed. Another workshop was held in 1985 when the team from Singleton CHC was integrated and the Cessnock sub-team separated off to form a Northumberland CHC team. The focus this time was on ‘what do you want the team to achieve?.’ Again the experience was seen as positive. Then in 1987, when Area Health Boards were established, the team held a planning day in recognition of stress created by organisational change which addressed the issue of ‘job satisfaction ― what it means to you’. Outcomes for this CHC team were generally positive. Practitioners at Windale CHC had a different experience. In the view of some who attended, the use of encounter group techniques in 1976 fostered divisions between baby health nurses and GCNs which grew over time (Allied Health Interview 54). When practitioners here were divided to form two CHC teams Eastlakes and Westlakes nothing was done about team building. The Westlakes CHC team started team building activities in December 1986, seven years later. The catalyst for this decision was the problematic relations between practitioner groups, mainly GCNs and HACC nurses and centre managers over the uneven distribution of home nursing, as well as personality conflicts and poor facilities. Practitioners at Newcastle West CHC began team-building activities in September 1984, immediately it was established, in order to establish and foster a collective ethos. These activities were undertaken during team meetings. Armstrong wrote to Regional Office requesting $10,000 to cover the cost of team training and consultation as ‘essential and integral to a multi-disciplinary Generalist Team’ (Armstrong to Miller 10.10.1984). He also requested that baby health nurses cease attending education sessions conducted by the Child and Family Psychiatry and the Child Development Teams. His reason, explained in a letter to Geoffrey Rickerby, team leader Child and Family Psychiatry Team, was that he wanted to emphasise a normal rather than psychiatric approach to assessment and care (Armstrong to Rickerby, 9.8.1984). Collaboration between CHC practitioners was facilitated or hindered by decisions concerning resource use, in particular how office space was used. At most CHCs allied health practitioners were allocated single rooms while GCNs and later HACC nurses shared. Different disciplines had more contact at some CHCs than at others as one explained at Maitland ... the fact that here nobody has an office, so you cannot shut yourself in and worry anymore, which you used to be able to do. At the original centre some of us had our own little offices and could shut ourselves away. It was certainly a big thing at Parry Street. You all had to have your little room, and while we might complain now about 13 of us working out of the one room it does make for much better working relationships ... … It is hard to explain but you see more of people, find it easier to grab them and discuss things. You do not tend to ... build up a resentment or a personality ... it is hard to explain. I mean, if you have got to share an office with 13 people you have got to get to know them, you have got to get on, and I guess that happens with 13 in one office and 8 in another. And you learn to get to know people very quickly. You also learn to make allowances ... You overhear phone calls. You overhear the hassles

235 people have. You have to get to know how other people work ... While in a way it can be distracting, it seems to make for better working relationships (Allied Health Interview 28). Whether practitioners felt part of a team depended partly on how they came to work at a CHC and their opportunities to develop new skills. Those who chose to work at CHCs felt part of a team more quickly than those assimilated into CHC teams via restructuring. However, team records and interviews illustrate different disciplines worked together for specific purposes, for example they consulted when concerned about clients and sought assistance with health promotion activities. Members of all practitioner groups participated in school projects conducted in the Maitland area. Practitioners, in general, learnt to draw upon the skills and abilities of colleagues and sometimes volunteers.

Working with Volunteers Practitioners started programs they handed over to volunteers. For example, allied health practitioners developed a parenting program and screening programs which parents continued (Allied Health Interviews 28, 30). Pre-school educations programs were handed over to pre-schools. Elderly people continued a social program established by a GCN (Senior Nurse Interview 2). Women who attended a menopause group continued meeting for several years (Personal Recollection). Volunteers helped run day centres.

Impact of Area Boards CHC teams commenced as a collection of individuals working in relatively autonomous organisational units. Administrative control was imposed over time as they were integrated into regional health care systems along with hospitals. Change began in 1985 when selected district hospitals, Wallsend and Maitland, became administratively responsible for all CHCs prior to hospital boards being disestablished to form four Area Boards. During this period administrative staff at these hospitals were introduced to the operational procedures used by Regional Offices. When four Area Boards were formed in 1986 CHCs and nursing were represented. Appointees to the Lower Hunter Area Board included the Director of Nursing of Maitland District Hospital and senior nurse from Maitland CHC. Team leaders, now Sector Coordinators, Community Health, were able to use this formal structure to keep Boards informed of CHC activities (Correspondence, Merriman March 1987). CHCs in Greater Newcastle had little contact with their Area Board. Four boards and Regional Office were disestablished within a year to form one Area Health Board established for the entire Hunter Region. The Chair of the new Board, Judge Varnum, appeared uninterested in CHC teams or the services they provided. The new Regional Director of Nursing, Margaret Marks, previously Director of Nursing, Royal Newcastle Hospital, expressed some interest, visiting Newcastle and Westlakes CHCs and accompanying a GCN on home visits (Senior Community Nurse Interview 2). The Westlakes CHC team invited the Chair of the new Board to visit to enable them to ‘showcase’ their work and appraise him of their difficulties. After several cancellations he declined (WLTM 21.10.1987).

236 In Summary During the 1970s practitioners felt active and purposeful. They reached out to other service providers, started identifying local needs, and responded by offering new services. They worked alone, with team members and employees of other organisations. They felt accountable for the clients and populations living in their CHCs catchment area. Their awareness of people's needs increased. Most worked with individual clients. Increasingly their work was undertaken from a position of understanding the circumstances in which people lived. They began trying to improve people's circumstances, by involving colleagues and other organisations, by increasing the resources available to them. Planning, short and long term, became a normal part of practice. Practitioners planned their year, teams planned for longer periods. An ongoing lack of resources, fiscal, human and material, hindered this process. By the time regional planning started in the early 1980s practitioners were concerned about growing workloads. GCNs in particular had begun to examine ways to gain control. In some teams they decided to give priority to providing one-to-one services rather than remaining involved with health promotion, health education and community development. In working with clients they continued to promote independent decision-making and take an educative approach. Most practitioners considered how they provided services to be as important as the type of services provided. Thus the CHP policy was being implemented. The delivery of health care services was evolving as envisaged, with concern for preventative measures, population health and community involvement. Running counterpoint to a story of successful implementation, however, were other trends. Allocation of diminishing resources was the responsibility of Regional Administrators, not all oriented to CHP policy or supportive of it. Further, the differences between the outlook of original practitioners oriented to that policy and enthused by it and the outlook of those not so oriented, community physicians and practitioners enlisted later in difficult times, placed limits on the success of policy implementation.

237 CHAPTER 10 CONCLUSION: POLICY IMPLEMENTATION BUILT SOCIAL CAPITAL IN A DISADVANTAGED REGION … There is nothing more difficult and dangerous, or more doubtful of success, than an attempt to introduce a new order of things … For the innovator has for enemies all those who derived advantages from the old order of things, whilst those who expect to be benefited by the new institutions will be but lukewarm defenders. This indifference arises in part from the fear of their adversaries who were favoured by the existing laws, and partly from the incredulity of men who have no faith in anything new that is not the result of well-established experience. Hence it is that, whenever the opponents of the new order of things have the opportunity to attack it, they will do it with the zeal of partisans, whilst the others defend it but feebly, so that it is dangerous to rely upon the latter (Niccolò Machiavelli, 1512). Although the array of available options, each having a certain net gain or cost to the chooser, will shape the direction of choices made by practitioners or consumers, this does not mean that they are wholly determinative. Rather this suggests that only a small proportion of any group of people may be expected to choose an option that requires a high cost to themselves in return for what they gain. … Most people will most often choose the least costly options available. (Milio 1981, p.97).

Introduction The previous Chapter discussed how practitioners implemented the CHP policy. It illustrated that they did indeed develop something new, a different type of service wherein traditional modes of practice changed over time. It illustrated that practitioners' interpretations of the scope of their responsibilities varied and that while practice changed, a complex array of volatile situational influences beyond their control affected what they achieved. This final Chapter discusses the findings, significance and limitations of this study as well as implications for further research.

Reflections on Key Findings The essential key finding of this study was that practitioners changed the way they practised once they began working at CHCs. As an organisational environment CHCs provided them with opportunities to work and learn with other discipline groups and exposure to populations and communities that sensitised them to the circumstances in which people lived. The effect on some practitioners was that they became concerned about population health and helping people resolve their problems. Over time practitioners, especially GCNs, abandoned a narrow professional focus to one on people's needs. In trying to address people's needs they began crossing the boundaries which had until then separated different types of services and different levels of services or sectors. Before beginning a discussion of the key findings of this study, its purpose needs to be restated. The purpose of this in-depth descriptive case study was to answer one broad question. How was the national CHP policy implemented, in what context did this event occur, what processes were used and why, and how did generalist community nurses participate?

238 Implementing the CHP Policy The findings show that by the time this study began the CHP policy had been implemented quickly by a myriad of organisations, without the protection of enacted legislation, by a short-term federal government. Funding for the CHP policy, as is commonly the case with federal policies, remained vulnerable to changes in political circumstances. What this study found in relation to the Hunter Region is that while the NSW government implemented this policy vigorously through a new Health Commission and newly formed Regional offices, the same unstable situation was replicated at a state and regional level. The CHP policy was implemented relatively quickly with little infrastructure and no guarantee of a sustained level of funding, through regional offices staffed by public servants with little or no understanding of its intentions. All who participated in implementing the policy in the Region effectively learnt on the job, even the nurses employed prior to late 1976 who had been orientated to the intentions of this policy. Situational influences, outside and within the Region influenced how the policy was implemented and what was achieved. In the Hunter Region political decisions limited funding and impacted on the implementation process at a critical stage − as recruitment for, and appointment to, generalist community health teams commenced. This set the scene for the future. The historical circumstances in which the CHC policy was implemented laid the foundations for what followed. Context was important. The CHP policy was compatible with the NSW government's own plans to establish a CHP which, like the national policy, sought to combat the endemic maldistribution of primary and other health care services. Instead of allowing non-government organisations to obtain funds as occurred in other states, the NSW government tightly controlled implementation, vetting all submissions for funding, obtaining a block grant and dispensing funding at will. The plan was to consolidate resources to enable more effective and efficient use by creating integrated coordinated area systems administered by Area Health Boards. This bold, rational, but contentious plan threatened the autonomy of powerful stakeholder groups. Neither this proposal nor the CHP policy was radical. Rather, they were policies reflecting ongoing concern about the cost and organisation of health systems and how professionals practised. The increasing segmentation symptomatic of contemporary health care systems was incompatible with the health care needs of total populations. In the Hunter Region the officers initially responsible for implementing the CHP policy were committed to change, to improving and broadening the breadth of services provided by the health care system. However, a less than vigorous approach was taken in the Hunter Region which was poorly resourced. The vision in the Hunter was to take a slow, incremental approach to building a CHP as needs were identified and qualified staff became available. As this study has found however, implementation lurched along from one funding crisis to another as the State government's fiscal problems created difficulties that were later compounded by a myriad of decisions taken at a local level by subsequent Regional Administrators. Responding to criticism that the CHP policy was implemented too quickly, and that this was the cause of its problems, Sax argued that speed was not inconsistent with good management (H&HSC 1976, p.21). While implementation began and progressed more slowly in the Hunter Region, the

239 term ‘good management’ does not spring to mind when exploring how this process occurred during the critical early years. Yet despite poor administration and little leadership, a diverse range of new services was developed, directed at individuals with existing health problems and those with the potential to develop health problems. Practitioners were guided by their growing understanding of people's needs and the circumstances in which they lived. The significance of psycho-social influences on health was also recognised. The implementation process began and continued in a politically and organisationally unstable environment. New programs need advocates: committed, persistent officials who are willing to overcome resistance from opponents. Many who participated in implementing the CHP policy in the Hunter Region were of this ilk. However, a leadership vacuum existed for much of the period of interest to this study at a Regional and state level. Powerful local stakeholders played a part, opposing the cultural and structural changes inherent in the CHP policy and the other policies the government tried to implement concurrently, to rationalise general hospital beds and to establish a regional health system. The one condition for effective implementation present when implementation began was that the CHP policy was a good policy. The H&HSC (1973) policy document was not, in my view, ambiguous nor were its goals fuzzy. It was however open to interpretation depending on who read it and what views they brought to their reading. Had its goals been more specific, implementation would have generated further resistance. The intention was to develop a broad range of accessible, responsive and relevant primary health care services and to promote attitudinal change amongst service providers and users. H&HSC Commissioners, predominantly public health advocates, considered GPs and community nurses as central (Sax 1972a; H&HSC 1973). The policy document sought to change how doctors and nurses practised for sound reasons. These professional groups provided first contact and ongoing care for the very young, frail elderly, families, and persons with chronic illnesses or disabilities − groups the health care system tended to ignore and who had most to gain from routine use of preventive strategies. Internationally, community nurses had a tradition of working preventively with disadvantaged and poor populations, women, the very young and the elderly. Their work involved assisting individuals in these populations to access relevant services and gain skills to better care for themselves, their children or families, by offering timely and relevant information and assistance. GPs had similar opportunities but the literature indicates this group rarely worked preventively with clients or took a population focus. The CHP policy was intended to influence how GPs worked with non-medical practitioners, especially with community nurses. The findings of this current study reveal that the decision to establish CHCs was sound. A forty year experiment conducted overseas since the 1930s suggested they were effective in changing how various disciplines related to and worked with one another, how they conceptualised problems presented by their clients, and how clients used health services (Alford 1975; Andrew 1971; Andrews 1973; Beloff & Korper 1972; Gordon 1972; Gross 1973; Hall 1973; Lewis 2003 vol.2; Pang 1973; Pearse & Crocker 1943; Silver 1963; Swanson & Nies 1997). Co-locating different practitioner groups at CHCs appeared to shift them away from a curative disease orientation towards a more generalist probabilistic preventive orientation.

