Introduction by Croakey: Genuine community engagement is required to deliver equitable outcomes for people living in rural and remote Australia, according to Mark Burdack, CEO of the Healthy Communities Foundation Australia.
In the second article in a two-part series, Burdack outlines the Foundation’s proposed policy for Community Hubs in rural areas, which he describes as “a one-stop-shop for services that are engaged in addressing the social determinants of health”.
Similar to the Aboriginal Community Controlled Health (ACCHO) model, Community Hubs would be funded by both state and commonwealth governments, and led and governed by communities, he says.
Read the first article in this series about community-based healthcare: Ahead of the New South Wales election, major parties urged to rethink rural healthcare.
Mark Burdack writes:
In 2016 the World Health Organization (WHO) approved the Integrated People-Centred Health Systems (IPCHS) Framework to advance the goal of universal access to primary healthcare.
According to the WHO:
For health care to be truly universal, it requires a shift from health systems designed around diseases and health institutions towards health systems designed for people. A renewed focus on service delivery through an integrated and people-centred lens is critical to achieving this, particularly for reaching underserved and marginalized populations to ensure that no one is left behind.”
The WHO recommends five interwoven strategies that need to be implemented to improve equity of outcomes for Australians under-served by health and social services:
- Engaging and empowering people and communities
- Strengthening governance and accountability
- Reorienting the model of care
- Coordinating services within and across sectors
- Creating an enabling environment.
Many of these ideas will be familiar to people working to reform our health system. For example, giving communities a leading role in the design and delivery of healthcare has been a central theme of health reform since the Declaration of Alma-Ata in 1978, which stated: “The people have a right and duty to participate individually and collectively in the planning and implementation of their healthcare”.
But community engagement in Australia too often involves a health provider turning up to tell the community that it has relocated a dialysis machine from the local hospital the day after it was moved. This is not community engagement.
Genuine community engagement
Community engagement means listening to people before you make decisions that impact their lives.
It does not mean coming along with a pre-determined set of issues that the system thinks reflects rural and remote community needs, and “parking” the issues that communities actually want to discuss and address. It does not mean coming to a community meeting with five options that a health provider has decided it can deliver before even talking with the community.
The real innovation in the IPCHS framework however is its prioritisation of ‘people-centred’ care, rather than the traditional focus on patient or person-centred care. This shift of focus from the individual to the community is significant.
It challenges us to stop thinking only of the small minority of people in hospital who are ill or injured, and start thinking about the vast majority of Australians who desperately want to remain healthy and out of hospital.
The second innovation is the recognition of the importance of “coordinating services within and across sectors”. This is an acknowledgment that helping to maintain health and wellbeing leans more heavily on the skills and expertise of actors outside our acute hospital system.
This is the missing link in our approach to human health and wellbeing. Without teachers building the health literacy of young people, local governments constructing and maintaining sporting facilities to promote physical activity, police engaging with young people to divert them away from crime, housing officers getting a leaky roof fixed to reduce the risk of childhood asthma, and planners designing community spaces that enable elderly people to get out and about independently and safely, our acute care-focused system would collapse under a tsunami of chronic disease.
PwC has argued that:
The social determinants…often-ignored social factors such as employment; housing; income inequality; and level of access to clean water, education and transportation – undermine progress and can swamp the health systems that ignore them. Because even the most advanced health interventions are rendered ineffective when people struggle with social isolation, income inequality, poor nutrition and pollution. As social factors counteract…best practices, health systems often remain focused on creating solutions at the wrong interaction point: after people are already sick and in crisis.”
Health leaders talk a lot about the social determinants of health, but this rarely amounts to on-the-ground change. This is because the expertise and capacity to address the social determinants of health resides largely outside the health system as we understand it today.
Community-based primary healthcare
This is where IPCHS offers a structural solution through the integration of community-based primary healthcare and social services. According to WHO, integrated care must encompass “intersectoral action at the community level in order to address the social determinants of health and optimize use of scarce resources…”.
The need for better integration and coordination of primary healthcare and social services is clear. The latter point about ‘scarce resources’ is, however, important in any discussion of rural and remote health.
The fragmented model of fee-for-service healthcare in rural and remote communities does not work. Medicare has never appropriately recognised the demands of supporting large numbers of people with complex multi-morbidities, or the higher backend cost of meeting the health needs of rural and remote people.
