A Case Study of the Hunter Region, New South Wales 1974 -1989
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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 COPYRIGHT STATEMENT 'I hereby grant the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all proprietary rights, such as patent rights. f also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation. I also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstract International (this is applicable to doctoral theses only) . I have either used no substantial portions of copyright material in my thesis or I have obtained permission to use copyright material; where permission has not been granted I have appliedlwill apply for a partial restriction of the digital copy of my thesis or dissertation. _ Signed Date AUTHENTICITY STATEMENT 'I certify that the Library deposit digital copy is a direct equivalent of the final officially approved version of my thesis. No emendation of content has Occurred and if there are any minor variations in formatting, they are the result of the conversion to digital format' 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