240 Such environments afforded practitioners what Milio (1981, p.95-96) would describe as opportunities for choice making. The administrative structures, organisational policies and funding mechanisms of CHCs fostered changes in practice and promoted a culture which fostered multi-disciplinary teamwork based on understanding of each other's roles and responsibilities and a growing understanding of community and client need. H&HSC (1973) Commissioners like Sax saw understanding this need as central to the CHP policy. As he explained to me in an interview the idea was that GPs and general nurses, the ‘basic team’ would ‘relate to a defined geographic area’ to ... get to know a local community, and we used words like "the confidence that comes with familiarity". If a local community gets to know its primary health care workers and respects them, and has confidence in them, who listen to what they say... (Sax Interview 1991). The CHP policy was not conceptualised as a consumer movement: this was not ‘the NSW concept of community health services’. Rather the emphasis in NSW was to promote more appropriate and opportunistic use of allied health and nursing skills by the public and GPs. GPs in Australia, unlike their peers in the United Kingdom, lacked a tradition of working collaboratively with qualified community nurses, health visitors or district nurses and midwives, whose responsibilities were defined, legislated and reinforced by mandatory post registration education. Baby health nurses came closest and relations between this group and GPs were variable. Structural and attitudinal barriers limited GPs’ access to, and contact with, community nurses. Similarly staff employed by general hospitals, unless the hospital had a district nursing service, had no tradition of referring persons discharged or denied admission to hospital, to a GP or a community nurse to ensure continuity of care. Referrals occurred, as the literature shows, but this practice was not routine. The paucity of community nurses freely accessible to GPs and to the public, independently of hospitals, acted as a barrier to change. Australian health care services, mostly funded from the public purse operated separately, divided by payment systems, sectional and professional interests. Competition was the norm. To encourage GPs and the public to make more appropriate use of the services offered by allied health and nurses, structural barriers to access had to be removed. In proposing the establishment of CHCs the CHP policy offered a new structure for facilitating cultural change. However, the H&HSC (1973) observed that teamwork would be hindered by differences in employment conditions and status. Teamwork, ‘coordinated action, carried out by two or more individuals jointly, concurrently or sequentially’ implies practitioners share ‘commonly agreed goals’ and understand and respect each other's contributions to the problem at hand (WHO 1988, p.6). Herein lay the problem that needed addressing. The organisations and professionals who collectively comprised the health care system did not have common goals (H&HSC 1976; Sax 1972a).

Aspects of Context The findings of this study revealed that when implementation of the CHP policy commenced in the Hunter Region the context in which this occurred had major implications for what was achieved. None of the circumstances identified in the literature as essential for effective policy implementation were present. The

241 national CHP policy was fortuitous for NSW. Deinstitutionalisation was under way in the Schedule 5 sector but plans to build nurse centres in under-served areas and attract GPs by offering facilities for rent, rationalise general hospital bed use, and create regional health services, had stalled for want of funds and agreement on structural and process issues. A malfunctioning state bureaucracy added to the state's administrative problems (Wilenski 1986). The government wanted to take greater control of the state health care system, but while some officers wanted to devolve responsibility for administration to regional administrators, others wanted to maintain central control (Alaba 1994; Duckett 1983). Implementation of the CHP policy began under a Coalition government and continued under a cautious Labor government. The process commenced and continued in a volatile bureaucratic context beset by fiscal problems and poor Ministerial leadership. The tensions arising were played out in the Hunter Region. The Hunter Region was not defined as an area of health scarcity but it had its own problems. As this study indicates, the Hunter population was socially and economically disadvantaged, with a legacy of heavy industry, limited opportunity and economic dependence. A geographically isolated Region, its population remained culturally insular and distrustful of outsiders. Locality and occupation determined loyalties and social networks for this predominantly blue collar population, amongst which education levels remained low, unemployment high and many men continued working in dangerous industries. Traditional, conservative values dominated in what evolved as a politically and economically divided region. A shift in the economic profile, from an industrial to a service economy, from the late 1970s to the mid 1980s created social disruption and personal turmoil as employment opportunities closed for local men, while they opened for women and attracted new residents to the region. The Hunter population remained disadvantaged, its health poor, with death rates for men remaining high. Socioeconomic differentials increased. Local circumstances put the population at risk of risk as illustrated by high death rates for preventative illnesses and high rates of admission to general hospitals into the late 1980s. The health services accessible to the population in 1975 were not the most relevant to their needs. There were few ambulatory care services or services directed at assisting individuals, families or population groups to address psychosocial problems known to arise from their circumstances. Local hospitals remained parochial closed shops where tradition and culture emphasised their own progress and the superiority of their nurses and doctors. Boundaries were tight, trust limited to their staff and with regard to nurses, their graduates. The culture of hospitals remained authoritarian. Traditionally the Hunter population had relied on hospitals, on episodic care of acute problems or acute exacerbations of chronic problems, while making less use of primary medical care even following introduction of a national health insurance scheme. The Hunter population lacked the protective features social epidemiologists and salutogenic researchers now identify as protective of health: cohesion, a sense of belonging, and social supports. A culture of competition, lack of trust, was evident amongst different populations and the various providers of health care services.

242 Consideration of Processes As this study revealed, implementation of the CHP policy commenced within a hostile and competitive and under-resourced environment wherein powerful stakeholders were oppositional to the policy and the proposed new responsibilities for community nurses. Efforts to involve local stakeholders in planning health services for the Region failed to achieve the desired outcomes. A shortage of funds forced Regional Administrators to consolidate their available resources, maternal and child health nurses and mental health teams, to form CHC teams rather than recruit and appoint from outside the public service. Little guidance was given to the disparate group of professionals concerning what was expected of them as members of CHC teams. Existing employees were however expected to continue offering traditional services. Only GCNs were provided with a Statement of Duties. While lacking guidance CHC practitioners began working as teams focused by a common interest in providing appropriate services to the myriad of local communities they came to understand and to which they felt some commitment. CHC teams established and provided a broad range of primary health care services, including formal health education and health promotion programs. Despite a culture of reliance on in-patient hospital care and episodic use of primary medical care individuals began using these new services, including preventive, educational services. This was an achievement that suggests the beginning of change in cultural norms, a shift towards proactive preventive self-care. This study also revealed that practitioners, mostly graduates of rigid hierarchical training environments, began working differently and began to use different processes. They reached out, became pro-active, and sought ways to assist other service providers to provide relevant services. Contacting other providers challenged their previously blinkered way of practising. GPs may not have liked the visits they received from community nurses initially but over time they began to refer to CHCs, which suggests they began to change how they practised, how they worked with other providers and with public sector organisations. Most referrals were to nurses, to GCNs. Local circumstances appear to have influenced GPs’ willingness to interact with CHCs. GPs working in population growth areas, where many of their clients experienced psychosocial as well as physical problems, who had few options available to them were quicker to refer. GPs working in rural areas were slower to refer maybe because general hospital beds were more accessible to patients with psychosocial or mental health problems. Under such circumstances necessity, people’s problems, prompted change and promoted inter-professional dialogue. A similar process occurred in CHC teams. Co-locating specialist and generalist nurses and allied health professionals encouraged interaction. Teamwork arose from propinquity, from contact. Social relationships and networks evolved. New practice norms were established: monitoring client progress, consulting with colleagues and peers became routinised, facilitated by new administrative processes. Practitioners developed personal skills. Their knowledge and problem solving ability and their capacity to take on new activities increased beyond being merely competent. They learnt to learn. Close contact between disciplines led to cooperation, disagreement and conflict. How conflict was resolved varied, depending on the resources available to teams. Teams with stable management and leadership resolved

243 issues and developed an egalitarian collaborative culture in which individuals felt respected as professionals. In teams with insufficient resources, unstable or authoritarian management or lack of leadership, conflict grew and over time a hierarchy evolved. Under these circumstances relations between allied health disciplines and nurses, and different categories of nurse, remained poor. Some nurses felt oppressed, dispossessed. By the late 1980s there was some evidence of what Roberts (1983) refers to as ‘horizontal violence’ occurring in some teams. Despite the difficulties inherent in developing CHC teams, most practitioners felt they grew as people, and as professionals, and became more responsive, more flexible, and better able to understand and respond to people’s needs. Short and long term planning became the norm for individuals and for teams. Resource issues affected enactment. Health promotion and community development activities arose from connections being made between individual and collective problems and needs. Practitioners established and handed over sustainable services to local community groups, to volunteers, or organisations such as hospital midwifery departments. Service development and provision involved different organisations, private and public, health, non-health and non-government. Networks, collaborative relationships were forged and norms of reciprocity evolved. The level of administrative and managerial support given to teams and discipline groups varied over time. Despite periods of limited support and constraints imposed by lack of funding, unfilled vacancies, an emphasis on one-to-one clinical services, practitioners developed something different, a new type of service. The problem, as a new Deputy Regional Director of Nursing pointed out to the Deputy Regional Director in early 1979, was that the evidence lay buried in team records, it was not reported (McMellon 8.3.1979). Practitioners worked differently with clients. Most shifted from a task orientation to a focus on people's needs. They came to see their professional responsibility as assisting people gain resources necessary to improve their health. Helping, rather than keeping ‘patients’ became the norm. Practitioners recognised that some clients needed ongoing support either because they were unable to learn the necessary skills they required to help themselves or their problems were such that only death would resolve them. While recognising that some clients depended on their services, practitioners, especially nurses, tried to provide services in a way that promoted independence and a sense of control. They assisted people to cope with situations that could not be changed or assisted them to change their situation. However, people’s need for care often increased before it decreased, limiting practitioners’ ability to control their workloads. GCNs were affected most.

The Role of Generalist Community Nurses This study revealed that practitioners changed the way they practised, even if they continued to see individual clients. The greatest change occurred amongst GCNs. These, mostly general trained, nurses whose past experience included working in an acute hospital, initiated most of the health promotion and community development activities that CHC teams engaged in. Some of the health promoting community development activities and health education projects that evolved would be considered appropriate and

244 innovative, even in contemporary circumstances, as for example, attempts by GCNs to have school canteens desist from selling ‘junk’ food and educating apprentices to engage in ‘safe sex’. These ‘street level bureaucrats’ saw it as their responsibility to promote CHCs and the services they offered, or could offer, to local communities. More than any other discipline group, GCNs reached out to other service providers, to GPs, non-government organisations, school teachers, and their specialist nurse and allied health team members. They established and maintained links because their responsibilities were diverse. They had to work with people in different organisations; they had their feet in different camps. One outcome was that GCNs became ‘people’ rather than professionals, who knew other people in different organisations. Their need to contact different groups led to their developing the capacity to act as a link to connect people to other people who could assist with a problem. This provided them with an opportunity to contribute to building social capital in those areas in which they worked. One of the problems with a pluralistic health care system and the segmentation of health and social care is that each service in each sector operates separately. There were no structures to facilitate connecting people seeking assistance from one service to another prior to CHCs and GCNs. There was a gap in the health care system, a structural hole (Burt 1992). GCNs, perhaps unwittingly, filled it as they sought to assist people with their problems. Vimpani (Communication 20.7.01) argued that a segmented system required ‘professional intersectoralists’, people aware of various networks who were capable of connecting people in one network to those in another. He called them ‘boundary riders’ and this is the role that I believe GCNs developed for themselves.

Unanticipated Aspects of Implementation Unanticipated aspects of implementation revealed by the findings concerned the opportunities seized and squandered by various groups. Regional Administrators were in a difficult, no-win, ‘damned what ever they did’, situation. I found an unexpected empathy for these officers whose problems were complex and unexpected. They were expected to implement the CHP policy with insufficient fiscal, physical or human resources. Decisions taken by Central Office limited the implementation process from the start. They asked for too little and they received less. Attempts to involve local stakeholders in planning a CHP for the Region were stymied by the linking of this policy with two other politically sensitive policies, rationalising the use of general hospital beds and disestablishing hospital boards to form area health boards. They had a further challenge in establishing a new community medical school in a Region with an antiquated, under funded, system of hospitals and a local medical fraternity with little or no experience or understanding of new developments in medical education. Sectional interests, GPs and general hospitals, remained oppositional to the CHP policy, and to decreasing bed numbers. They wanted new buildings and more beds. Political will was required to overcome situational constraints on implementation processes. A paucity of local resources provided the impetus for change. Nevertheless, the catalyst for improvement in the Hunter health care system was the Region’s CHP. Advocates of the CHP policy drew public attention to the deficits of the Hunter Region's health care

245 system, its lack of adequate resources. The sorry state of the Region's health care system, the budget deficit, was finally revealed and Senior Administrative Officers paid the price. They were transferred. It is difficult to believe the Region's problems were unknown to the government until they were proclaimed in the Newcastle Herald. It was, however, a sustained media campaign that forced the state government to act decisively to appoint a new Regional Director with a brief to develop a strategic plan for the Region's health care system. Another unexpected outcome of implementation was that in making district hospitals administratively responsible for CHCs in a defined geographic area, their boards became advocates for the CHP and CHCs. Structural change fostered purposeful contact through which the purpose of the CHP and CHCs came to be understood and more formal administrative processes were adopted before Area Health Boards were established. The final unanticipated aspect of implementation was that allied health practitioners, often team leaders, encouraged GCNs, baby health and school medical nurses, to take more generalist roles, including greater responsibility for assessment, counselling, and community work and to act more independently. By the late 1980s GCNs' practice had become more restricted. However, it was nurse managers, senior nurses/nurse unit managers, and psychiatric nurses who fostered this retrograde change. Some GCN and HACC nurses were happy to focus on home nursing. However, senior nurses imposed a daily client load, and this along with the expectation that GCNs would return to a CHC each afternoon limited the freedom of this group of nurses. In some teams intra-professional nursing hierarchies evolved with baby health and HACC nurses being viewed by their psychiatric and generalist nurse peers as engaging in less important, one-to-one, work. As a profession, nurses missed an opportunity to extend their generalist responsibilities, clarify their role, and take control over their practice. Rather they handed responsibility back to their nurse managers. Opportunities to influence policy were also lost due to a lack of nursing leadership.

