Primary Health Care In Australia Research Articles

Cost-Effectiveness of Treating Hepatitis C in Clients on Opioid Agonist Therapy in Community Pharmacies Compared to Primary Healthcare in Australia.

Meeting the World Health Organisation 2030 target of treating 80% of people with hepatitis C virus (HCV) in Australia requires accessible testing and treatment services for at-risk populations. Previous clinical trials, including those in Australia, have demonstrated the efficacy of outreach programmes to community pharmacies offering opioid agonist therapy (OAT). This analysis evaluates the potential cost-effectiveness of introducing an outreach programme in community pharmacies. Using a decision analytic model, we estimated the impact of adding a temporary hepatitis C outreach and treatment programme in community pharmacies to the standard treatment pathway available through general practice. We compared the expected number of tests, diagnoses, cures and costs occurring through the addition of this outreach and treatment programme to those expected through general practice alone over a 12-month time horizon. We examined costs from the perspective of the health system and conducted one-way and probabilistic sensitivity analyses to assess uncertainty in model parameters and test key assumptions. In the model adding the outreach programme pathway increased the number of tests from 4178 to 8737, the number of diagnoses from 615 to 1285 and the number of cures from 223 to 777 among people on OAT over a 12-month period. Each additional cure achieved through the addition of the outreach programme was estimated to incur $48,964 (AUD 2023) to the health system, with > 85% of these costs attributable to medication and dispensing expenses. The average cost per cure was estimated to be $49,152 through routine care and $49,018 in the outreach programme. Although outreach models of care incur large upfront costs, they can capture otherwise unreached populations and result in comparable or favourable cost per cure, due to higher levels of engagement and lower rates of loss to follow-up.

Transforming health care delivery: The role of primary health care nurses in rural and remote Australia.

This paper describes the policy context and approaches taken to improve access to primary health care in Australia by supporting nurses to deliver improved integrated care meeting community needs. In Primary Health Care (PHC), the nursing workforce are predominantly employed in the general practice sector. Despite evidence that nurse-led models of care can bridge traditional treatment silos in the provision of specialised and coordinated care, PHC nurses' scope of practice varies dramatically. Nurse-led models of care are imperative for rural and remote populations that experience workforce shortages and barriers to accessing health care. Existing barriers include policy constraints, limited organisational structures, education and financing models. The Australian Primary Health Care Nurses Association (APNA) received funding to implement nurse-led clinics as demonstration projects. The clinics enable PHC nurses to work to their full scope of practice, improve continuity of care and increase access to health care in under serviced locations. We reviewed a range of peer-reviewed literature, policy documents, grey literature and APNA provided sources, particularly those relevant to rural and remote populations. We argue more focus is needed on how to address variations in the scope of practice of the rural and remote PHC nursing workforce. Despite growing evidence for the effectiveness of nurse-led models of care, significant policy and financial barriers continue to inhibit PHC nurses working to their full scope of practice. If their potential to transform health care and increase access to health services is to be realised these barriers must be addressed.

Successes and challenges of primary health care in Australia: A scoping review and comparative analysis.

Australia has achieved universal health insurance for its population since 1975 - a major step forward for increasing access to primary care (PC). Nevertheless, there are reports of several multi-layered challenges, including inequity, that persist. This analysis aims to undertake a scoping review of the success, explanatory factors, and challenges of Primary Health Care (PHC) in Australia guided by the World Health Organization (WHO)-defined key characteristics of good PC. We searched PubMed, Embase, Scopus and Web of Science using key terms related to PHC principles, attributes, system functioning and health care delivery modalities. We also used key PC terminologies used to assess key characteristics of good PC developed by WHO and key terms and attributes from Australia's health care landscape. We then integrated our search terms with the PHC Search Filters developed by Brown, L., et al. (2014). We restricted the search from 2013 to 2021. Two authors independently assessed study eligibility and performed a quality check on the extracted data. We presented findings according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We identified 112 articles on primary health care (PHC), represented from all Australian states and territories. Overall, Australian PHC has achieved comprehensiveness, access and coverage, quality of care, patient / person centeredness and service coordination indicators with exemplary evidence-base practice/knowledge translation and clinical decision-making practices at the PC settings. Yet, we identified complex and multilayered barriers including geographic and socio-economic berries and inequality, staff dissatisfaction/turn over, low adoption of person-centred care, inadequate sectoral collaboration, and inadequate infrastructure in rural and remote primary care units. Primary health care in Australia, which has evolved through major reforms, has been adapting to the complex health care needs of the socio-culturally diversified nation, and has achieved many of the PC attributes, including service diversity, accessibility, acceptability, and quality of care. Yet, there are persistent gaps in service delivery to socio-economically disadvantaged populations, including indigenous people, culturally and linguistically diverse (CALD) populations, and rural- and remote-residents. These challenges could be mitigated through system-wide and targeted policy-level intervention to further improve service delivery through effective and functional local health service coordination, sectoral integration, and improving health care providers' cultural competence.

