New Initiatives in Primary Health Care Health

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New Initiatives in Primary Health Care Health

• Now More Than Ever
• An International
• Perspective
• Professor
• Barbara Parfitt CBE PhD MSc
• MCommH RGN RM FNP

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Current Shortcomings of Health Care delivery
(World Health Report 2008 PHC now more than
ever)

• Inverse Care
• Impoverishing Care
• Fragmented Care
• Unsafe care
• Misdirected care

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Four sets of PHC reforms
Universal coverage Reforms
Public Policy Reforms
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Multi-disciplinary and multi-agency team working
Integrated care approach
Public health approaches to protecting the public
Family Physician Family Health Nurses / Midwives
Community participation
Supporting self care
Meeting the health needs of communities
Working directly with individuals and their carers
Supporting anticipatory care
Co-ordinating services
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Family Health Nurse Role

• Guided by
• WHO Europe definition
• NHS Education Scotland Competency framework
• learning from all pilot countries

• Characteristics
• based on a generalist model
• Advanced nursing practice
• combines clinical care with health improvement
• works at 3 levels individual, family community

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Different Cultures Scotland Tajikistan

• Family Health Nurse (WHO Euro model
• Scotland Tajikistan)
• Community Health Nurse (RoNIC model Scotland)
• Different
• Geographies
• Health needs
• Different support systems

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Scotland FHN Site Locations (Phases 1 and 2)
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Tajikistan site locations
Varsob
Medical College Post graduate Institute
Kulob
Qurghon teppe
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The National Project Scotland

• To test the FHN model as a way of delivering
  community nursing services to remote rural
  areas (phase1) and urban areas (phase 2)
• To develop and test the educational preparation
  of FHN

• Scottish Executive (2006) The WHO Europe Family
  Health Nursing Pilot in Scotland, Final Report.
  Edinburgh Scottish Executive. http//www.scotland
  .gov.uk/Publications/2006/10/31141146/0

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The National Project Tajikistan

• To evaluate the contribution of Family Health
  Nurses towards the National Health Reform
  Programme
• To review the learning outcomes achieved by
  community nurses following completion of the four
  year curriculum and the six month re training
  programme.

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Indicative OutcomesScotland

• Improved patient and family experience
• Identification of problems at an early stage
• Reduced need for hospitalisation
• Improving outcomes of care
• Increasing organisational efficiency
• Larger pilot required, implementation of
  development sites and full evaluation to test a
  generic advanced community nursing role

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Tajikistan Outcomes

• Community based curriculum for all nurse
  education pre-qualifying programmes (4 Med
  colleges 9 Schools)
• Reduction in infant deaths and childhood malaria
  cases
• Timely interventions
• Improved access to health services
• 1000 new Family Health Nurses
• 300 community nursing bags supplied
• Raised self esteem of nurses

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Outcomes Shared in Both Countries

• Benefits
• Intervention for those who might fall through
  the cracks
• First point of contact and accessibility
• Early detection and prevention of high risk
  health threats
• Integrated team approach at community level
• Empowerment and role modeling

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Risks of the model

• Community Dependency
• Possible time issues / 24 hour on call
• Financial un-sustainability
• Change of status and position for nurses (HVs,
  DN,s)
• Non engagement by the team
• Focus on acute intervention rather than public
  health

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Issues

• Interface with other services
• Workforce modelling
• Change management
• Generic vs specialist model

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Family-centred health care modelKey Components
INPUTS
CARE CONTEXT
OUTPUTS
Education, training culture
Family centred health care Measurable outcomes

• Country specific Primary Health Care Model
• Accessibility
• Tackling MDGs
• Cost effective

Integrated team network
Advanced nursing Expertise
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WHO Multi-country EvaluationFamily Health Nursing

• Data from 8 countries using questionnaires
• Similar concepts in role across Europe
• Improved communication in team when shared focus
• Move towards clinical disease public health
• Further work on role clarity and sustainability
• Education programmes differed due to in-country
  system resources

WHO Europe (2006) Report on the Evaluation of the
WHO Multi-country Family Health Nurse Pilot
Study, Copenhagen WHO Europe http//www.euro.who
.int/document/e88841.pdf
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Scottish Government Visible, Accessible
and Integrated Care Review of Nursing in the
Community (RoNIC)
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Main drivers

• Patient and carer needs
• Scotlands population profile and health care
  needs
• Health and social policy
• Nursing, health and social care workforce issues

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Scotlands population profile and health care
needs

• Increasing numbers of older people
• Health is worse than either the rest of Great
  Britain or Europe on a range of indicators, from
  premature deaths to dental health among children
• Within this, substantial inequalities between
  different parts of Scotland and between different
  groups within the population

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Nursing, health and social care workforce issues

• Diminishing number of work-age adults
• The age profile of community nurses different
  from nurses in the acute sector
• Increasing demand on health care services
• Modernisation agenda with increased delivery of
  health care in primary care.
• Maintenance of current levels of service in the
  face of recruitment and retention problems

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Nursing Service Model
Individuals, carers, families and communities
Clinical Team Leader/Advanced Practitioner
Nurse Consultant
Primary Health Care Team, including GP. practice
nurses, pharmacists, maternity services etc
Community Health Nurse (CHN)
Acute Sector Community Hospitals Local
Authority Teams
Community staff nurse Health care support worker
Individuals, carers, families and communities
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CHN Practice Framework (RONIC model)
Working directly with people
Meeting health needs
Public health / Protecting the public
Nurses working in the community
Supporting Anticipatory care
Co-ordinating services
Multi disciplinary Team working
Supporting self care
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Current Status of the roNIC Project

• Four development sites identified
• Project Director appointed
• Four Project leads in each development site
  appointed
• Competencies identified for the new Role
• Educational programmes developed

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• Educational transition taking place
• Base Line Study Completed
• New teams in place
• Full evaluation commencing July 2009

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RoNIC base line studyMain findings (79/09)

• Experienced workforce
• Community Nursing teams with varied organisation
• Engagement confidence
• The invisible nurse
• Mid range levels of satisfaction
• Mixed views about proposed changes
• Rural areas seen to fit the new model

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Key areas for investigation

• Staff, patient, client, carers perceptions and
  satisfaction levels
• Time and cost of the implementation (value for
  money)
• Team working / roles responsibilities
• Patient outcomes
• Impact measures

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Limitations

• Short time span for implementation prior to
  evaluation. Possible distortion of results
• Variance between different development sites
• Difficulty in separating net versus gross
  outcomes
• Number of variables within each situation

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Evaluation Questions

• Does everyone understand what we are trying to
  do?
• Did we manage the implementation effectively?
• Have we achieved our objectives?
• Have we made any impact on the problems that gave
  rise to the implementation of the project in the
  first place?
• Do we understand the contribution that Community
  Health Nurses and the RoNIC model can make
  towards improving the health of our communities?

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Some final points

• Health systems that maximise the skills and
  expertise of nurses are more likely to achieve
  the Millennium Development Goals.
• Nurses are key players in providing an effective
  primary health service for our communities.
• Appropriate community based education and
  advanced levels of competence are necessary for
  nurses to undertake this role.

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Thank you