New Initiatives in Primary Health Care Health

1. New Initiatives in Primary Health Care Health ‘Now More Than Ever’ An International Perspective Professor Barbara Parfitt CBE PhD MSc MCommH RGN RM FNP

2. 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

3. Service Delivery Reforms Leadership Reforms Four sets of PHC reforms Universal coverage Reforms Public Policy Reforms

4. 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

5. 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

6. 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

7. Scotland: FHN Site Locations (Phases 1 and 2)

8. Tajikistan site locations Varsob Medical College Post graduate Institute Kulob Qurghon teppe

9. 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

10. 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.

11. 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

12. 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

13. 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

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

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

16. 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 MDG’s • Cost effective Integrated team network Advanced nursing Expertise

17. 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

18. Scottish Government ‘Visible, Accessible and Integrated Care ‘Review of Nursing in the Community (RoNIC)

19. Main drivers • Patient and carer needs • Scotland’s population profile and health care needs • Health and social policy • Nursing, health and social care workforce issues

20. Scotland’s 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

21. 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

22. 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 Acute Sector Community Hospitals Local Authority Teams Community Health Nurse (CHN) Community staff nurse Health care support worker Individuals, carers, families and communities

23. 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

24. 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

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

26. 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

27. 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

28. 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

29. 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?

30. 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.

31. Thank you