Significance of the Findings This in-depth socio-historical case study, which I expected to be a revelatory case, makes a contribution to the CHP policy, CHC and community nursing literature. The findings of this study, gained using a combination of qualitative methods, support those of some earlier studies of the CHP policy, but question the long held assertion that practitioners were illness orientated because they worked with individuals. This study makes a contribution to the community nursing literature as the first in-depth, contextualised historical account of the activities of GCNs in NSW. I rejected the 'broad brush' triumphalist approach to nursing history criticised by Davis (1980) choosing to provide a detailed account of GCNs' and CHC teams' work. This approach has provided new insights concerning the activities of CHC practitioners and their employers, Regional Administrators, and the context in which these Public Servants worked. It has illustrated that the context in which the policy was implemented imposed severe constraints on how it was implemented, which in turn constrained practitioners. However, it has also shown that nurses gained unprecedented opportunities to take control of their practice, to decide what they did for clients and the

246 communities in which and with which they worked, although this was ultimately limited by nurse managers. Administrative processes eventually constrained and restricted the responsibilities of GCNs. The findings of this study raise questions about, or add weight to, the findings and conclusions of earlier studies of CHCs. Like earlier studies, this study found that most practitioners worked with individual clients and that CHC services reached the population groups they were intended to reach. Earlier studies found practitioners were illness focused. This study has revealed that they focussed on people’s problems, problems associated with normal life events and their personal circumstances. GCNs in particular came to recognise, as various theorists had asserted, that some people required the type of ongoing assistance that can only be provided on a one-to-one basis (Antonovsky 1972, 1987;Caplan 1964; Jackson 1985; Jackson et al 1989; Milio 1970, 1975b, 1981; Seligman 1975). The limits to formal health promotion activities were recognised by those who made a connection between individual and community problems. This shift in perspective often took time. Current research illustrates that one-to-one work is beneficial, relevant, and that what matters is how services are provided. The work of Brooten, Kumar, Brown, Butts, et al (1986), Ciliska, Hayward, Mitchell et al (1994), Cowley (1991), Cowley and Billings (1997,1999), Hayward, Ciliska, Mitchell et al (1993) Keleher (2000), Luker (1982), McMurray (1991), McWilliam (1996), McWilliam and Sargent (1994), McWilliam and Wong (1994), McWilliam, Brown, Carmichael et al (1994), McWilliam et al (1997), McWilliam, Stewart, Brown et al (1999), Maglacas (1988), Milio (1970, 1975, 1976a,b, 1988b), Ross & Mackenzie (1996), St John (1996) and Twinn (1997) amongst others, provides evidence that community nurses' work with individuals can be health promoting, salutogenic, empowering. The approach taken by practitioners is what matters. How nurses work with the elderly is now considered central to their being maintained in their homes. Keeping elderly people out of hospitals is recognised as an important step for preventing loss of ability. In NSW for example government policy is now promoting community care to keep people out of hospitals (Robotham 21.7.2006), the sub-acute fast track elderly (SAFTE) program seeks to minimise admissions and improve quality of life (9.2.2006). Similarly, the Families First and Better Futures initiatives promote use of a preventive and early intervention framework for families and children from birth to adolescence. While these initiatives focus on act risk groups the also promote a partnership approach. They seek to provide support that, from an individual and community standpoint, builds capacity and is considered to be empowering. This is the essence of a preventive approach that many community nurses and nurse researchers have promoted. However, such an approach has to have organisational and management support. Lennie et al (1990) and Bryson et al (1992) found the administrative context in which practitioners worked and the concerns of centre managers influenced whether CHC teams developed a community or a client orientation. In the Hunter, as this study has revealed, some managers promoted clinical services, however this focus reflected a realistic assessment of a specific population’s very real need for home nursing and counselling services. As Gibson (1980) found in Brisbane, practitioners and managers in the Hunter reacted to situational influences. Gibson (1980) found red tape and bureaucratic incompetence

247 played no part in determining the focus of CHC practitioners. This was not the case in the Hunter Region where bureaucratic processes restricted implementation. As this study has revealed CHC team leaders and senior nurses’ ability to gain resources was hindered by red tape, by administrative policies and processes. Duty Statements set the parameters in which GCNs and other specialist nurses worked and the type of client services they were expected to provide. An ongoing lack of resources imposed a burden on all who participated in the implementation process. Practitioners and administrators responded to a situation created by decisions taken or not taken at a state level, by the Public Service Board, Treasury, and the Premier's Department. Responding to local needs created unreasonable workloads for CHC team members, especially those GCNs working in areas where populations included a high proportion of elderly, chronically or terminally ill persons and persons on low incomes with few personal resources. GCNs and their managers had two choices, to reject new referrals or accept them. Most chose to accept them. Studies of CHCs that differentiated between the activities of different discipline groups found community nurses more committed to a preventive approach and teamwork. This case study revealed a similar situation. Most allied health practitioners focussed on providing much needed clinical services. They were less involved in working with groups or communities, especially if they worked part-time. The static state of community psychiatric services also meant that less attention was directed at working with families than might have been desirable. Despite a policy of deinstitutionalisation few services were directed at supporting persons with diagnosed psychiatric conditions. One outcome was that the attention of most psychiatric nurses was directed at providing services for this population. The most significant finding of this study concerns changes in practice. ACHA (1986) found CHC practitioners practising much as they had in other settings. In their view CHCs provided a conservative service. However, as this study has revealed, practitioners changed how they practised. Nurses began working independently and inter-dependently with other professional groups. They began teaching their clients the skills they required to attend to specific needs, for example caring for a young child, administering their own insulin or dressing a wound. Their focus shifted, they became more person focused, more responsive. Working with other services, other providers and other disciplines created new norms. Different disciplines learnt to respect the skills of their colleagues. Collaboration and teamwork became commonplace. The way they practised differed from the approach described by the H&HSC (1974) as typical of general hospitals. Societies work best, as Rotberg (2001 p.1) has argued, when ‘citizens, work cooperatively for common goals, and thus share a civic culture’. According to Putnam (1993) a civic community has egalitarian political relations, a social fabric reflecting trust and cooperation. In the Hunter Region hierarchical relationships were more common than cooperative relationships. Loose horizontal ties were rarely found between different types of organisations. In implementing the CHP policy CHC teams developed loose relationships with other organisations which led to accumulation of reciprocal trust. Coleman (1990) described social capital as the benefits derived from relations established between people which enable

248 action to be undertaken and offers a way to understand different outcomes in different situations. Coleman identifies three factors as creating and maintaining social capital: closure, stability and ideology. These characteristics were shown to be evident in the Hunter amongst GCNs, who despite intra-team problems developed a sense of themselves as a collective. CHC teams developed an ideology operating separately from the broader health system. Some closure was gained. Processes were established which fostered a sense of belonging and while resources were limited, CHCs remained stable entities. What CHC practitioners achieved in the Hunter Region was rather remarkable. In a Region where parochialism extended to health services they broke down barriers, established trust and became the channel that linked various services. They opposed their managers' decisions and behaved in ways which brought the needs of the Hunter population to the foreground as they advocated for a policy they sought to implement and the services established under its auspices. How can I explain the poor administrative performance found by this study? Alford (1975) cautions against using theories which seek to explain the functioning of organisations by reference to individual psychology, status and power, organisational failure, or unenlightened leadership as they ignore structural influences. When implementation of the CHP policy began few conditions identified in the policy literature as essential for effective implementation were evident. The outcome can be viewed as a struggle between those Alford refers to as ‘professional monopolists’, who controlled health resources, the ‘corporate rationalists’, who challenged their power, and ‘equal health advocates’ who argued for communities' need for access to better health care. The power of Regional Administrators and CHC practitioners to implement the CHP policy as intended was constrained by struggles between three groups. Professional monopolists were the GPs, medical specialists, and executive officers of large general hospitals, seeking to remain gatekeepers to medical and community nursing services. The ‘corporate rationalists’ were Public Service bureaucrats who challenged their power and who wanted to establish a tiered interlocking system of community based and inpatient services. Finally, the ‘equal health advocates’ were the coalition of employees of Regional Office, public servants, administrative officers and CHC practitioners, medical academics, and employees of non-government organisations, who wanted the population to have access to a broad range of services, some of which were threatened by the Region's precarious fiscal state. In the Hunter, as occurred in Canada (Lomas 1985; Church 1993), the CHP policy provided the focal point for disenchanted advocates to challenge the State government's authority to limit the services people could access. A public campaign to ‘save community health’ gained support in this Region and finally the Newcastle Herald's public exposure of the Region's problems could only have occurred with insider support. A major problem for those seeking to implement the CHP policy was that practitioners and managers lacked an understanding of what types of health services populations require and how best to provide them. The idea that people's circumstances influenced their health and their use of health services raised eyebrows in academic circles into the early 1990s despite the plethora of social science research pointing to this conclusion. Now the evidence is overwhelming, the idea is accepted (Baum 1998; Berkmann &

249 Kawachi 2000; Lynch & Kaplan 1997; Wilkinson 1996). This suggests that all health professionals and health service managers would benefit from pre-service education which involved common core subjects concerning determinants of health, undertaken together to foster interaction. Learning is fundamental to people's lives, so professionals need to grasp the fundamentals of learning theory and an understanding of how different management approaches and organisational cultures affect outcomes for themselves as practitioners and for their clients (Main 1989; Milio 1981). This study has shown that when practitioners are provided with a collegial, more democratic environment that they can do what Sax (1972 p.187) proposed: establish their own professional committees and devise standards and processes for monitoring performance and referrals and engaging in joint planning exercises. This was not achieved by line managers directing, but by guidance offered by the first Regional Administrators responsible for implementing the CHP policy. The problem they did not solve concerned workloads. In the Hunter the CHP policy changed the health care landscape. The public now has direct access to services provided by nurses and allied health professionals and evaluation, promoted by CHC practitioners and the Australian Community Health Association1, is now an accepted way to monitor service outcomes (1991).

Limitations This study focused on how the national CHP policy was implemented between 1974 and 1989 in the Hunter Region. As data were collected from CHCs in this Region the findings pertain to the practitioners working at CHCs here at this time. This is a limitation of the study. It is possible that the lack of team records for the years 1974 and 1975 as CHCs were being established and 1986 when Area Health Boards were being established means that I missed some significant occurrences which might have altered my analysis. However I sought to access multiple primary and secondary sources, including participants' accounts of significant events, and offer the readers sufficient evidence to enable them to interpret the case from my perspective. Some aspects of context were barely touched upon, for example the influence of the NSW and Australian Community Health Association, the NSW doctors' strike, or the internal machinations of the NSW Nurses Association that led members of Royal Newcastle Hospital branch to call for a state wide strike. These matters were considered beyond the scope of this thesis.

Implications for further research. The findings of this study raise numerous questions about the provision and organisation of health services appropriate to population needs. This in turn raises questions regarding the educational preparation of those who are to take up positions as managers, administrators or providers of health care. This study found practitioners' practices changed when working at a CHC. This raises questions which could be further researched about what circumstances sustain these changes in practice. Do the changes

1 By the late 1990s the Australian Community Health Association had ceased functioning as an effective lobby group following ceasation of its Federal Government funding.

250 made, the change in focus, transfer to another setting, for example back into a hospital setting? Are professional education programs, especially nursing programs, providing students with the knowledge, experiences and skills they require to work effectively as community nurses? Are post-graduate courses in community nursing required? Would the public be better served by a new type of GCN, one based at a school, who works in a defined area with people of all ages, providing some personal services but spending most of their time coordinating primary health care services and working with teachers? How are judgements made regarding what constitutes adequate resources for a CHC and how those resources are used? Is it appropriate for GCNs to spend nearly half a day, each day, under the watchful eye of their Nurse unit Manager, writing up files? Do the methods currently used to allocate client loads to community nurses compromise effective provision of care for administrative efficiency? Does prescribing the time spent with clients prevent appropriate nursing care being given? Is the current trend to develop specialist community services creating new structural holes? Would the public be better served by generalist CHCs, by a one stop shop? What is the legacy of the NSW and Australian Community Health Association?

