Synthesis of these data comprised progressive readings of each document, and the identification, categorisation and comparison of recurring themes across documents, involving the research team and the Reference Group. This allowed the development of a typology of models of PHC within five broad categories, each with a different rationale and addressing particular sentinel issues (see Table ). Thirty six of the 161 papers constituted evaluations. Evaluation measures varied widely between studies. Some of these are summarised in Table .
Typology of rural and remote PHC models
Drawing on information about model type, location and service population size, it was evident that in general the different categories of models relate to different geographical contexts, with a notable association with population size and remoteness. While larger rural communities are generally able to support a greater variety of local, discrete, more specialised health care services, increasing remoteness and diminishing population size and density constrain service model options and increase the impetus for the development of more integrated and comprehensive primary health services in order to maximise the economies of scale and use of existing health workforce.
'Discrete primary care services
' are delivered from an identifiable site located in the community they serve (for example, [17
]). Their primary purpose is to sustain a general practitioner service in those rural and larger remote communities experiencing significant difficulties in recruiting and in retaining an adequate general practitioner workforce. They accomplish this through ensuring attractive practice opportunities for doctors and continuity of medical care for the community when doctors leave. Exemplars of this type are characterised by practice infrastructure owned and maintained by an entity such as a local council, university or other incorporated body, such that incoming general practitioners can execute both an 'easy entry' on recruitment and 'gracious exit' free of concern about return on capital investment.
' offer a range of integrated primary health care services from sites located in the communities they serve [23
]. Their scope is significantly broader than general practitioner services, but may include coordination with general practitioner services. Integrated services provide single point access to a range of services and sufficient numbers of health professionals to ensure mutual professional support. Because these communities cannot usually sustain necessary allied health and specialist services in a discrete form, this model enables the population to sustain such a service.
'Integrated services', which usually emerge from a community health service or allied health team approach to primary health care services, comprise a variety of models. For example, the 'shared care' model of mental health care addresses access to and co-ordination of service across primary and specialist care [23
]. The Multi Purpose Services (MPS) program provides a specific model of Commonwealth/state financing which allows for the co-location and common administration of acute care, residential aged care, community and allied health services, rehabilitation and health education activities [29
'Comprehensive primary health care services
' (CPHC) are best typified in Australia by the Aboriginal Community Controlled Health Services (ACCHSs). ACCHSs have adopted a primary health care approach to healthcare delivery over the past 30 years, and provide some of the best examples of this model [33
]. CPHC services aim to improve health outcomes through better access to services and by addressing underlying social determinants of health. The main impetus for the development of ACCHSs has come from poor service access and availability, inadequate funding of services, low acceptance of mainstream services by Aboriginal patients, the poor health status of the Aboriginal population, and a desire for community control of these services. CPHC services are broader in scope than most 'Integrated Services' models. They include primary clinical care, preventive and health promotion activity, as well as education and development in relation to workforce training and governance/community capacity building.
' are characterised by the periodic supply of services from one location which has services to other locations which do not [40
]. The arrangement may be either centrally located services providing services to satellite communities though a 'hub and spoke' arrangement, or some other visiting mechanism, such as where a general practitioner resident in one community may visit a second community for short periods, or services are supplied on a fly-in fly-out basis. Outreach services thus improve access to health services for widely dispersed and isolated populations and often co-exist with other integrated and comprehensive PHC services.
' and 'telemedicine
' have been widely used in Australia over the past decade as a means of overcoming problems of access to health care and the shortage of health professionals in rural and remote areas [44
]. The extent to which telehealth and telemedicine constitute a 'model' of care in its own right is a moot point. In many cases, telemedicine and telehealth are used to augment other service delivery models.