Allied health leadership : critical for successful primary health care reform

Study Aim This study examined the ways in which primary health care was represented by Medicare Locals and how these representations impacted on how Allied Health Professionals formed meanings and therefore approached integration, collaboration and multidisciplinary ways of working as leaders in primary health care. Background In the early 2000's, the Australian government made a commitment to improve the health and wellbeing of its diverse populations by undertaking major reform in the primary health care sector. Major structural reforms, including the dismantling and reorienting of the Divisions of General Practice to establish 61 Medicare Local organisations, was implemented in 2011. To diversify leadership and foster interprofessional collaboration, Medicare Locals were mandated to appoint Allied Health Professionals to their governing Boards. The establishment of a skill base that included Allied Health Professionals provided a rich basis for a case study on ways primary health care was constructed in the overarching policy documents for Medicare Locals and enacted in leadership practices. Methods In this critical, retrospective study a qualitative research design informed by a language-centred approach brought together different theoretical orientations. It used power as the main theoretical lens and drew on Foucault's socio-cultural theories of language, power, discourse and identity. Critical discourse analysis refers to various semiotic methods used for examining the signification and meaning explicit and implicit in written and spoken texts. Use of Fairclough's critical discourse analysis framework made it possible to critically examine how power was exercised through discourse. The framework enabled an in-depth analysis of the Medicare Local documents, and interviews with seven Allied Health Professionals who were in leadership roles on the Boards of Medicare Locals. Allied Health Professionals' leadership identity was also explored, and these combined insights enabled a deep examination of the cultural dimensions of comprehensive primary health care reform, including integration, collaboration and multidisciplinary ways of working. Findings Complex relations of power exist in primary health care. The major themes from analysing the policy framework documents were the Australian government's prescribed vision and mission for Medicare Locals, the interpretation of the guidelines to develop Constitutions and health for all, which included the sub themes the need for health improvement and discursive tensions in promoting health and primary care. The medical model, its associated biomedical discourse and a professional discourse that underpins the traditional hierarchy within the health professions persists. Medicare Locals, charged with implementing primary health care reform, and its associated discourses of health, health promotion and community dimensions, were sites of tension for Allied Health Professionals acting as leaders in their Board member roles. The seven Allied Health Professionals interviewed were profiled. The major themes emerging from the interviews were bringing Allied Health Professionals to the table, experiences of being at the table, and enacting leadership to achieve the vision and mission of Medicare Locals, and the tension between directives, rhetoric and reality. Experiences of Being at the Table included the sub-themes: Being Silenced, Finding Voice, and Being Heard. Being Silenced. Enacting leadership to achieve the prescribed vision and mission of Medicare Locals included contributions to health planning, leading Primary Health system transformation, and the glue in the system. There was a tension between the directives, rhetoric and reality experienced, however some Allied Health Professionals considered their inclusion in Medicare Locals facilitated integration and multidisciplinary collaboration by providing a new vision, and through their multidisciplinary ways of working, saw Allied Health as the Glue in the System. Bringing Allied Health Professionals to the Board table facilitated a new vision for comprehensive primary health care, and integrated, multidisciplinary collaboration. However, processes of othering marginalised communities as well as the Allied Health Professionals who had to negotiate belonging. Some were at risk of falling into a subservient role of Doctor's Assistant and playing a 'Doctor-Allied Health Professional game' while others found voice and developed a strong Allied Health leadership identity which they used to ensure they were Being Heard in primary health care. Conclusion Bringing Allied Health Professionals to the Board table in Primary Health Care is merely the first step in achieving better health through integrated, multidisciplinary collaborative practice. The next step involves Being at the Table and ensuring they are Being Heard and supported to share their views, understanding and ideas about advancing comprehensive primary health care. Transformative, inclusive and democratic leadership attributes were demonstrated by some of the Allied Health Professionals. These qualities are instrumental for transforming the health professional hierarchies and cultures that have impeded successful primary health care reform and replace them with innovative leadership for coordinating, connecting and managing services and interventions. They are also important for disrupting the othering of communities to situate them at the centre and engage them in health service planning at the local level. With ongoing support and development, Allied Health Professionals are well-placed to lead comprehensive primary health care, the preferred model for improving Australia's health. Lurching from one policy directive to another in the absence of timely and robust evidence is disruptive and counterproductive. Supportive mechanisms to inspire and foster strategic change management, innovation and leadership are lacking. Discourse, power and identity influence cultural perspectives in primary health care and shape what people can and cannot do. The ongoing evaluation of primary health care renders understanding these dimensions critically important for improving the success of future health reform. Critical transformative research can give voice to the intended beneficiaries of policies and provide a mechanism for driving meaningful change in primary health care practice.