In Summary As Alford (1975) has pointed out it is easy to look at health care systems and identify a crisis but it is also useful to look back at what has been achieved, what has improved, and what hindered progress. Five conclusions were drawn from this study. Conclusions drawn were first, that context strongly influenced how public health policies were implemented and the services offered by different discipline groups. Second, teamwork would have been improved if pre-service health professional education had fostered a common understanding of the aim of health care and the broader determinants of health. Third, a preventive orientation needed reinforcing via an organisational context, administrative processes, ongoing learning opportunities and leadership. Fourth, generalist community nurses’ commitment to a preventive approach was embedded in a growing understanding of people's circumstances and health problems. Finally, while policy implementation was constrained in the Hunter Region during the study period, it achieved what its architects intended, that is, a broader mix of accessible services, and collaboration between organisations and groups as the boundaries that maintained their separation were bridged. These findings have resonance for NSW in a political climate that promotes community care. The same mistakes are being repeated. Specialisation in community nursing is increasing. By promoting a specialist model in what needs to be a generalist field the fractured nature of provision of health care services will continue to disadvantage many seeking access to assistance. It is also likely to hinder the ability of GCNs to engage in health promotion and community development activities.

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333

APPENDICES

334

Appendix 4.1

Interview Guide

Demographic information on the interviewee

Professional qualifications, experience, career aspirations, length of employment in community health, why they sought work in this setting. 1. What changes (organisational/professional) have occurred since you commenced working in community health? 2. In what way has the reorganisation of community health services affected you as a worker? 3. Is there a formal orientation to community health for all new staff members and how did you find it? 4. What do you see as the objectives of the community health centre? 5. Did all staff regularly attend team meetings? Did all staff contribute? 6. Were all staff involved in community activities? 7. Were nurses and allied health staff involved in planning or evaluating centre activities? 8. How were decisions made regarding the activities and emphasis of the centre? 9. Did you work with any profession other than your own during your employment in community health? 10. To whom were you answerable professionally and administratively? 11. What opportunities have you had to access continuing education? 12. What had been your experience/education/contact with community health before commencing in this position? 13. Why did you chose to work in a community health centre? 14. How did your work in a community health centre differ from your former position? 15. Has working in a community health centre inhibited or enhanced your professional practice? 16. Have you spent any time on areas other than clinical practice (prevention, teaching, research, community development)? 17. How do you feel about the level of continuity of care in your clinical work? 18. Describe your working relationships with administration, peers, other health professionals, clerical staff and clients? 19. Describe how you have worked with clients? 20. What have been the expectations of clients? 21. How have you found the level of managerial and administrative support you have received? 22. Have centres kept files on the local community? How adequate do you consider these to be? 23. How did you organise your working time? 24. How did you reconcile demands for individual patient care with time spent on team/community activities? 25. Have you been involved in any staff education activities in the past? 26. How did you report on the work performed? Which jobs? where and when? 27. Is there anything else you would like to add?

335

Hunter_ Area Health Service LOOKOUT ROAD, NEW LAMBTON Locked Bag No. 1 New Lambton 2305 Our Reference: SH Fax: (049) 56 1367

Enquiries:, (049) 5 6 0 319

Your Reference :

27 April 1990

Ms S Schulz 274 Darby Street COOKS HILL 2300

Dear Shirley

Your request =or access to Newcast=le -West and Newcastle mast to undertake research into the roles of health professionals, in particular nurses, is approved . A copy of your letter of request has been forwarded to Mrs Lee Hughes, Director of Community Nursing and Primary Health Care, and Mrs Mona Wacker, Director of Child and Family Nursing Service . Would you please contact the above Service Directors to make arrangements for your visits to the Centres .

I wish you every success with your research .

Yours sincerely

S Fardy Group Manager Area Community Services r S% be

Not just Living, but being in Good Health is LIFE PLEASE ADDRESS ALL CORRESPONDENCE TO CHIEF EXECUTIVE OFFICER

Hunter Area Health Service LOOKOUT ROAD, NEW LAMBTON Locked Bag No. 1 New Lamblon 2305 Our Reference:_ KHN : JHC . 316 Fax: (049) 56 1367

Enquiries:.: (049) 560339

Your Reference:

26 April 1990

Ms . S . Schulz, 274 Darby Street, COOKS HILL .... .2300

Dear Shirley,

I refer to your recent letter concerning your research work for your Doctorate .

I see no problem in your talking to staff working in Community Health Centres in the Hunter Region and I am sure that full co-operation will be extended to you . Naturally it will be necessary for you to approach the Team Leaders in each instance in order to make satisfactory arrangements .

Although it may be difficult to access documentation in relation to the development of Community Health Services in the Hunter Region, I can see no reason why anything that can be located should not be readily made available to you .

As you will be aware the Community Health Services in Newcastle have recently been re-organised and it will be necessary for you to discuss this with Ms . Sue Fardy in order to ensure that the correct lines of communication are followed .

Yours faithfully,

K .H . Mill GROUP MANAGER .

cc : Ms . S . Fardy, Group Manager - Community Health .

Not just .._ .__ __---- Living, but being in Good Health is LIFE PLEASE ADDRESS ALL CORRESPONDENCE TO CHIEF EXECUTIVE OFFICER

Hunter Area Health Service

DIVISION OF MENTAL HEALTH SERVICES

CENTRAL ADMINISTRATION P.O. BOX 833 NEWCASTLE N.S.W. 2300 Our Reference: - Phone: . . (049):,257800 Facsimile: @49) 25 7802 YourReference: /EDU/ RESSTUD . S02

9 May 1990

Ms 'S A Schulz 274 Darby Street COOKS HILL 2300

RE : Research Studies

I refer to your letter received 7 May 1990 outlining your requirements and wishing to meet with staff of Newcastle West, Newcastle East and Lower Hunter Community Mental Health .

Your request is agreed . For further information of service development' please contact me on 25 7809 .

Team Leader will be advised of your request and my approval this week . I Suggest you negotiate directly regarding times with each centre. The contacts are : Mr S Ramsey - Newcastle East and Newcastle West 29 4821 Mr D Browne/Mr K Merriman - Hunter Valley Mental Health Team 33 4422

I look forward to further contact .

Yours sincerely

J L Kennedy Assistant Director Manager, Area MHS Development;, and Manager, Area Community MH Services

- 10046 Australian Recycled Paper- Protecting Our Environment Appendix 4.3 Profile of Interviewees.

NUMBER OF YEARS INTERVIEWEES WERE EMPLOYED INTERVIEWEES ACCORDING TO POSITION/S HELD AT A CHC Admini, research Allied health 13% under 1 year Admini, research Regional admini 15 years HACC 4% 11% 19% 6% Regional admini Team leaders 13% 5 years 15 years CMHNs 10 years 8% SCNs/NUMs 35% Team leaders BHCNs 5 years 13% 8% GCNs under 1 year SCNs/NUMs GCNs 10 years 10% BHCNs 18% 42% CMHNs CMHN: Psychiatric Nurse

COMMUNITY HEALTH CENTRES AT WHICH INTERVIEWEES INTERVIEWEES' EXPERIENCE WORKING AT DIFFERENT HAVE WORKED CHCS AND/OR DISTRICT OR DOMICILLIARY NURSING SERVICES

OTHER CHCS ELS CHC 8% 13% CHCS/HOSP NE CHC ELS CHC 26% 19% WLS CHC 1 CHC LH CHC 2 CHCS WLS CHC 1 CHC 3 CHCS 25% NW CHC 3 CHCS 49% NW CHC CHCS/HOSP 8% NE CHC 4% OTHER CHCS 2 CHCS LH CHC 21% 27%

340 340 Appendix 4.4 Interviews conducted, by date, code, interviewees years of involvement with the CHP policy/ CHCs, discipline and position/s held. Years involved Date Code Discipline Position/s held 1.3.91/3.7.1991 1 >10 Doctor Administrator 4.9.91/ 4.10.91 2A,B <15 Nurse Psychiatric nurse, NUM* 18.10.91 3 <5 Nurse Psychiatric nurse, GCN 2.12.91 4 <5 Nurse Psychiatric nurse 27.9.91 5 >10 Counsellor Administrative 9.1.92 6 <5 Nurse GCN 9.1.92 7 <15 Nurse GCN, NUM 10.1.92 8 >5 Nurse Psychiatric nurse, Team leader 14.1.92 9 <5 Nurse HACC, CNC 14.1.92 10 <1 Nurse Administrator 16.1.92 11 <5 Nurse HACC, NUM 20.1.92 12 >10 Nurse Administrator 16.1.92/23.1.93 13 A,B <15 Nurse Administrator 29.1.92/4.11.94 14 >15 Admin. Administrator 5.2.92 15 1 Nurse GCN 10.2.92 16 <5 Nurse GCN 12.2.92 17 >10 Nurse Community nurse paediatric 31.3.92 18 >10 Nurse HACC 2.4.92 19 <5 Nurse HACC 29.4.92 20 >10 Nurse GCN, 29.4.92 21 >10 Nurse GCN 5.5.92 22A,B 10 Nurse Community nurse paediatric 13.7.92 23 <5 Nurse GCN 15.6.92 24 >10 Nurse GCN 23.6.92 25 >5 Nurse GCN, NUM 18.9.91 26 5 Nurse CNC# 25.9.91 27 <5 Nurse Administrator 28.7.92 28 <15 Allied health Clinician 31.7.92 29 <5 Nurse GCN 28.4.92/17.7.92 30 A.B <15 Allied health Area Coordinator 11.8.92/24.8.92 31 A.B >10 Nurse GCN, NUM 28.8.92 32 <10 Nurse Psychiatric nurse 21.8.92 33 15 Nurse Psychiatric nurse 7.9.92 34 >5 Degree Researcher 16.9.92/17.9.92 35 A.B 10 Nurse Early childhood nurse, GCN 16.9.92 36 >5 Nurse GCN, Early childhood nurse 13.10.92 37 >10 Nurse Psychiatric nurse 12.11.92 38 <5 Nurse GCN, NUM 12.11.92 39 >10 Nurse GCN 14.12.92 40 >10 Nurse Was a GCN 22.12.92 41 >10 Nurse Area Coordinator 23.12.92/21.7.93 42 A.B >10 Nurse Baby health nurse, NUM 23.12.92 43 NA Allied health Community Services 10.3.93 44 15 Nurse Psychiatric nurse 8.5.93 45 15 Nurse BHC nurse, Administrator 23.5.93 46 15 Nurse GCN, Administrator 24.5.93 47 <10 Nurse GCN, Senior community nurse 28.5.93 48 >10 Doctor Administrator 1.6.93 49 NA Doctor/res Administrator 12.7.91 50 10 BA Health Education Officer/

341 Years involved Date Code Discipline Position/s held 10.12. 92 51 >5 Allied health Clinician/Policy Analyst 16.7.93 52 >5 Clerk Administrative Officer 19.3.93 53 NA Doctor Administrator 8.11.93/19.11.93 54 >15 Allied health Team leader 30.11.93 55 >10 Nurse Team Leader 20.12.93 56 NA Arts degree Researcher 21.12.93 57 >10 Allied health Clinician 8.2.94 58 NA Clerk Administrator 11.2.94 59 >10 Nurse Team leader 10.2.94 60 NA Nurse Community Nurse 10.2.94 61 NA Clerk Administrative officer 10.2.94 62 NA Clerk Administrator 7.9.94 63 <5 Nurse GCN, Psychiatric nurse 8.9.94 64 >10 Nurse GCN, Educator 4.10.94 65 >10 Doctor Doctor, Administrator 8.11.94 66 >10 BA Team Leader 17.11.94 67 <5 Doctor Specialist 1.11.94 68 10 Allied health Team Leader 10.2.96 69 NA Economist Researcher *Nurse Unit Manager #Clinical Nurse Consultant

Interviews conducted with Hunter CHC practitioners and administrators from May to September 1988 Date Code Years of Experience Discipline Positions held 1988 1.1 <10 Doctor Community Physician 1988 1.2 >10 Allied Health Area Coordinator 1988 1.3 >10 Nurse Psychiatric nurse 1988 1.4 >10 Nurse Administration 1988 1.5 >10 Nurse Education 1988 1.6 <5 Nurse GCN 1988 1.7 >10 Nurse Psychiatric nurse 1988 1.8 >10 Nurse Psychiatric nurse 1988 1.9 <5 Nurse Psychiatric nurse 1988 1.10 >10 Nurse Baby health nurse 1988 1.11 .>10 Nurse GCN 1988 1.12 >10 Nurse GCN 1988 1.13 >10 Nurse BHC 1988 1.14 >10 Nurse Psychiatric nurse 1988 1.15 >10 Nurse GCN 1988 1.16 >10 Nurse Psychiatric nurse 1988 1.17 >10 Nurse GCN

342 Appendix 4.4.2 Interviews conducted with academics, practitioners and health services managers in Canada and the United Kingdom during 1994 and 1997 Location Position Disciple Code Canada, Ontario Hamilton Home Care Manager Nurse A Hamilton Director Research Unit Nurse B St Thomas CHC Manager Nurse C London Professor, Medicine Doctor D London CHC Health Workers Community Workers E London Public Health Nurse/Medical Centre Nurse F London Family Practitioner/ Medical Centre Doctor G London Family Practice Nurse/ Medical Centre Nurse H London Researcher /lecturer Nurse I United Kingdom London Researcher/lecturer Nurse J London Researcher/lecturer Nurse K Newcastle-on-Tyne Director of Nursing Nurse L Edinburgh Emeritus Professor Nurse M Edinburgh Lecturer and Head Nurse N London Manager Nurse Practitioner Team Management O Liverpool Director/Professor Public health Doctor P Liverpool Head, Health Sciences Nurse Q Liverpool Researcher Nurse R London Professor and Head Nursing Nurse S London Nurse Practitioner Nurse T Newcastle-on-Tyne Lecturer Nurse U Greenwich (1997) Health Visitor/homeless Nurse V

343 Appendix 5.1

Chronology of Selected Key federal and state events 1959 -1989

1959 Regional planning for mental health services began in New South Wales.

1961 First interim report on preventative psychiatry was released by the Health Advisory Council.

1961 Division of Establishments created within the central administration of the New South Wales Department of Public Health to administer psychiatric hospitals.

