Establishing community-controlled health commissioning: a grounded theory study of the Torres and Cape Health Care (TORCH) Commissioning Fund project

Community-controlled commissioning entities can drive innovation through healthcare service engagement, planning, contracting, funding, and evaluation, enhancing a focus on what matters most to First Nations families and communities. In May 2024, Australia’s first regional community-controlled health commissioning body was established through the Torres and Cape Health Care (TORCH) Commissioning Fund project as a pathway to improved health system accessibility, equity, sustainability and population health and wellbeing outcomes for the population of Cape York and the Torres Strait, the majority of whom are Aboriginal and/or Torres Strait Islander. This paper explores the enabling conditions and strategies for establishing what became known as the Cape and Torres Health Commissioning (CaTHC) Ltdentity and the commissioning project. Constructivist grounded theory methods were used to understand the processes and interrelated conditions inherent in the reform. Interviews and workshops were conducted with 48 leaders and representatives from community, heath service providers, and governments. 135 Queensland Health and Commonwealth Department of Health and Aged Care documents and reports were reviewed. Data were imported into NVivo and coded, then sensitised using the domains of the Ngaa-bi-nya Indigenist evaluation framework. Codes were then grouped into higher order categories which were used to structure the storyline. In a landscape of complex geographical, cultural, and service system factors, four key conditions enabled the establishment of the TORCH Commissioning Fund project and CaTHC entity. The four key conditions were: (1) Agreeing to a vision of change, (2) community leadership, capacity and control; (3) government commitment, partnerships and coordination, and (4) scope of and accountability for funding. Four key strategies for planning the early stages of commissioning were also identified: (1) Engaging and communicating with community leaders and service providers, (2) building organisational capability within CaTHC, (3) delivering the enabling environment, and (4) determining how commissioning operates. Outputs included the co-design of the entity and mapping of pathways for a proposed phased implementation over 10 years. The evaluation provides evidence of the enabling factors and strategies for establishing community-controlled commissioning. This evidence can be used to inform similar initiatives in other parts of Australia. It also contributes to the reform by informing a continuous quality improvement approach and guidance for ongoing development of the TORCH project by the Queensland Health Reform Office and partners as the project progresses.