When primary healthcare meets queerstory: community-based system dynamics influencing regional/rural LGBTQ + people’s access to quality primary healthcare in Australia

BackgroundLesbian, gay, bisexual, transgender, Queer, and people of any other minority sexuality or gender identity (LGBTQ + or “Queer”) are often marginalised from accessing quality primary healthcare (PHC) in their local community. This is largely due to Queerphobic, cis-heteronormative/sexist systems pathologising Queer life and identities. The study aims were to: (1) identify key priorities for increasing Queer people’s access to quality PHC as told by Queer people themselves, (2) identify the feedback loops that reduce or support Queer people’s access to quality PHC in non-metropolitan, regional/rural communities, and (3) identify potential action areas to improve system structures to increase Queer people’s access to quality PHC.MethodsGroup Model Building (GMB) workshops were held with a small group (n = 8) of LGBTQ + people in regional Victoria with lived experience of using PHC services. This participatory approach permits exploration and visual mapping of local structures causing behaviour patterns of community concern over time – in this case, Queer people’s ability to access quality PHC in the Geelong-Barwon region. This is the first study that specially applies GMB in Queer PHC in the non-metropolitan regional/rural context.ResultsKey community identified PHC priorities were: (a) providers’ level of Queer Literacy, (b) the responsibility of Queer Advocacy (at individual, systemic, and collective levels), (c) support from safe Queer Spaces, (d) strength from a Queer Presence, and (e) power from Intersectional Queer Life. These priorities interconnected, creating system-level feedback loops reinforcing barriers and enablers to Queer people’s access to quality PHC in the Geelong-Barwon region; with potential action areas identified.ConclusionsImproving Queer people’s access to quality PHC in the Geelong-Barwon region requires embedding principles of Queer Literacy, Queer Advocacy, Queer Space, Queer Presence, and Intersectional Queer Life within practices and service systems. The study findings were distilled into a novel, preliminary set of Queer Equity Principles. These need to be taken back to regional Queer communities for further co-design and planning for translation across PHC practices and systems, with potential applicability in other areas of the healthcare spectrum.

Nurses Transitioning to Primary Health Care in Australia: A Practice Improvement Initiative.

Current nursing programs provide little pre-registration information and clinical exposure to primary health care nursing practice. Newly graduated nurses and those transitioning to primary health care report disorientation and confusion. Limited knowledge about the ideal elements of a program to support transitioning nurses is an imperative to understand how best to support nurses during this period. The peak body for nurses in primary health care was funded to develop and implement a 1-year transition to practice improvement initiative for nurses in Australia about to be employed in or who are new to primary health care. This quality improvement evaluation study aimed to determine the impact of the transition program on participants' nursing knowledge, skills, and confidence, and their overall satisfaction with the program. A mixed methods evaluation of the project utilized data from online pre- and post-participation surveys, mentor meetings, and field notes. Descriptive statistics and paired t-tests were employed for quantitative items. Free text and field notes were subject to broad thematic analysis. Findings from qualitative and quantitative data were triangulated. Ninety-three nurse participants and 62 mentors were recruited. There were statistically significant differences between mean summed post-completion and pre-completion self-assessment rating scores for knowledge, skills, and confidence. Program elements were well received. The orientation workshop, mentoring, and education activities were identified as most influential in supporting transition. The self-assessment framework was identified as least influential. A 12-month transition program was effective in building the knowledge, skills, and confidence of participants to deliver comprehensive and effective nursing services.

Principles guiding ethical research in a collaboration to strengthen Indigenous primary healthcare in Australia: learning from experience

IntroductionIndigenous communities worldwide are leading calls for all research involving Indigenous people to be underpinned by values and principles articulated by them. Many researchers are explicitly adopting these principles to...

