Health systems are increasingly recognised to be complex adaptive systems (CASs), functionally characterised by their continuing and dynamic adaptation in response to core system drivers, or attractors. The core driver for our health system (and for the health reform strategies intended to achieve it) should clearly be the improvement of people's health — the personal experience of health, regardless of organic abnormalities; we contend that a patient‐centred health system requires flexible localised decision making and resource use. The prevailing trend is to use disease protocols, financial management strategies and centralised control of siloed programs to manage our health system. This strategy is suggested to be fatally flawed, as: ➢people's health and health experience as core system drivers are inevitably pre‐empted by centralised and standardised strategies; ➢the context specificity of personal experience and the capacity of local systems are overlooked; and ➢in line with CAS patterns and characteristics, these strategies will lead to “unintended” consequences on all parts of the system. In Australia, there is still the time and opportunity for health system redesign that truly places people and their health at the core of the system.

Background Rising health costs and health inequity are major challenges in Australia, as internationally. Strong primary health care is well evidenced to address these challenges. Primary Health Networks (PHNs) work with general practices to collect data and support quality improvement; however, there is no consensus regarding what defines high quality. This paper describes the development of an evidence-based suite of indicators and measures of high-quality general practice for the Australian context. Methods We reviewed the literature to develop a suitable framework and revise quality assurance measures currently in use, then reviewed these in three workshops with general practitioners, practice managers, nurses, consumers and PHN staff in western Sydney. We used a descriptive qualitative research approach to analyse the data. Results A total of 125 evidence-based indicators were agreed to be relevant, and 80 were deemed both relevant and feasible. These were arranged across a framework based on the Quadruple Aim, and include structure, process and outcome measures. Conclusions The agreed suite of indicators and measures will be further validated in collaboration with PHNs across Australia. This work has the potential to inform health systems innovation both nationally and internationally.

BackgroundThe health disadvantage in socioeconomically marginalised urban settings can be challenging for health professionals, but strong primary health care improves health equity and outcomes.AimTo understand challenges and identify needs in general practices in a socioeconomically marginalised Australian setting.Design & settingQualitative methodology with general practices in a disadvantaged area of western Sydney.MethodSemi-structured interviews with healthcare professionals and their patients were transcribed and analysed thematically under the guidance of a reference group of stakeholder representatives.ResultsA total of 57 participants from 17 practices (comprising 16 GPs, five GP registrars [GPRs], 15 practice staff, 10 patients, and 11 allied health professionals [AHPs]), provided a rich description of local communities and patients, and highlighted areas of satisfaction and challenges of providing high quality health care in this setting. Interviewees identified issues with health systems impacting on patients and healthcare professionals, and recommended healthcare reform. Team-based, patient-centred models of primary health care with remuneration for quality of care rather than patient throughput were strongly advocated, along with strategies to improve patient access to specialist care.ConclusionThe needs of healthcare professionals and patients working and living in urban areas of disadvantage are not adequately addressed by the Australian health system. The authors recommend the implementation of local trials aimed at improving primary health care in areas of need, and wider health system reform in order to improve the health of those at socioeconomic and health disadvantage.

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Current approaches to health care reform are largely based on the metaphor of imminent flood waves threatening to inundate the health care system. This metaphor reflects the system's preoccupation with disease and disease management in a hospital‐centric environment. We suggest that the debate needs to be reframed around health, or more precisely the patient's health experience. Most patients are healthy most of the time, and even those with identifiable morbidities generally regard themselves as being in good health. The majority of people receive most of their care in the community from primary care professionals. An integrated, effective and efficient primary health care system supports continuity of care through a primary care provider and fosters clinical leadership that is supported by other primary health care professionals and medical specialists. Each primary care setting will have its own model that best provides flexible and responsive services to meet its patients’ needs and expectations.