1965 The Minister for Health A.H Jago proposed the Public Hospitals Act 1929 and state wide organisation of health services be examined.

1965 The Report of the Consultative Committee on the Care of the aged, prepared for the Minister for health was published.

1965 At North Ryde Psychiatric Hospital the Fraser House therapeutic community began a community psychiatric program for Lane Cove area. The program emphasised social and preventative psychiatry.

1966 The Meyers Report, Public Health Administration in New South Wales, was released. It recommended standardising curricula for medical practitioners, general practitioners and allied health (paramedical) professionals, integrating public health services, that hospitals provide some community services, and that closer relationships be developed between hospitals and general practitioners and hospitals and health teams.

1967 The Director of Psychiatric Services, New South Wales Department of Health, Dr W. A. Barclay, proposed developing regionalised mental health services and sub-regions, decentralisation, and community mental health clinics and establishing units in general hospitals, with area responsibility.

1968 The Eglinton Report, entitled Community health Services and the Public Hospitals Act, was presented in January 1968 and published.

1969 A working party on medical education was established under Professor Charles Kerr to establish guidelines for introducing behavioural and social sciences into the medical curricula at Sydney University.

1969 The Minister for Health appointed a committee of inquiry into nursing education which was chaired by Mr. V. J. Truskett. The report was published in June 1970.

1969 Dr Barclay, Director of Psychiatric Services in his annual report proposed that the number of patients in psychiatric hospitals be reduced and that community mental health services, domiciliary nursing, outpatient services, sheltered accommodation and employment, be expanded.

1969 Sir Kenneth Starr, chaired a committee to examine the Eglinton report this Report of the Committee on Community Health Services, submitted in November proposed forming a Health Commission, regionalising services, involving community health staff in service administration, redefining public hospital boards responsibilities. It supported decentralisation, accessibility, flexibility and responsiveness to community involvement.

344 1970 The Truskett Report, which inquired into nursing education was published and recommended amongst other changes combining clinical experience with tertiary study, transferring nurse education to Colleges of Advance Education, establishing regional schools of nursing and transferring responsibility for education from health to the Minister for Education.

1970 A Division of Health Services Research and Planning was established within the New South Wales Department of Health to undertake studies at the request of the Department of health and the Hospitals Commission.

1970 A Standing Committee allocated projects to the Division of Research and Planning, Dr Sidney Sax was the Director until the end of 1972.

1970 A Standing Committee on Community Health was established by the New South Wales Department of health.

1971 The interim Committee of the Hospitals and Health Services Commission report, A medical rehabilitation programme for Australia recommended expanding community services, rehabilitation centres, day centres, domiciliary care.

1971 The New South Wales Department of Public Health changed its name to the New South Wales Department of Health.

1971 The Department of Health in New South Wales began conducting orientation courses for state employed community nurses.

1971 An Aboriginal community established a self help medical centre at Redfern.

1971 A review of psychiatric domiciliary nursing services recommended expanding the responsibilities of nurses and extending their education.

1971 The Queenscliff Health Centre opened providing the first centre in New South Wales to provide a comprehensive range of services to a locally defined population, Manly-Warringah.

1971 A report by the Division of Health Services Research and Planning, released a report Health and Hospital Services in the South-West Sector Sydney Metropolitan Area, 1970-1985.

1972 The New South Wales Minister for Health, A.H. Jago issues The Proposed Health Commission of New South Wales: Consultative Document (the Green paper) which outlined the structural and legislative changes required to implement the recommendations of the Starr report to achieve one administrative organisation. The Hunter Region was established in early 1972.

1972 The Blacktown health Centre was officially opened.

1972 A committee was appointed under Professor P. Karmel to advise on medical education.

1972 A Commission of Inquiry into Poverty was established under the Chairmanship of Professor Henderson to investigate the distribution of poverty and who was effected.

1972 A report entitled Health Centres in Australia was published by the Australian Medical Association in September. It proposed that general practitioners should be the first contact with the health system and that health centres support general practice.

345

1972 The New South Wales Health Commission Bill was tabled in parliament incorporating the Hospitals Commission and New South Wales Department of Health into one administrative body.

1972 With the election of the Australian Labour Party on December 5th Gough Whitlam became Prime Minister.

1972 The Bureau of Personal Services was established within the New South Wales Health Commission. One of the Bureau's responsibilities was to develop comprehensive health facilites with an emphasis on community care.

1972 In New South Wales the Report of an Advisory Committee, Personal Health Services within Metropolitan Regions, was published. It proposed guidelines for expanding community services and gave detailed outlines for establishing teams and centres to provide regional services. It varied from the proposals in the report of the Division of health Services Planning and Research.

1972 Glebe Community Health Centre provided a comprehensive range of community services and was used as a teaching units for nursing, allied health and medical students.

1973 An interim Hospitals and Health Services Commission was established on April 5th, chaired by Dr Sidney Sax.

1973 The Health Commission was using baby health centres for community mental health clinics. Orientation courses for community practice were being conducted and attended by nurses and allied health.

1973 A report on A Community Health Program for Australia, was released in June by the Interim Hospitals and Health Services Commission. This report proposed development of community health services. Emphasis was to be given to areas with too few services and to populations with identified unmet needs. The Commission was formally established in November. The Commission was abolished on August 15th 1978.

1973 The New South Wales Health Commission appointed five task forces to examine mental health, mental retardation, geriatrics paediatric and special projects to recommended projects for incorporation into the national Community Health Program. A central coordinating committee was establish to facilitate implementation.

1973 Establishment of a one year diploma in community nursing at the New South Wales of College of Paramedical Studies (Cumberland College of Health Sciences) was approved. It began in January 1974. The first such course in Australia was conducted by the New South Wales College of Nursing.

1973 The Nurses Education Board was established a major responsibility was to formulate proposal for the reform of nurse education in New South Wales. A report released in 1974, Report on the future development of nurse education in New South Wales, it addressed the recommendations of the Truskett Report.

1973 The Karmel Report, Expansion of medical education, report of a committee on medical schools, was published. It recommended, establishing departments of community practice, a medical school at Newcastle, Hunter Region, increasing the student intake (to achieve a ratio of 1 doctor to 543 people).

346 1973 The New South Wales College of Paramedical Studies was established to conduct courses in nursing, physiotherapy, speech therapy, orthoptic and occupational therapy. The college took over the teaching responsibilities of professional colleges.

1973 Pilot community health centres were established at Scullin and Melba in the Australian Capital Territory. The AMA opposed employment of salaried doctors at the Melba Centre.

1973 Dr Sidney Sax was appointed by Douglas Everingham, Minister for Health, as chair of The Committee on Health Careers (Personal Training). It examined the responsibilities of health professionals in the community sector and identified a need to establish Chairs and departments of community practice to ensure adequate preparation. The report of a sub committee Continuing medical education supported interdisciplinary education.

1973 The Royal College of General Practitioners established a Family Medicine Program replacing a vocational program which began in the 1960s run in conjunction with the Commonwealth Department of Health.

1973 The Federal Minister for Health Douglas Everingham, asked for a report on proposals to establish and Institute of Health. The School of Public health and Tropical Medicine was renamed the Commonwealth Institute of Health in 1980.

1973 The Social Welfare Committee was established as a statutory body.

1973 The Mental Health and Related Services Assistance Act replaced the States Grants (Mental health Institutions) Act in November, which had funded capital expenditure on a $1 to $2 basis, and allocated to Community Mental Health, Alcoholism and Drug Dependancy Program 7.5 million for 1973/1974 and 1974/1975 (under 7 million was spent) before ceasing in July 1975 when projects were incorporated with the CHP.

1974 Students entered the Diploma in Community Nursing program at the New South Wales College of paramedical studies.

1974 The University of New South Wales introduced a new medical course with emphasis on behavioural and social sciences and community medicine.

1974 The Hospitals and Health Services Commission presented A Report on Hospitals in Australia which proposed expanding and upgrading hospitals, regionalising health services and developing better coordination between hospitals and community health centres. Also identified were the need for improved Management and data collection.

1974 The Doctors Reform Society was established in New South Wales. New Doctor the journal began publication in 1976.

1974 The Royal Commission into Human Relationships was established under the Chairmanship of Justice Elizabeth Evatt.

1974 The Chairman's Nursing Consultative Committee was established by the State Government.

1975 The Health Commission of New South Wales published The Corporate plan 1974-1984, which specified accessibility to health care, participation by the public in health services and the integration of preventative and curative health care. Community health services were identified as contributing to the efficiency of the health care system.

347 1975 The Department of Community medicine was established at the University of Sydney.

1975 The Foundation Dean of The University of Newcastle Medical School took up his appointment in January. The problem-based course was based on a philosophy that doctors should be agents of social change.

1975 The Hospitals and Health Services Commission funded a project proposed by the Australian Medical Students Association, an undergraduate Family Health Team. The project was renamed Student Initiatives in Community Health in 1977.

1975 The Mount Druitt Polyclinic commenced and offered a comprehensive range of services.

1975 The Health Commission of New South Wales Annual Report for this year notes 16 community health and community mental health centres were operating.

1975 The New South Wales Ambulance and Transport Board was incorporated into the Health Commission in July. 1975 All projects conducted under the Community Mental Health program were incorporated into the CHP.

1975 A working party was established by the Universities Commission to examine Rehabilitation Medicine and Geriatrics.

1975 The Health Commission of New South Wales established a task force to review regionalisation and the Management of the health commission. The community health program was considered.

1975 A Federal Liberal Coalition Government was elected and Malcolm Fraser became Prime Minister.

1976 The Hospitals and Health Services Commission published a Review of the Community Health Program, which reviewed achievements up until November 1975.

1976 The commission of Inquiry into Poverty published The Third Main Report, Social/medical aspects of poverty in Australia, in May.

1976 A report, The role extension of the registered nurses, was published by The Chairman of the Nursing Consultative Committee. The report discussed expanding the responsibilities of generalist community nurses to include counselling, child and maternal health advisory services, domiciliary nursing, case-finding and working with at risk populations.

1976 The Health Commission of New South Wales issued a report Monitoring Community Health Services by the Division of Health Services Research which identified the populations with whom community health services should be concerned and the services that might be provided to meet identified needs.

1977 The Community Health Books 1-6 (the rainbow books) were released. They outlined objectives and strategies for achieving seven goals, prevention, self-help, participation, integration, area responsibility, accountability and teamwork.

1977 A Committee of Inquiry into Nurse Education and Training was established under the chairmanship of Dr Sidney Sax by the Minister for Education, J.L.Carrick. The committee recommended increasing the intake of nurses into Colleges of Advanced Education.

348

1978 The Consultative document on regionalisation and management structures of the Health Commission of New South Wales, implementation and recommendations, was released.

1978 Community health workers and supporters of the CHP commenced a ‘save community health’ campaign in New south Wales in September which ceased in 1979.

1979 A report of the Senate Standing Committee on Social Welfare, Through the glass darkly; evaluation in Australia's health and welfare services, was published.

1979 The federal Minister for Health, Ralph Hunt established an inquiry into the Efficiency and Administration of Hospitals, chaired by J.H. Jamison.

1979 A report Health promotion in Australia; 1978-1979, was published by the School of Public health and Tropical Medicine. Prevention, health promotion, health education were found to be given little emphasis and most activity occurred in CHCs.

1980 The Report of the Inquiry into the Efficiency and Administration of Hospitals, was presented.

1980 In December the foundation meeting of the New South Wales Community Health Association was held following reactivation of the ‘Save community health’ campaign in July after the Commonwealth announced the fourth cut in funding in four years.

1981 The Commonwealth government replaced the Hospitals Cost Sharing Agreement and replaced it with a block funding system as recommended by the Jamison Report in May.

1981 Laurie Brereton, State Minister for Health requested that the Public Accounts Committee inquire into budget overruns in second and third schedule hospitals. The report proposed implementation of block finding, needs based funding and establishment of area boards.

1981 In November the Standing Committee on Community Health provided the Health Commission of New South Wales with a report on Community Health.

1981 In December 1981 the Community Health Unit under the auspices of the Standing Committee on Community Health issued a draft Community Health Policy for discussion.

1981 Laurie Brereton, State Minister for Health initiated a review of the Health Commissions staff establishments. The report of this Ministerial Task Force, handed down on December 31, recommended reducing the number of staff at central office, staffing community services with hospital staff in pilot regions, and reducing the number of health regions from 13 to 9.