Strife of Interests: Constraints on integrated and co-ordinated comprehensive PHC in Australia.

The 1978 World Health Organisation Alma Ata Declaration on Primary Health Care (PHC) emphasised a comprehensive view which stressed the importance of cure, prevention, promotion and rehabilitation delivered in a way that involved local communities and considered a social, economic and political perspective on health. Despite this, selective approaches have dominated. This paper asks why this has been the case in Australia through a multi-method study of regional PHC organisations. Interviews with senior policy players, focus groups with non-government organisations and document analysis inform an institutional and power analysis of PHC. The findings indicate that there are different interests competing for attention in PHC but that medical perspectives prove the most powerful and are reinforced by the actors, ideas and institutions that shape PHC. Community perspectives which stress lived experience and social perspectives on health are marginal concerns in the implementation of PHC. The other important interest is that of a neo-liberal perspective on health policy which stresses cost-containment, close measurement of activity and fragmented contracting out of services. This perspective is not compatible with a social determinants of health perspective and can also conflict with a medical view. The result of the interplay between competing interests and the distribution of power is a selective PHC system that is not likely to change without radical shifts in power and perspectives.

Primary health care policy and vision for community pharmacy and pharmacists in Australia

There is evidence that the Australian Government is embracing a more integrated approach to health, with implementation of initiatives like primary health networks (PHNs) and the Government’s Health Care Homes program. However, integration of community pharmacy into primary health care faces challenges, including the lack of realistic integration in PHNs, and in service and remuneration models from government. Ideally, coordinated multidisciplinary teams working collaboratively in the community setting are needed, where expanding skills are embraced rather than resisted. It appears that community pharmacy is not sufficiently represented at a local level. Current service remuneration models encourage a volume approach. While more complex services and clinical roles, with associated remuneration structures (such as, accredited pharmacists, pharmacists embedded in general practice and residential aged care facilities) promote follow up, collaboration and integration into primary health care, they potentially marginalize community pharmacies. Community pharmacists’ roles have evolved and are being recognized as the medication management experts of the health care team at a less complex level with the delivery of MedChecks, clinical interventions and medication adherence services. More recently, vaccination services have greatly expanded through community pharmacy. Policy documents from professional bodies highlight the need to extend pharmacy services and enhance integration within primary care. The Pharmaceutical Society of Australia’s Pharmacists in 2023 report envisages pharmacists practising to full scope, driving greater efficiencies in the health system. The Pharmacy Guild of Australia’s future vision identifies community pharmacy as health hubs facilitating the provision of cost-effective and integrated health care services to patients. In 2019, the Australian Government announced the development of a Primary Health Care 10-Year Plan which will guide resource allocation for primary health care in Australia. At the same time, the Government has committed to conclude negotiations on the 7th Community Pharmacy Agreement (7CPA) with a focus on allowing pharmacists to practice to full scope and pledges to strengthen the role of primary care by better supporting pharmacists as primary health care providers. The 7CPA and the Government’s 10-year plan will largely shape the practice and viability of community pharmacy. It is essential that both provide a philosophical direction and prioritize integration, remuneration and resources which recognize the professional contribution and competencies of community pharmacy and community pharmacists, the financial implications of service roles and the retention of medicines-supply roles.

Welcome to The Lucky Country: the Royal Australian College of General Practitioners deters overseas-trained academic general practitioners.

In assessing overseas-trained general practitioners (GPs) applying for specialist recognition in Australia, the Royal Australian College of General Practitioners (RACGP) sets a minimum requirement of 2 days per week 'undertaking general practice activities' over the 3 years prior to application. The RACGP does not consider academic practice (i.e. relevant teaching and research) to be a 'general practice activity', thereby blocking overseas-trained full-time academic GPs from specialist recognition in Australia. The actions of the RACGP have implications for access to quality primary health care in Australia.