Similarly, the population size of rural and remote towns has often made it inappropriate or nonviable to support a fractional or single appointment of a social services worker in a small town. This has led to the centralisation of the social assistance workforce, loosening any real connection to community.
While all the evidence tells us we must invest more in building up local capacity and solutions (what former Minister for Regional Development Simon Crean called ‘bottom-up’, ‘joined-up’ planning), economic rationalism and administrative convenience drives us towards further centralisation. This does not reduce costs, it just amplifies and shifts them to other parts of government or to the individual.
Rural community hubs
The Healthy Communities Foundation Australia has developed a policy proposal for “Community Hubs” to re-energise our approach to the delivery of health, social and development services in rural and remote communities and bring jobs back to where they belong. Think of the Hub as a one-stop-shop for services that are engaged in addressing the social determinants of health.
The first principle of the Community Hubs is that health is everyone’s business in rural and remote towns from the local convenience store to the school, pub, local council, police station and Aboriginal land council.
A Community Hub would be a State and Commonwealth government funded centre (similar to the Aboriginal Community Controlled Health Organisation or ACCHO funding model) that is community-governed and led.
Each Hub would have a community board comprised of community members, key stakeholders (education, police, hospital, community services, jobs network, enterprise centres, regional development, local government, business) and independent experts. It would work with the community to develop and deliver a comprehensive Community Plan that reflects the priorities of the community.
Services that already exist in towns, such as schools or business enterprise centres, would continue to operate as per usual but their priorities and plans would be collaboratively determined through engagement with the community through the Hub.
While these Plans would have common government-determined outcome goals – for example, improve educational attendance, improve health outcomes, reduce youth incarceration – the model would allow communities to identify how this would be achieved in their town.
It would be a “one-size-fits-all” model that embeds a “one-size-doesn’t-fit-all” mentality.
Block funding would go straight to Community Hubs for health and social care eliminating the scandalous dilution of rural health funding in administrative fees as it travels from one agency to another. This alone would return millions of dollars in funding to rural and remote health and care.
Many existing agencies and bodies that act as barriers between government and the people could be abolished as we move away from centralised to localised decision-making.
Data would inform and drive all decisions to achieve positive progress.
Each Hub would have the capacity to configure its business model and staffing to reflect the local availability of skills and the priorities identified within a community.
For example, a Hub may have a part-time Women’s Health Nurse who could be appointed to a conjoint part-time Domestic Violence Officer role. The capacity to mix and match resources based on what is available locally would overcome the challenge experienced by individual agencies of supporting lone and fractional officers in far away places.
Jobs would return to the bush, addressing one of the key social determinants of health – economic exclusion.
In some smaller towns, Hubs may only require two days a week of on-site medical services. Instead of the Hub closing for three days, it would continue to function five days a week because of its broader role. That would allow nurses and other professionals to continue to be available across the week to maintain high quality healthcare delivery even when doctors are not physically in the office.
Instead of multiple agencies running multiple programs in isolation, the Hubs would have a single community approved plan that would guide and direct all services towards common community-approved goals and government-determined State and national priorities.
A team-based service model would enable the free flow of information between professionals, with appropriate confidentiality and privacy rules in place, enabling staff to work together to align services based on community and individual needs. A single care record would enable the Hub to identify factors beyond the biomedical that may be impacting upon individual or community health.
As a locally based service, Hubs could undertake health promotion and prevention in a way that reflected the local community. No more posters designed in Melbourne, and ‘workshop facilitators’ flown in for a half day ‘workshop’ from Brisbane touching the sides of an issue, but never really embedding change.
Local people would design local programs that target the issues that are a priority for their community. Community Hubs would design and deliver programs that embed positive community-wide cultural change that its essential for programs to deliver lasting impacts.
Departments would have direct access to on-the-ground intelligence from rural and remote people to inform strategies and share information about programs that work, while communities would have access to highly coordinated, integrated and responsive services through which the needs of people could be case managed holistically.
A critical function of these Hubs would be local development. A core driver of poor health is lack of jobs which contributes to low educational aspiration, poor educational attainment, unemployment and poverty. If we are to address the social determinants of wellbeing, we need to tackle economic exclusion head on.
The Hubs, as employment nodes, would make an important contribution to employment generation in their own right as both employment and training centres. However, their role should extend to working with local businesses and others to identify strategies that would contribute to meaningful and locally-informed economic development and employment creation.