1982 The AMA rejected the move by the State government to abolish the right to private practice in public hospitals.

1982 In March Roderick McEwin, Chairman of the Health Commission, released a report on Planning Health Services in the 1980s. The purpose of the document was to provide a statement by the Commission regarding major health issues and strategies through which they could be met.

1982 In July Laurie Brereton, State Minister for Health announced he intended to abolish the health Commission. Departments were to be established including a Division of Community Health.

349

1982 In December Hausfeld, Boleyn and Stevenson presented the Report of the Community Health Interim Evaluation working party to the Minister for Health, Dr Brereton. In addition to this report the working party wrote an historical overview of the development of the CHP in New South Wales. The report identified funding deficits as preventing rational development of the CHP. This report recommended against integrating CHCs and hospitals.

1982 Webster Report, Professional Services Advisory Council. Report of an Inquiry of a Sub-Committee into the institutional care of persons with long-term impairment, disability or handicap in New South Wales, with particular reference to the present and future role of country hospitals was handed down.

1983 On March 8 the term of reference were provided to the Task force on Co-ordinating Health Services in the Community, M. McHarg, J. Lawson, J. Martins, J. & R. Hicks. On August 5 they handed a report on the Development and Expansion of Community Based Services to the Hon. L.J. Brereton, Minister for Health, New South Wales Health Commission. This report recommended integrating CHCs with hospitals.

1983 Richmond Report the Inquiry into Health Services for the Psychiatrically Ill and Developmentally Disabled completed.

1985 Nursing education in New South Wales transferred to Colleges of Advanced Education, a generic diploma replaced general, psychiatric and developmental disability hospital nursing certificates. One register is created.

1986 In October the Area Health Boards Act came into operation. Four Boards were established in the Hunter Region.

1987 The number of Area Health Boards was reduced. In the Hunter Region four boards were disestablished to form one Board for the Region.

Sources; Duckett & Crouch 1983 The Course of Community health in New South Wales, 1958-1982; New South Wales State Government Annual Reports 1972-1990; New South Wales State Government Year Books 1972-1990; Federal Government Year Books 1972-1990; Government Reports.

350

Appendix 5.2 Selected Chronology of services employing community nurses between 1870 and 1975. 1870s Australian Inland Mission Nursing Service established remote area nursing services in Victoria, South Australia, Queensland and by late 1890s, the Northern Territory, and Western Australia. 1885 Melbourne, Victoria, The Melbourne District Nursing Society, renamed the Royal District Nursing Service (RDNS). 1892 The Hobart District Nursing Service (1892), Tasmania; 1890 St John of God nuns offered services in West Australia at Kalgoorlie and Coolgardie 1894 The Royal District Nursing Service, South Australia. 1900 The Sydney Home Nursing Service, New South Wales. 1904 Maternal and child health services established in NSW by non-government organisation before taken over by the Department of Health. 1905 Silver Chain Nursing Service, Western Australia. 1907 School medical services established in New South Wales 1910 The Bush Nursing Association had established services in isolated areas of South Australia, Queensland, Northern Territory, West Australia and Victoria. 1911 Occupational health nursing commenced by British Tobacco Company and the Temperance and General Life Insurance Society in Melbourne and later a similar service was initiated by the Commercial Mutual Life Assurance Company in Sydney. 1928 Flying doctor service established. 1953 The Blue Shield Nursing Service, Queensland 1957 Home Nursing Subsidy Act, 1957 introduced. Services were required services to furnish reports and annual statements to the Federal Minister for Health 1960 Child Guidance Centres established in New South Wales. 1975 GCNs employed at CHCs. Source ABS 1972, 1986, 1996.

351

NEW SOUTH WALES 2

Marks 20 3. Write short notes on : NURSES' REGISTRATION BOARD (a) institutional neuroses ; (b) delusions ; REGISTRATION EXAMINATION-PSYCHIATRIC NURSES (c) plnenylkclonuria ; (d) communication ; (e) the role of the nurse in the after care of patients. Psychiatric Medicine 20 4. Write what you know of the causes and treatment of TUESDAY, 30TH MAY, 1967. 9.30 A.M. TO 12.30 P.M. epilepsy. Describe in detail the nursing care and management of a patient suffering from severe epilepsy of the grand mal type who is still subject Five questions only to be answered to frequent fits .

Marks 20 5. Write brief notes on : 20 1 . It is believed that early experience in infancy and childhood are of importance to future mental (a) the causes of insomnia; health. Write what you know of some of the (b) how would you describe to a junior nurse, things in the mother-child relationship and early clectro-convulsive therapy as a form of experiences within the family which are regarded treatment. as being of importance for future mental health. 20 6. What observations and enquiries would you make when admitting a 20 2. Briefly describe the physical and mental characteristics patient who is aggressive, hyper- active and confused, in order to assist the of "Down's Syndrome" (mongolism). Describe a psychiatrist daily programme which could be developed for a to make his diagnosis? group of adolescent patients handicapped by mongolism. Or, 20 Briefly describe the physical and mental characteristics of chronic brain syndrome due to old age. Describe how you would develop a daily programme for a group of patients suffering from senile dementia who are physically well and able to dress themselves and walk around.

91643-1

NEW SOUTH WALES 2

Marks 20 3. What can be done, to reduce the need for administration of the following types of medications? NURSES' REGISTRATION BOARD (a) Analgesics. (b) Apcrients . REGISTRATION EXAMINATION-PSYCHIATRIC NURSES (c) Antacids. (d) Sedatives. (e) Tranquillizers.

Psychiatric Nursing 20 4. Describe the conditions caused by dietary deficiency, stressing the differences between starvation and i malnutrition . TUESDAY, MAY, P.M. To 30TH 1967. 2 5 p.m. Why may these conditions be found among psychiatric patients? Five questions only to be answered 20 5. How would a nurse reassure the following persons?

Marks (a) A man who is very anxious because he is 20 1 . You are to accompany a small group of long-stay to have psychological tests. patients to Industrial Therapy or a Sheltered (b) An elderly woman who fears that she will Workshop five days a week. die having electrotherapy. (a) Explain the underlying aims of this treatment . (c) A young; migrant who is sure that everyone dislikes him because he is a foreigner. (b) How will you help to make the treatment (d) An anxious man who keeps refusing his successful? prescribed medicine. (c) You are also asked to prepare a programme (e) A middle-aged spinster who rings up several for these patients when they are in the ward. times a day to ask how her mother is. State your main considerations . 20 6, What do you understand by domiciliary care? Which members of a psychiatric team would be 20 2. Outline the most important factors in the nursing care of: involved? Suggest how a psychiatric nurse may assist in (a) a severely depressed patient ; / this form of care. (b) an acutely anxious and phobic patient.

91643-2 NOBBYS CAMP. SHANYTOWN SPRUNG FROM THE 'DEPRESSION',1930-1940

HUMPIES AT PLATTS ESTATE, 1953

Newcastle Herald © Newcastle Region Library TABLE 6.2.1 DEMOGRAPHIC AND SOCIO-ECONOMIC INDICATORS FOR THE CATCHMENT AREAS OF FOUR COMMUNITY HEALTH CENTRES BY LOCAL GOVERNMENT AREA FOR 1976 AND 1986. CHARACTERISTICS OF POPULATION AND AGE.

NSW HUNTER LAKE NEWCASTLE MAITLAND CESSNOCK Statist'l Div'n. MACQUARIE 1976 1986 1976 1986 1976 1986 1976 1986 1976 1986 1976 1986 CATCHMENT AREAS, CHCs (sq km) 800,764 30,925 640 195 392 1,962 TOTAL POPULATION (1,000s) 4,777 5,402 419 483 132 154 139 129 36 44 36 42 % of HUNTER POPULATION N/A N/A 100 100 31 31.8 33.1 26.8 8.6 9.2 8.6 8.6

Aboriginal/ Torres St Islander 40451 59011 2008 3839 408 1195 662 910 256 395 98 233 % pop'n Aboriginal/ Torres St Islander 0.8 1.1 0.5 0.8 0.3 0.8 0.5 0.7 0.7 0.9 0.3 0.6 % of total population born in Australia 80.7 77.6 90.1 89 89.8 89 87.7 86.5 92.8 91.9 91.5 91.1 Non-English Speaking Background: % of population overseas born 11.2 13.5 4.4 5.1 3.9 4.7 6.8 7.9 3.8 3.9 2.2 2.6

AGE as % of Total Population. 0 to 4 8.7 7.6 8.6 7.6 9.1 7.7 6.9 6.1 10.3 9.2 9.2 8.2 5 to 14 17.6 15.5 18.1 15.6 20.1 16.6 15.5 12.0 19.4 18.0 17.2 17.3 15 to 24 16.7 16.1 16.9 15.9 16.4 15.5 18.3 17.6 17.3 16.8 16.4 15.3 25 to 44 26.8 30.3 25.1 29.3 26.9 29.8 22.9 27.5 26.7 31.1 24.6 30.1 45 to 64 20.6 19.6 21.6 19.8 19.9 20.1 24.7 21.8 18.7 16.3 21.2 17.8 65 + 9.2 6.9 9.6 11.7 7.6 10.3 11.7 15.0 7.7 8.6 11.4 11.3

Data sources: Australian Bureau of Statistics, Microfiche Census Data on LGAs, 1976, 1986; 1976 Census: Population and Dwellings: Summary Tables (2409.0); Census 86 - Persons and Dwellings in Legal Local Government Areas, Statistical Local Areas and Urban Centres/ (Rural) Localities, New South Wales (2462.0); Census 86 - Age and Sex of Persons in Statistical Local Areas and Statistical Divisions, New South Wales (2454.0). TABLE 6.2.2 DEMOGRAPHIC AND SOCIO-ECONOMIC INDICATORS FOR THE CATCHMENT AREAS OF FOUR COMMUNITY HEALTH CENTRES BY LOCAL GOVERNMENT AREA FOR 1976 AND 1986. MARITAL STATUS AND EDUCATION.

NSW HUNTER LAKE NEWCASTLE MAITLAND CESSNOCK Statist'l Div'n. MACQUARIE 1976 1986 1976 1986 1976 1986 1976 1986 1976 1986 1976 1986 MARITAL STATUS - MALE 15+ as % of Total Population. MARRIED 23.0 22.0 23.7 22.7 29.9 23.2 30.5 21.5 23.2 22.1 23.7 22.3 UNMARRIED 10.6 12.3 9.8 11.5 8.9 10.6 11.0 13.8 9.6 10.5 9.6 10.7 DIVORCED/SEPARATED 1.6 2.6 1.5 2.7 1.4 2.5 1.9 3.3 1.3 2.2 1.5 2.6 WIDOWED 1.0 1.0 1.2 1.1 1.0 1.0 1.4 1.4 0.9 0.8 1.5 1.1 MARITAL STATUS - FEMALE 15+ as % of Total Population. MARRIED 22.9 22.0 23.7 22.8 24.3 23.4 23.5 21.8 22.9 22.2 23.5 22.1 UNMARRIED 7.9 9.5 6.8 8.3 6.2 7.8 8.2 10.2 7.0 8.5 6.0 7.5 DIVORCED/SEPARATED 2.1 3.2 1.8 3.1 1.7 3.1 2.4 3.9 1.6 2.0 1.7 3.1 WIDOWED 4.3 4.3 4.6 4.6 3.6 4.1 5.8 6.0 3.9 3.8 6.0 5.1

EDUCATION MALE as % of Total Population. NONE, or LEFT SCHOOL <15 yrs 8.5 6.9 8.9 7.0 7.9 6.4 9.4 7.7 7.4 5.6 10.5 7.7 TERTIARY EDUCATION 2.5 3.6 1.8 2.5 1.7 3.3 2.2 3.8 1.6 2.9 0.9 1.7 NON-TERTIARY TRADE 8.1 11.0 9.1 12.6 10.4 18.1 9.2 15.2 8.0 16.3 7.9 14.8 NO QUALIFICATIONS 21.4 20.1 21.4 19.9 27.4 24.3 28.0 25.9 30.9 25.5 31.9 27.2 EDUCATION FEMALE as % of Total Population. NONE, or LEFT SCHOOL <15 yrs 9.0 7.5 9.7 7.8 8.7 7.3 11.4 9.7 7.9 6.1 11.4 8.7 TERTIARY EDUCATION 1.8 2.9 1.4 2.2 1.4 3.0 1.7 3.2 1.3 2.9 0.6 1.4 NON-TERTIARY TRADE 4.2 7.0 3.5 6.0 3.7 8.2 3.7 7.7 0.5 7.7 2.9 6.9 NO QUALIFICATIONS 26.7 25.3 28.0 26.9 38.2 34.9 38.2 35.5 39.0 33.1 39.8 37.2

Data sources: Australian Bureau of Statistics, Microfiche Census Data on LGAs, 1976, 1986; 1976 Census: Population and Dwellings: Summary Tables (2409.0). TABLE 6.2.3 DEMOGRAPHIC AND SOCIO-ECONOMIC INDICATORS FOR THE CATCHMENT AREAS OF FOUR COMMUNITY HEALTH CENTRES BY LOCAL GOVERNMENT AREA FOR 1976 AND 1986. INCOMES AND BENEFITS.