Innovation to improve patient care in Australian Primary Health Network: an insider’s perspective

Purpose The purpose of this paper is to review the establishment of Primary Health Network (PHN) in Australia and its utility in commissioning Primary Health Care (PHC) services. Design/methodology/approach This study is an analysis of management practice about the establishment and development of a PHN as a case study over the three-year period. The PHN is the Hunter New England and Central Coast PHN (HNECCPHN). The study is based on “insiders perspectives” drawing from documentation, reports and evaluations undertaken. Findings HNECCPHN demonstrates a unique inclusive organisation across a substantial diverse geographic area. It has taken an innovative and evidence-based approach to its creation, governance and operation. HNECCPHN addresses the health challenges of a substantial Aboriginal and/or Torres Strait Islander population. It contains significant and diverse urban, coastal and distinct rural, regional and remote populations. It can be described as a “virtual” organisation, using a distributed network of practice approach to engage clinicians, communities and providers. The authors describe progress and learning in the context of theories of complex organisations, innovation, networks of practice, knowledge translation and social innovation. Research limitations/implications The study provides initial publication into the establishment phase of a PHN in Australia. Practical implications The study describes the implementation and progress in terms of relevant international practice and theoretical concepts. This paper demonstrates significant innovative practice in the short term. Social implications The study describes significant engagement and the importance of that with and between communities, service providers and health professionals. Originality/value This is the first study of the results of the implementation of an important change in the funding and delivery of PHC in Australia.

Increased private health fund involvement in Australia's primary health care: Implications for health equity

AbstractThis study identifies current practices of private health funds (PHFs) in Australian primary health care (PHC), including areas where their involvement is increasing, and examines the risks and benefits of these practices for quality of, and equity of access to PHC. The paper draws on research to investigate equity implications of current PHF involvement in PHC in Australia. We reviewed literature, analysed documents relating to a Senate Committee inquiry and interviewed stakeholders and experts in private health insurance policy from government, private sector and nongovernment organisations. Involvement of PHFs in the PHC sector in Australia is increasing, presenting risk of increased inequities in access to PHC based on insurance status, which could undermine the universality of PHC under Medicare. However, some stakeholders think these risks can be managed within current policy arrangements. There are also risks for quality of PHC services arising from greater involvement of PHFs in service delivery and “preferred provider” models. Differing stakeholder views on equity implications of PHF involvement in PHC are associated with different views on desirable policy action. We conclude that there is a risk of increased involvement of PHFs in PHC risks exacerbating existing inequities in the health system, but this is moderated by public support for Medicare.

Implementation of continuous quality improvement in Aboriginal and Torres Strait Islander primary health care in Australia: a scoping systematic review

BackgroundContinuous Quality Improvement (CQI) programs have been taken up widely by Indigenous primary health care (PHC) services in Australia and there has been national policy commitment to support this. However, international evidence shows that implementing CQI is challenging, impacts are variable and little is known about the factors that impede or enhance effectiveness. A scoping review was undertaken to explore uptake and implementation in Indigenous PHC, including barriers and enablers to embedding CQI in routine practice. We provide guidance on how research and evaluation might be intensified to support implementation.MethodsSearches were conducted in MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews. Key websites and publications were handsearched. Studies conducted in Indigenous PHC which demonstrated some combination of CQI characteristics and assessed some aspect of implementation were included. A two stage analysis was undertaken. Stage 1 identified the breadth and focus of literature.Stage 2 investigated barriers and enablers. The Framework for Performance Assessment in PHC (2008) was used to frame the analysis. Data were extracted on the study type, approach, timeframes, CQI strategies, barriers and enablers.ResultsSixty articles were included in Stage 1 and 21 in Stage 2. Barriers to implementing CQI processes relate primarily to professional and organisational processes and operate at multiple levels (individual, team, service, health system) whereas barriers to improved care relate more directly to knowledge of best practice and team processes that facilitate appropriate care. Few studies described implementation timeframes, number of CQI cycles or improvement strategies implemented and only two applied a change theory.ConclusionInvestigating barriers and enablers that modify implementation and impacts of CQI poses conceptual and methodological challenges. More complete description of CQI processes, implementation strategies, and barriers and enablers could enhance capacity for comparisons across settings and contribute to better understanding of key success factors.

Impacts of continuous quality improvement in Aboriginal and Torres Strait islander primary health care in Australia

