specialty focus
specialty focus
Another example of an innovative international model for primary care that you chose to highlight was Cuba’ s, which you said is strongly grounded in primary healthcare and public health. What are some of the tenets of the Cuban model that you believe make it successful? The death of Fidel Castro late last year shone a light on his legacy of free universal health and education, and some of the key elements of the Cuban success include the emphasis on inclusion with home visits that ensure individuals don’ t slip through the cracks and miss out on care. Again, there’ s a very strong emphasis on prevention and on training.
In addition, there’ s widespread establishment of polyclinics, which could be seen as the parallel to the Primary Health Networks here in Australia. In Cuba, it moved from originally a very uniform structure across the country to a much more locally responsive structure that has led to much improved healthcare, and with the polyclinics having a very important role in quality control and capacity building and service provision based on the needs of the local population rather than a top-down fund allocation.
Interestingly, Cuba’ s GDP is relatively low and they spend about 10 per cent on healthcare – which is similar to what Australia does – and their health status has improved substantially over the last 40 years to be much closer to that of the United States, including life expectancy. Infant mortality has dropped below that of the United States, so one of the key elements of this is the relationship between the doctors and nurses, who work as a team. The nurses do home visits in the local community, and they rarely move out of the community, so they develop this real strength in terms of the continuity of care.
A Cuban-trained medical graduate [ writing for The
Conversation, recently argued ] that this high level of general access and the dedication of the healthcare workers was a real strength [ along with almost all of Cuba’ s ] medical graduates being required to have a specialisation in family medicine.
You also pointed to the Alaskan Nuka system of care. How do the central elements of this system work together to create a successful healthcare system and what changes has the model brought about? This is a really interesting model. It was established by the South Central Foundation under tribal authority of the Native Alaskan community back in the 1980s. It’ s a non-profit, native-owned and operated healthcare organisation and it takes a very holistic approach to healthcare. It also acknowledges the impact of multiple factors on the physical, mental, emotional and spiritual wellbeing and the unique influence of the local culture and practice.
Firstly, this model uses an empowerment approach to enhance the native Alaskan culture and to give individuals and their families the power to make their own health choices, so those three elements, the patients are not called patients, they’ re called‘ customer-owners’, and they’ re treated as equals who share the decision making about their healthcare.
The second element is about the relationships and in particular the relationship between the customer-owner and the primary healthcare team, so healthcare decisions are tailored to the unique situation of the customer-owner and includes their values and their preferences.
The third element is the whole system transformation, and this is not just about healthcare delivery, but it’ s about getting the right balance in the workforce, including the training and the development and the financial considerations, of course.
This system moved away from the patients as beneficiaries of the long-established Indian Health Service that was controlled by Washington, and patients were waiting weeks to get appointments. They saw somebody different every time, and both patients and the employees had very low satisfaction. There was a real disconnection between the mind and the body and it also ignored the cultural needs of the community. Now this is much more than just training indigenous staff; it’ s quite relevant to the Australian Indigenous population, who also argue for an empowerment approach.
The results from this have been quite outstanding. The satisfaction rate has gone well over 90 per cent for both the customer-owners and for the employees, and there’ s been about a 25 per cent reduction in emergency department visits and also in primary healthcare visits. Yes, it’ s not a perfect system, but it’ s been quite long established and they’ re doing some really interesting things there, particularly for indigenous populations.
What other promising international models should Australia look to? There’ s a Dutch model of primary healthcare that says that no person should be more than 15 minutes from a GP. That probably wouldn’ t work so well here in Australia with the distances that people might have to travel, but it certainly works in the Dutch situation. In the United States, there are the healthcare homes that also target chronic diseases that are quite successful, and here in Australia too there are some individual groups that are making a difference.
It could be useful to have something like a repository along the lines of the clinical trial databases that show a number of these different models that could be drawn on. But for the PHNs, they’ re all responsible for quite different regions and populations, and no one model is likely to meet all of their needs. Even within a PHN it’ s unlikely, but having some kind of inbuilt flexibility, which is quite common across these models, can overcome many of those different issues. For example, the GM model is quite exciting, but it’ s really suited more to the urban populations and it still has to be evaluated.
The Nuka model and the Manukau model from New Zealand are also useful where there are high levels of indigenous populations and where cultural influences need to be taken into consideration. So for each of the PHNs the models that provide guidance might differ.
How should PHNs go about integrating successful models – or parts thereof – into their operations? This is something that needs to take a multilevel approach, so it has to come from a macro-level, at policy, the meso-level of the organisation, such as the Primary Health Networks, and also the micro-level service delivery. I think, firstly, it’ s got to be a willingness to invest in primary healthcare. One common feature of all the different successful models is a really strong primary healthcare focus. Also, there has to be some flexibility so that there’ s an acknowledgement from the bottom up of the needs, but also some influence from the top down in terms of quality and evidence and standards, etc, and training and all of that kind of thing.
The other things that are very common across these models is a very strong focus on prevention, and that’ s quite clear in all of them. The other thing is the kind of neighbourhood or contextual focus, where the problems that arise from the local context can also provide some of the solutions for the local context. Integrated care is the other big issue – but on its own, it’ s insufficient. It really needs to have that focus on prevention as well. ■
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