NSW HUNTER LAKE NEWCASTLE MAITLAND CESSNOCK Statist'l Div'n. MACQUARIE 1976 1986 1976 1986 1976 1986 1976 1986 1976 1986 1976 1986 FAMILY INCOMES, as % of FAMILIES STATING INCOME Arranged in four bands for comparison 1. 0-$1500 (0-$2000 in 1986) 3.4 1.2 3.0 0.8 2 0.6 3 0.8 3 0.7 3 0.9 2. to $5000 (to $12000 in 1986) 23.1 17.8 27.7 20.5 24 18.8 30 22.3 25 16.9 34 21.2 3. to $9000 (to $26000 in 1986) 30.4 32.7 31.3 34.1 31 33.1 31 34.2 33 33.6 29 32.0 4. above $9001 (>$26000, '86) 43.0 48.2 38.0 44.5 43 47.4 36 42.6 39 48.8 35 45.9

MALE INCOMES, % of MALES aged 15, 15+ 1. 0-$1500 (0-$2000 in 1986) 9.8 7.4 8.9 6.0 9 6.2 9 6.2 10 6.0 10 5.2 2. to $5000 (to $12000 in 1986) 20.6 30.8 24.4 34.3 23 32.9 24 37.4 22 29.2 28 34.1 3. to $9000 (to $26000 in 1986) 41.0 40.4 41.8 38.6 41 38.8 43 39.2 46 43.1 38 33.2 4. above $9001 (>$26000, '86) 23.5 15.9 21.0 16.5 24 18.0 21 13.2 19 16.8 19 20.6

FEMALE INCOMES, % of FEMALES aged 15, 15+ 1. 0-$1500 (0-$2000 in 1986) 33.9 23.2 37.5 25.3 41 26.5 34 21.2 38 27.2 35 26.5 2. to $5000 (to $12000 in 1986) 33.5 44.7 36.6 49.5 34 48.3 39 52.4 34 46.5 41 51.2 3. to $9000 (to $26000 in 1986) 19.7 21.9 14.6 16.3 14 16.1 16 18.1 16 17.8 14 13.8 4. above $9001 (>$26000, '86) 3.6 3.1 2.5 1.9 3 1.9 3 2.1 3 1.7 2 1.1

% POP'N RECEIVING BENEFITS 16.8 19.2 18.9 22.0 16.5 23.2 Data sources: Australian Bureau of Statistics, Microfiche Census Data on LGAs, 1976, 1986; 1976 Census: Population and Dwellings: Summary Tables (2409.0) The information on benefits was not gathered in 1986 Census Appendix 6.2. Unemployment Comparisons

1976 Unemployment as % of Population aged 15-64

4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 NSW LAKE

HUNTER FEMALE MALE MAITLAND NEWCASTLE CESSNOCK TOTAL

1986 Unemployment as % of Population aged 15-64

6 4 2 0 NSW LAKE

HUNTER FEMALE

MAITLAND MALE NEWCASTLE CESSNOCK TOTAL

Source: ABS Census Data 1976, 1986.

354a Appendix 7.1. Vacancies in the Hunter Region (Summary of Newcastle Herald reports)

8 August 1981.

HUNTER SHORT OF HEALTH WORKERS (by Faye Lowe)

The Minister for Health, Mr. Stewart, and the chairman of the NSW Health Commission, Dr. McEwin, had acknowledged that the Hunter Region was short of 25.5 community health positions and needed 34 positions filled to give the region parity with other regions, Dr. Paul Mofit said yesterday. Dr. Mofit, director of the Diabetic Education and Stabilisation Unit at Royal Newcastle Hospital was part of a four-man delegation that met Mr. Stewart and Dr. McEwin on Wednesday to ask for more community health staff in the Hunter Region. The delegation resulted from two public meetings on community health held in Newcastle on April 23. Dr. Mofit said the delegation went to Mr. Stewart to stress the importance of community health on the Hunter Valley and to suggest some remedies.

Matter rests on finance

Mr. Stewart and Dr. McEwin said they knew that the Hunter Valley was disadvantaged in community health and were hopeful of correcting it. But the matter rested on the amount of finance that would be available, they said. One firm commitment that Mr. Stewart and Dr. McEwin had made was that Dr. Tom Boleyn would be appointed acting deputy regional director with executive autonomy over community health. "But in fact they promised us nothing," Dr. Mofit said. "They have given us Tom Boleyn, but have given him nothing to work with."

9 September 1981

COMMUNITY HEALTH LIFT (by Faye Lowe)

Approval for the recruitment of 19 more community health workers is expected to be given to the Hunter Region of the NSW Health Commission in the next few weeks, according to a spokesman for the Minister of Health, Mr. Stewart. Already wheels are in motion for 12 of those appointments to be filled, bringing numbers to wight above the existing ceiling. But the 19 replacement appointments, which are expected to be filled by the end of the financial year, will not bring the Hunter Region into line with staffing levels in the rest of the State. It was reported in The Newcastle Herald on August 8 that the Minister for Health, Mr. Stewart, and the chairman of the NSW Health Commission, Dr. R. McEwin, had acknowledged that the Hunter was short of community workers and needed 34 to give it parity with other regions.

Ceiling lifted

The issue was being discussed with a four-man community health delegation from the region. Although the Commission's regional director, Mr. B. Geraghty, could not comment on the proposed new appointments it is understood they will include a baby health sister for the Upper Hunter, a speech pathologist for the Lower Hunter, a receptionist for the East Lakes team, a community nurse for the city team, a senior community nurse for the East Lakes team and three more mental health nurses for the region. The increase in numbers of community health workers in the region is part of the State Government's new policy to lift the staff ceilings of the service from 1807 state wide to 1940. The Hunter's ceiling is expected to be lifted from 109 to 128. This proposal has yet to be ratified by the commission's central office in Sydney.

359 Community Health

Speech TD ;atrlolo~v

Appendix 7.3. Changes in the incumbents of community physician/team leader and senior community nurse positions in four teams between 1975 and 1989 in five year blocks.

1975-1978 1979-1983 1984-1989 CHC team TL SCN TL SCN TL SCN Maitland 2 2 2 2* 1* 2 Toronto 1** 1** 2** 4* Windale 4 2 2* 1 1 1 Newcastle West 2* 1 1 1 Source: Health Commission reports and team records. *Indicates that another team member relieved in this position as the appointed incumbent was absent for up to two months in any one year. ** Indicates periods of absence exceeding two months and as long as long as eight months. Absences due to annual leave are not included.

361 PROPOSED ORGANISATIONAL CHART FOR HEALTH EDUCATION, HUNTER RE LION

REGIONAL DIRECTOR

Deputy eg,l o uec r

Assistant Regional Director [from Dr W. Vickers for discussion at Conanunit} Health the 9 .12 .1974 meeting[

Senior Community Physician

SetAer Regional Health- Education Officer 'Heat Education officers uturmation FPa_ah~ ~arti4nG

East Lower Manning & Port Upper Lakes Hunter Great Lakes Stephens Hunter

r FCT M~Tos . COM.MTITY HEALTH .SPONMMf1'YRES CHART

REGION REGIONAL DIRECTOR L

Re gional Cotnnimity Physician 4 Professional Advisers * Nursing * .Paramedical Coordination Teem r- ClericalStafT 9 i

n . I Care

"Ace,a Ceritre Stet i , i * ~Istt~e~r~ic l i a' P~atruet~ cal ""etu -jr C otimiurdty Nuts e '" Syveciat st 3quzsing '" ~4enrtil II li

Tears Laders (Satellife Centres) * NeighbourhoocVDisttict~ L3ureau of Pzno: l He='th Servces Discussion Paper T Shopfront j Communil",ryHea1th Proposed Re ~'.oral Re-ponsbility Structure DH JF.77I lssuedbv I~r «. Barclay, Commissioner for Personal Services] *Prim= Appendix 8.2. GCN Statement of Duties

STATEMENT OF DUTIES

Title under Award or Agreement COMMUNITY NURSE Code No. …………

Departmental Title COMMUNITY NURSE (GENERALIST) Grade or Class of Position … WITH PSYCHIATRIC CERTIFICATE

Department HEALTH COMMISSION OF NEW SOUTH WALES

Division of Department HUNTER REGION Branch or Town NEWCASTLE

Responsible to: The Community Physician or Team Leader for general administration of community services.

Responsible to: The Senior Community Nurse for the maintenance of professional nursing standards and nursing services.

Detailed statement of duties: This will include:

1. Perform school medical screening in allocated schools and assist the school medical officer in the medical examination and assessment of school children. Provide follow-up services in the home environment.

2. Provide support, counselling services, education and refer necessary members of the community with special health needs.

3. Provide assistance to meet the ongoing needs of members of the community requiring domiciliary care and provide such nursing care as necessary.

4. Liaise and consult, as necessary, with agencies and personnel in the fields of health, education, and welfare.

5. Stimulate and participate in health education of the family and the community.

6. Investigate and follow-up cases of infectious disease as necessary.

7. Maintain a daily diary of client contact and workload performed. These diaries are the property of the Health Commission and are legal documents, and must be produced on request.

8. To perform specific duties involving primary, secondary and tertiary levels of intervention in preventive psychiatric practice. … /over The statement of responsibilities should not exceed the space provided. The above is a brief statement of the duties of the position at ……………………………………….. Branch Head ………………….. Permanent Head ……………………………. Date ……………………. Date …………………..

As occupant of this position, I have noted this Statement of Duties. Name …………………………………………… Signature ………………………………………. Date……………………………………………..

364 Appendix 8.2. GCN Statement of Duties

To apply specific skills in case situations when the aims of intervention embrace early recognition of mental disorder, appropriate remedial action and maintenmance of optimal level of remission.

To assess and arrange suitable alternatives for clients in order to prevent, if possible, the need for psychiatric hospitalisation or re-hospitalisation.

9. Undertake primary psychiatric assessment visits to clients within the community, referred from a variety of sources which include voluntary, statutory, business agencies, local area and other psychiatric service agencies.

10. Conduct in depth assessment of client's presentation and circumstances; and responsible for decisions regarding appropriate psychiatric remedial intervention plans, or for alternative agency referral disposition.

11. Undertake priority crisis intervention visits to disturbed persons in the community and to provide emergency psychiatric assessment and appropriate intervention.

12. Undertake on such visits the initial and sole responsibility for intervention with acutely mentally disturbed persons.

13. Responsible for the various appropriate sections as laid down by the Mental Health Act.

14. To work in conjunction with visiting consultants - e.g. psychiatrists, psychologists, etc.

15. To have thorough knowledge of all services operating in the area and to make any changes that are necessary to ensure optimal efficiency.

17. (sic) Perform any other duties as required by Team Leader or Senior Community Nurse.

365 Appendix 8.3 Federal, State & Regional political and organisational changes affecting CHCs from 1975 to 1989

HISTORICAL DEVELOPMENT OF COMMUNITY HEALTH CENTRES

1973/1974 1975 1976 1977 1978 1979 1980 1981 Regional Director appointed, New Regional BHC Nurses School Medical Service Senior CMHP begins Director appointed amalgamated amalgamated with officers with CHCs CHCs transferred

Newcastle Psych Centre WINDALE CHC WINDALE CHC WINDALE CHC EAST LAKES Mental Health Teams Jun-75 CHC Charlestown Newcastle Morriset Psych Centre TORONTO WEST LAKES Mental Health Team Sub-team CHC Toronto School Medical Service NEWCASTLE NEWCASTLE NEWCASTLE Doctors & Nurses CHC moved to CHC CHC Parry Street NEWCASTLE NEWCASTLE Wallsend District Hospital WEST sub-team WEST sub-team District Nursing Service Royal Newcastle Hospital District Nursing Service Morriset Psych Centre LOWER HUNTER LOWER HUNTER LOWER HUNTER Mental Health Team CHC CHC CHC Cessnock Allendale Hospital Sub-Centre Sub-Centre Domicilliary Nursing CESSNOCK CESSNOCK

Maitland District Hospital District Nursing Service Cessnock District Hospital District Nursing Service Family Psychiatric Team, Parry Street Child Guidance Service

Problems Based CHC statistical data Save Community Report on Save Community Records,SOPE collection Health Campaign Teamwork Health campaign July 1974 freeze imposed on Embargo on new Staff postions Recruitments Freeze Freeze- extended Total freeze. review filling vancies in CMHP. RDs postions and filling approved by PSB allowed within recruitment to January 1981 of Establishments advised to recruit in December vacancies and Treasurary budget ceases CHA formed in Weekly monitoring NSW

Source: Regional, State Records and Reports.