PurposeContinuous quality improvement (CQI) programmes have been taken up widely by indigenous primary health care services in Australia, but as yet there has not been a systematic assessment of their focus and achievements. A scoping review of the literature from studies of CQI in indigenous primary health care services was undertaken to explore impacts on service systems, care and client outcomes with the aim of providing guidance on future evaluation efforts. The paper aims to discuss these issues,Design/methodology/approachSearches were conducted in MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews to December 2016 and handsearching of key websites and publications. Studies of CQI programs or activities in Indigenous primary health care services which demonstrated some combination of CQI characteristics, as described by Rubenstein (2013) were included. A two-stage approach to analysis was undertaken. Stage 1 identified the range and scope of literature, and Stage 2 investigated impacts to service systems, care and client outcomes. The Framework for Performance Assessment in Primary Health Care was used to frame the Stage 2 analysis.FindingsThe majority of Aboriginal community controlled health services have been involved in CQI but there are gaps in knowledge about uptake in general practice and government clinics. There are as many baseline studies as studies on impacts over time. Of the 14 studies included for further analysis, 6 reported on impacts on service systems; all 14 reported on impacts on care and 6 on client outcomes. Changes to services systems are variable and studies of impacts on care and client outcomes show promising though uneven improvements. There are no economic studies or studies addressing community engagement in CQI activities.Research limitations/implicationsTo supplement existing limited knowledge about which service system change strategies are effective and sustainable for which problems in which settings, there needs to be investment in research and development. Research needs to be grounded in the realities of service delivery and contribute to the development of CQI capacity at the service level. Knowledge translation needs to be built into implementation to ensure maximum benefit to those endeavouring on a daily basis to constantly reflect on and improve the quality of the care they deliver to clients, and to the stewardship structures supporting services at regional, state/territory and national levels.Practical implicationsImproved approaches, methods, data capture and reporting arrangements are needed to enhance existing activity and to ensure maximum benefit to services endeavouring to reflect on and improve quality of care and to the stewardship structure supporting services at regional, state/territory and national levels.Originality/valueAlthough there is a growing body of research evidence about CQI both nationally and internationally, and considerable investment by the federal government in Australia to support CQI as part of routine practice, there has not been a systematic assessment of the achievements of CQI in Indigenous primary health care services. Many unanswered questions remain about the extent of uptake, implementation and impacts. This is a barrier to future investment and regional and local programme design, monitoring and evaluation. The authors conducted a scoping review to address these questions. From this, the authors draw conclusions about the state of knowledge in Australia with a view to informing how future CQI research and evaluation might be intensified.

A narrative review and synthesis to inform health workforce preparation for the Health Care Homes model in primary healthcare in Australia.

The Australian Government Health Care Homes (HCH) model recently implemented in general practice targets people with chronic complex conditions. Identifying how general practitioners (GPs) and practice nurses (PNs) can work within this model is important given existing health workforce challenges. A narrative review and synthesis has been undertaken to develop a preliminary understanding of this, incorporating literature describing health workforce challenges, GP and PN functions, and team-based care; supplemented by interviews with key informants from within the primary healthcare system. Narrative synthesis principles guided literature analysis. Interview data were thematically analysed. A clear rationale for health workforce reform was ascertained and functions for the GP and PN under the HCH model were determined. The model was found to be an opportunity for an enhanced PN role in a team-based approach to care with the GP. Challenges to advancing the PN role and team-based care were identified, including the medical dominance of the health system and the significant culture change required by general practices to fully implement the model. Enablers included strong nursing leadership and improved ongoing education for PNs to unlock their capacity. The HCH model is an opportunity to strengthen primary healthcare, provided concerted action is taken regarding these challenges and enablers.

Recalibrating intercultural governance in Australian Indigenous organisations: the case of Aboriginal community controlled health

ABSTRACTAboriginal Community Controlled Health Services (ACCHSs) have a strong track record of delivering comprehensive primary health care in Australia, but the sector also suffers from governance challenges. This article argues that a combination of settler-state dominance of governance arrangements and inadequate conceptualisation of governance in the sector have led to the risk of ‘controlled communities’ – either quasi-government control of organisations or the control of individual ACCHSs by a small cohort of members. In response, we deploy a political rather than technical approach to governance to consider the contested and intercultural nature of ACCHSs governance alongside recent governance initiatives in Southeast Queensland that signal the value of disaggregating and delineating different forms of governance in the sector. Key conceptual steps and a matrix for recalibrating intercultural governance are presented to support further research, to clarify lines of jurisdiction, and inform governance reform in and around ACCHSs.