Rather than having 10 organisations delivering fragmented services from afar, we would have one community-governed and led organisation delivering integrated services in town.
Strengths of rural communities
It may be argued that this concept incorporates too many functions and roles so as to become unmanageable. This is where one of the unique characteristics of rural and remote towns comes to the fore – the inherent ability of rural and remote people to innovate and multi-task.
The Maranguka Community Hub in Bourke and Maarubaa Galariinnbaraay-gu Community Hub in Collarenebri are just two examples of where this approach is already being applied with success.
The Hub model extends on the excellent work of the National Rural Health Alliance in its proposal for Rural Area Community Controlled Health Organisations (RACCHO). But the NRHA model still assumes that the problem rural and remote communities are trying to address is a health workforce problem.
The Community Hubs model assumes that the problem communities are trying to address is how to sustainably and systemically improve community health and wellbeing. This change in starting-point frees communities to think more deeply about the type of workforce they actually need.
For example, a town with a high diabetes risk may find that it is best served by recruiting a Diabetes Educator to support individuals and develop a targeted community-led health campaign around nutrition and exercise. Closely located Community Hubs could work together to share resources while retaining local direction and control over how this function fits into the delivery of the Community Plan.
Another town with student absenteeism may choose to work with the local school to invest in a youth counsellor to case manage engagement with young people around education, contributing to increased health literacy.
Some of the capabilities required will already exist in rural and remote towns (schools, police, paramedics, NGO), while others would need to be funded. Regardless, the Community Plan would become the driver of a multidisciplinary and multi-jurisdictional approach, and would identify the long term funding needed to achieve transformative change at the root cause level.
The Aboriginal Community Controlled Health (ACCHO) sector has shown us how we can effectively support communities and merge health promotion, prevention and intervention using multi-jurisdictional funding models. We have the capacity and models to do things differently in rural and remote health if there is a will to do so.
But this requires decision makers to recognise that rural and remote people have the knowledge, skills and capacity to create more equitable access to healthcare, and more equitable health outcomes, if they receive the right support and investment needed to lead that change.
See Croakey’s extensive archive of articles on rural and remote health.
Dear Croakey and Mark,
You raise some very important and interesting points. I believe however you have misinterpreted the PRIM-HS (formerly known as RACCHO) model.
The model is very much about working with the community and is more than a workforce model; it is a community capacity building model, which is population health need and current service delivery based and adding value…… to individuals, industry and community.
The 30 percent of population that live in rural and remote Australia, has contributed to the economy and is not receiving the services they deserve, need and wish to have on a per capita basis, no matter which service you look at.
This 30% of the population, earns 50% of tourism income, provides 98% of the food that is eaten in Australia, contributes more than 2/3rds of our export income. ie they are an economic powerhouse. In the business world one would invest as much as you can, because this group would make the rest of the company (Australia) look fantastic. But this is not the case ….Crazy, I know!
There seems to be little appetite for communities to be given the right to plan locally (with another trial or pilot being the usual answer) , for health literacy to improve by involving communities, local and federal entities, without hamstringing them.
The PRIM-HS model is not for every community, nor will every community that considers such a model deliver the same services.
It is using population health need, seeing which services are needed, currently provided and where you might work together with existing service providers or stakeholders. Then where market fails there needs to be some local longer term (block or foundation) funding and the government needs to further step in. We cannot continue to shy away and “why don’t you collaborate?”, when that is the only way communities survive.
Governments must work together, rather than blame each other.
Levers and funding need to be provided to ensure they are supported to stay, rather than throwing funds to what we have always done. it isn’t working as we thought, but we have known this for 20 years.How many more times do we need to study it?
Building the capacity of communities to solve local problems is not easy, but often much easier than not having any services or being told to implement something, that has very little chance of working as it is based on city assumptions, or a system that underpays those who work in it, is so inflexible that it is easier to raise money from the community fundraisers (ie pay twice for health service access, because tax has already been paid from income) OR heaven forbid…. challenges the status quo.
Let’s support rural Australia to continue to add to our economy, for all to enjoy, by providing them every tool and access to health services they need, so they can do so.
Why? because they have kept us out of 2 financial crises and the aftermath of Covid. I would suggest, that this is a pretty good reason.