366 1982 1983 1984 1985 1986 1987 1988 1989 1990 Regional CHP Area Newcastle West Administration Hospital Four AHBs CHC CMHNs Director coordin- CHC of CHCs Boards disetablished tranfered to transferred ators administered tranferred from Disestablished to form one Mental Health New appointed by WDH as pilot Regional Office four AHBs formed AHB for the Service RD appointed to WDH & Hunter Region Health Promotion MDH ActivitySurvey Activity Survey Unit CHP (1) CHP (2)

Strategic Plan Strategic Guide to hospital Program HACC Nurses Review of CHP Report on for Hospitals Plan for CHP management, CHP Budgeting employed at CHCs administration Domiciliary Nursing New CHP Area Cordinators and Lake Macquarie disestablished to form a NEWCASTLE CHC

NEWCASTLE WEST CHC CHCs in Newcastle Newcastle CHCs in Primary Care and Nursing Service All health services, hosptials, AHBs. by CHCs administered CHC client of Collection registrations begins

LOWER HUNTER LOWER HUNTER CHC CHC CHC

NORTHUMBERLAND CHC teams Continued as generalist

Hausfeld McHarg Report report Freeze from Freeze on CHP Freeze Freeze Freeze Dec-81 and Schedule V ACHA established

366 Appendix 9.1. Generalist Nurses' Guidelines, 1975

GUIDELINES OF DUTIES : Dr. Vickers

COMMUNITY NURSE ― Lower Hunter Region

1. Responsibility:

1.1 Professionally responsible to Dr. Vickers; Co-ordinator of Community Health Services in the Hunter Health Region. 1.2 Responsible to the Regional Nursing Officer for all matters of an industrial nature. 1.3 In matters concerning Community Health requirements in geriatrics and chronic disability, Dr. Vickers will consult with Dr. Gibson (Regional Geriatrician and Co- ordinator of programmes for the chronic desabled).

2. Location:

2.1 The Team base will be at Maitland, but nurses will be posted at the discretion of the Team Leader. 2.2 A receptionist has been appointed to service the centre needs. Telephone 334422.

3. Transport:

3.1 Commission transport will be provided.

4. Geographic Areas of Working:

The Sectors and Geographic Areas they cover are as follows:― City of Maitland City of Greater Cessnock Dungog Shire

5. Source of Referral of Cases in Geriatrics and Chronic Disabled:

5.1 No matter what the source of referral the patient's own family doctor must be contacted, either prior to or immediately after first contact with the patient, in order to co-ordinate the medical and nursing care of each individual, co-ordination with the Medical Officer must be continuously preserved.

367 Appendix 9.1. Generalist Nurses' Guidelines, 1975

5.2 It is hoped that in the majority of cases, the source of referral will be the family doctor, 5.3 Cases may be referred, on or prior to discharge, by a hospital authority.

6. Reporting and Record Keeping:

6.1 In all cases, regular reporting of current status of a patient must be made to the referring source, (e.g. Local Medical Officer or Hospital Domiciliary Care Service). 6.2 Monthly reports must be furnished to the Community Physician or Team Leader. 6.3 Case records will be maintained on the forms issued by the Hunter Regional Office.

7, Equipment ― Drugs and Dressings:

7.1 Initially, and until other arrangements are made, equipment (walkers, Commodes, etc.,) will be drawn on loan from Allendale Hospital as part of the existing Domiciliary Care Service of that Hosp[ital. 7.2 Drugs should be supplied on prescription by the family Doctor. 7.3 Dressings should be drawn from the Allendale Hospital (including disposable draw sheets).

8. Liaison:

8.1 It is envisaged that a Local Community Health Management Group will be set up to coordinate the unctions of the various elements of the Community Health Service ― this will be a Management Committee not to be confused with any local Community Health Advisory Committee that may be set up in the future. 8.2 The local Community Health Management group should be constituted by:―

All salaried clinical staff attached to the team, School Counsellor ― Department of Education District Officer ― Department of Youth & Community Affairs. A local Government Health Surveyor A nominated General Practitioner. 8.3 The local Management Group may have power to co-opt ― e.g. a Hospital District Nursing Sister. 8.4 The Community Nurse must establish and continue the closest liaison with the Allendale Hospital and existing domiciliary services.

368 Appendix 9.1. Generalist Nurses' Guidelines, 1975

9. In general terms, the duties of the Community Nurse in the Lower Hunter Region would be such that maximum efficiency as maintained in all areas requiring the services of a nurse who works in the community, e.g. Community Nursing, Domiciliary Nursing, District Nursing, Health Education and liaison with all other agencies offering hospital and community health resources.

10. The nurses will be required to attend a three months inservice training programme and show a satisfactory performance during the course and at the examination.

369 Appendix 9.2 Ideal and Actual Population to Practitioner Ratios.

Ideal and Actual StaffingRatios.

450000 A

400000 B

C 350000

D 300000 E

250000 F

200000 G

H 150000 I

100000 J

50000 K

L 0 IDEAL ACTUAL M

A = COMMUNITY PHYSICIAN B = COMMUNITY NURSE C = BABY HEALTH CENTRE SISTER D = SPEECH THERAPIST E = CLINICAL PSYCHOLOGIST F = SOCIAL WORKER G = PHYSIOTHERAPIST H = CHIROPODIST I = CHILD PSYCHOLOGIST J = WELFARE OFFICER K = MEDICAL OFFICER L = SCHOOL MEDICAL NURSE M = HEALTH EDUCATION OFFICER

370 Appendix 9.3. Examples of the activities of CHC teams between 1975 and 1989.

Eastlakes CHC (Windale) Individuals and families • Counselling • home nursing (including some after hours) • drug and alcohol counselling • mental health clinics • speech therapy • social work Screening/prevention • baby health clinics • school medical • brush-in's (stannous fluoride application to teeth) • immunisation Self-help group, health education • self weight • self-help • dial a mum • health education for parents • problems with living • health education in high schools (breast self-examination, non-smoking and personal hygiene) Community development From 1985 • volunteer group Kahibah • volunteers group Swansea • pilot parents support group, Croudace Bay Spastic Centre • playgroups, Swansea, Charlestown and Windale.

Westlakes CHC (Toronto) 1985-1986; Individuals, families and groups • day centre for elderly persons at Cardiff • speech therapy groups for children with communication disorders • counselling • assessment • home visiting • mental health clinics • mental health consultations • clinic for persons with a chronic illness • home nursing for aged and terminally ill • crisis intervention • consultation between baby health and Youth and community services • grief and bereavement counselling • day centres/penny day centre

Screening/prevention • immunization programmes in high schools • school screening vision and hearing • diagnostic audiometry • scoliosis screening in high schools • baby health clinics

371

Self-help group, health education • courses on child care • mother support group • stress management and relaxation courses • Westlakes ADARDS group • CPR groups to sixth class school children • first aid lectures to high school students • talks to groups (eg. Westlakes carers group) • talks to toddlers groups • Community Youth Support Scheme committee • show day activities • Cardiff High School year eleven orientation to camp

Community development • representing the team as members of community committees • training program for volunteers • resource for playgroups • Myuna Bay Clinic • mental health week activities • health stall at Bolton Point school fete

Lower Hunter CHC (Maitland) Individuals and families • psychiatric clinics • counselling/therapy/testing • nursing assessment and home nursing management and support • information about health related services and groups in the local area • speech therapy and assessment • support for families and individuals in times of stress and crisis • support services for local medical practitioners and hospitals • sexual assault counselling • PAPD assessments • volunteer and staff training programs Self help and Health education • parenting programs • preparation for parenthood classes (difficulty experienced involving GPS (TLM 7.6.1978) • child behaviour management program • groups for mothers of toddlers • Preparation for school program • Woodberry school personal development program • women's discussion group • Mastectomy rehabilitation group (running independently, June 1978) • bereavement program for year ten students • stress management and relaxation courses • bereavement workshops • counselling training workshops • country freedom day centre (persons with mental illness) • agoraphobic group • child home safety

372

• education on domestic violence • health craft for over 50's • battered women's program • nutrition • heart week • allergy groups • post natal support group • divorce and recovery group • single parent groups • menopause programs • playgroups for children with handicaps • multiple birth groups • personal development programs in high schools • health poster and pamphlet displays at shopping centres and baby health centres • talk to nursing students about community health • Dental health week brush-ins at high schools • Senior citizens week, children's drawing competition, prizes donated, media used. • Lifestyles program Tocal Agricultural college (9 weeks) • Ran discussion groups for various organizations • Production of a video on hair care • womens health seminars • food and fitness classes • health craft for over 50's • nutrition • heart week Community Development • meals-on-wheels service established • Gresford Youth Group (ceased when transport identified as the major problem). • care for me program a pilot personal development project at a primary School involving teachers, parents and other agencies • small farms day • farm safety and small farms day • newspaper column • Seminar for education department on communicable diseases • Counselling course for trainee ministers at St Johns College special projects • isolated schools-speech pilot project • Cessnock Preventative heart risk program (with Health Promotion Unit)

Wallsend CHC Individuals and families • podiatry clinic • mental health clinic • early childhood clinic • domiciliary nursing Screening and prevention • school medical services • immunization programmes

373

Self help and health education • systematic training for effective parenting • mother craft programs • adolescent education for parents using schools • personal development study days, sexuality, drugs, community resources • stress management • health happening (an exercise promotion) • back care program in conjunction with Hunter Rehabilitation • osteoporosis seminar • menopause groups • Polish and Greek Diabetic group • walking for pleasure • middle years support group • skin cancer awareness in preschoolers • Wallsend self help group • Slip, slop, slap campaign • skin care awareness • talks to primary schools about community health services • skin cancer awareness • Senior Citizens week, safety week, kidney week Community development • study of services for aged/frail aged • Lambton Carer Group • Volunteer Groups • Carers education groups with hospital Rehabilitation unit • Frail aged concert with senior citizens • Coordination of Polish Day Centre • Liase with University, Cardiff Workers Club, Hunter Drug Advisory Service Community assessment • Wallsend Community Health Project (a survey with community) • New services established by June 1988 including • early childhood clinic with Marylands Neighbourhood centre • child health clinic with the child Development Unit with a registrar The team obtained funding to produce and distribute two health games, "Not so trivial pursuit" and "Heart care" , a slide tape "what is community health?" and a video on normal child development developed with a child care centre and education Faculty at the University of Newcastle. Team members were represented the team on various regional and community Committees including; • Health Advancement Group • Wallsend and community health Steering Committee • Wallsend Hospital health Advancement committee • Data collection committee • Ongoing in-service for Home and Community Care • Home Nursing Interagency

Source: Minutes of team meetings, team records, newspaper reports, interviews with practitioners.

374

Appendix 9.4a Neetings, structure and processes from 1975 to 1989

CHC TEAM ADMINISTRATIVE MEETINGS, 1975 to 1989

CHCs 1975 1979 1984

Week 1 EASTLAKES PM, fortnightly PM, fortnightly (Windale) Administration Administration Reporting Reporting Information giving Information giving Allocating clients Allocating clients Guest speaker Guest speaker

WESTLAKES PM PM, weekly (Toronto) Information giving Intake (W) Team meeting(W) Allocating clients Case review (W1) Guest speaker Team meeting (W1) Team meeting (W) Team meeting (W1) Rotating chair and minutes secretary

LOWER HUNTER PM, fortnightly PM AM Client allocation (W), Case Review (W2,4) (Maitland) Reporting Guest speaker (1/4) Client allocation (W)

Information giving Guest speaker (W1) Rotating chair and Allocating clients minutes secretary Guest speaker Team building days Intake system Annual planning day Case review (W)

NEWCASTLE WEST Client allocation (W) (Wallsend) Administrative meeting Education Rotating chair, minutes secretary Intake system Teambuilding Planning at sub-centres

376 1986 1986/1987 1987 1989 Area Health Boards Week 2 Week 3 Week 4 Week 5

Intake system

Intake Intake Intake Intake

Intake discussion Intake discussion Intake discussion Case review Team policies, Team policies,priorities priorities (W2&4) Team meeting (W2&4) Team policies,priorities Team meeting Team meeting Team meeting special issues (W5) Skills, nurses Speaker (W3) Skills, nurses(W2&4) Team building (W2&4) Intake system

AM AM AM AM PM(W1&3)

Client allocation (W) Client allocation (W) Client allocation (W) Client allocation (W) Administration

Case management Case management (W2&4) (W2&4) Case Review Case Management

371

376 Appendix 9.4b. New Program Proposals

NEWCASTLE COMMUNITY HEALTH CENTRE. NEW PROGRAMME PROPOSALS.

A formal procedure should encourage staff to submit proposals because it clarifies what they have to do. Some staff may be intimidated by the paperwork and formality, however, this will be less frustrating than having projects refused because certain steps were omitted. When assessing a programme proposal I will be considering the issues listed below. I wish to share these with you in an attempt to clarify our expectations of each other. 1. Give name and brief description of project. 2. Specify the primary target group, plus any secondary target group. 3. What are the specific objectives of the programme i.e. what are you hoping to achieve? 4. How do these objectives relate to health? 5. What have you done to find out if there is a need for this service and whether it is acceptable to the community? 6. What alternative approaches were considered and why were they rejected in favour of the present approach? 7. Is there any other agency or organization in your area carrying out this activity? If yes, specify. 8. What resources (including time and staff) would be required to implement this project? 9. Is there support from other Community Health Centre staff for this project? 10. What activities will need to cease so that this programme can proceed?

TONY TURNBULL Team Leader.

377 Appendix 9.4c Education Sessions 1982

EDUCATION SESSIONS FOR 1982

VENUE: Conference Room at 10.30 a.m. On the fourth (4th) Monday of the Month commencing in March.

March 22nd A report on the National Community Nursing Conference. Speakers: Liz Ballantine, Sybil Lovell, Shirley Schulz.

April 26th Depression: An overview of depressive Illness. Speaker: Dr. Jannette Martin

May 24th The effects of depressive illness On the family unit. Speaker: Dr. G. Rickarby

June 28th Topic to be confirmed

July 26th The law and the professional. Speaker: To be confirmed.

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