Experiencing integration: a qualitative pilot study of consumer and provider experiences of integrated primary health care in Australia

BackgroundThe terms integration and integrated care describe the complex, patient-centred strategies to improve coordination of healthcare services. Frameworks exist to conceptualise these terms, but these have been developed from a professional viewpoint.The objective of this study was to explore consumers’ and providers’ concepts, expectations and experience of integrated care. A key focus was whether frameworks developed from a professional perspective are effective models to explore people’s experiences.MethodsA qualitative pilot study was undertaken at one Australian multidisciplinary primary health care centre. Semi-structured interviews were conducted with consumers (N = 19) and staff (N = 10). Data were analysed using a framework analysis approach.ResultsConsumers’ experience of integrated care tended to be implicit in their descriptions of primary healthcare experiences more broadly. Experiences related to the typologies involved clinical and functional integration, such as continuity of providers and the usefulness of shared information. Staff focused on clinical level integration, but also talked about a cultural shift that demonstrated normative, professional and functional integration.ConclusionsExisting frameworks for integration have been heavily influenced by the provider and organisational perspectives. They are useful for conceptualising integration from a professional perspective, but are less relevant for consumers’ experiences. Consumers of integrated primary health care may be more focussed on relational aspects of care and outcomes of care.

Restructuring primary health care in Australia.

Restructuring primary health care in Australia.

Experiences of nurse practitioners and medical practitioners working in collaborative practice models in primary healthcare in Australia - a multiple case study using mixed methods.

BackgroundIn 2010 policy changes were introduced to the Australian healthcare system that granted nurse practitioners access to the public health insurance scheme (Medicare) subject to a collaborative arrangement with a medical practitioner. These changes facilitated nurse practitioner practice in primary healthcare settings. This study investigated the experiences and perceptions of nurse practitioners and medical practitioners who worked together under the new policies and aimed to identify enablers of collaborative practice models.MethodsA multiple case study of five primary healthcare sites was undertaken, applying mixed methods research. Six nurse practitioners, 13 medical practitioners and three practice managers participated in the study. Data were collected through direct observations, documents and semi-structured interviews as well as questionnaires including validated scales to measure the level of collaboration, satisfaction with collaboration and beliefs in the benefits of collaboration. Thematic analysis was undertaken for qualitative data from interviews, observations and documents, followed by deductive analysis whereby thematic categories were compared to two theoretical models of collaboration. Questionnaire responses were summarised using descriptive statistics.ResultsUsing the scale measurements, nurse practitioners and medical practitioners reported high levels of collaboration, were highly satisfied with their collaborative relationship and strongly believed that collaboration benefited the patient. The three themes developed from qualitative data showed a more complex and nuanced picture: 1) Structures such as government policy requirements and local infrastructure disadvantaged nurse practitioners financially and professionally in collaborative practice models; 2) Participants experienced the influence and consequences of individual role enactment through the co-existence of overlapping, complementary, traditional and emerging roles, which blurred perceptions of legal liability and reimbursement for shared patient care; 3) Nurse practitioners’ and medical practitioners’ adjustment to new routines and facilitating the collaborative work relied on the willingness and personal commitment of individuals.ConclusionsFindings of this study suggest that the willingness of practitioners and their individual relationships partially overcame the effect of system restrictions. However, strategic support from healthcare reform decision-makers is needed to strengthen nurse practitioner positions and ensure the sustainability of collaborative practice models in primary healthcare.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-016-0503-2) contains supplementary material, which is available to authorized users.

Doctors’ experience of the contraceptive consultation: a qualitative study in Australia

BackgroundContraception is a field in which good doctor–patient communication is crucial and core to shared decision making. Despite the centrality of contraception to primary health care in Australia, little is...

Population health performance as primary healthcare governance in Australia: professionals and the politics of performance

ABSTRACTA range of institutional and financial instruments has been used to drive population health outcomes in primary health care in Australia. However, GP sovereignty and the corporatized nature of general practice have generated major challenges. The core of government reform strategy since 1992 has been the creation and financing of Primary HealthCare Organizations (PHCOs), in various forms, to provide an organizational basis to connect GPs to population health performance, and a closer link between the state and GPs. The shift from Divisions of General Practice, the first PHCO, to Medicare Locals (MLs) in 2011 was notable. The latter constructed the object of performance as a raft of broader population health goals, which were framed in terms of accountability to communities through public reporting. Drawing on interviews with Federal government, health professional associations, ML executives and GPs, this paper examines the ways in which such performance instruments were imagined and understood, and areas of contestation. The findings show the different rationalities at play and how different actors seek control of the policy space. They also demonstrate the political precariousness of PHCOs, and the wider difficulty of steering market-based professionals in the achievement of population health objectives.