A collaborative primary health care model for children and young people in rural Australia: explorations of cross-sectoral leader action

Introduction

There are increasing calls for the establishment of cross-sector collaborations to address complex health inequities that are often linked to the social determinants of health (Baum et al. 2022). Cross-sectoral collaborations are considered necessary to address the complex interplay of health, social and environmental determinants that impact marginalised and disadvantaged populations (Lo and Lockwood 2022). Addressing concerns requires systems level integration which typically happens by strengthening connections (McGihon et al. 2018). Benefits associated with successful cross-sectoral collaborations include improved healthcare provision and associated health and educational outcomes; the efficient and effective utilisation of resources; and coordinated and integrated care provision (Chircop et al. 2015). However, limited evidence exists to describe how cross-sectoral collaborations are conceptualised, and the changes required at executive and senior management levels, across the collaborating sectors, that enable the formation and sustainability of such collaborations (Winters et al. 2016).

One such concern surrounded the inequitable outcomes of children and young people in a remote town that created a circle of poorer health and reduced educational attainment. There is a strong relationship between the health of children and their educational attainment; good health promotes positive learning whilst poorer health and adverse childhood experiences are associated with a decline in learning outcomes and a decrease in school participation, and in extreme cases, exclusion (Houtepen et al. 2020).

Many children and young people in the identified area were living in poverty. The median weekly family income in the study area of $650 (AUD) per week was well under the poverty line for all family configurations with 27.1% of household income below $650 (AUD) compared to 16.5% across Australia as a whole (Melbourne Institute 2021; ABS Census 2022). They were also less likely to have access to comprehensive health and social services exacerbating their vulnerability. Such complex challenges need to be met with new approaches to healthcare design and provision. Strategies that include developing primary healthcare models, locating services where need exists, strengthening local cross-sectoral collaborations for more effective service coordination and integration are seen as promising to tackle problems of inequity (Chircop et al. 2015). Intended outcomes of these new approaches are to ensure that the right care is available in the right place, at the right time and delivered by the right health professionals. Collaborative partnerships are seen as one strategy to seek resources, share knowledge and improve outcomes for issues that are often socially determined and impact many sectors (McPherson et al. 2017); hence school settings are ideal locations to promote education, health and social outcomes for children and young people. Evidence shows models of school-based health care, including embedding primary healthcare nurses within school settings, can address gaps in health service provision and improve health and academic outcomes, particularly for disadvantaged populations (Leroy et al. 2017). The Primary Health Care Registered Nurse: Schools Based (PHCRN:SB) program is a complex, cross-sector, multi-component primary healthcare initiative that supports a wellness model of care for children, adolescents and their families. It seeks to improve health and education outcomes for children and young people. The service is delivered by registered nurses employed by the Far West Local Health District (FWLHD), who are located on nine school campuses (seven primary and two secondary) and has been described in detail (Jones et al. 2019).

The implementation of the PHCRN:SB program provided an ideal opportunity to undertake research that has the potential to further inform the extension of cross-sector collaborative work at the local level and address significant gaps in the cross-sectoral literature, specifically from a rural Australian perspective. The senior executives from a University Department of Rural Health (UDRH), a Local Health District and a Department of Education came together to create the PHCRN:SB program. The collaboration took a social determinants approach, which acknowledges the importance of the non-health sector in contributing to healthy societies (Chircop et al. 2015). Leading a transformation to effect positive change on the common good is more than the strategic leadership of a single organisation, and this program signifies a change to challenge an entrenched problem requiring deep and broad changes and innovation (Bryson et al. 2021). Ensuring success requires commitment from executives and senior managers who play a major role in whether innovations progress or not (Heathfield 2016).

The aim of this study was to explore cross-sectoral executive and senior management level systems changes that were required to enable the innovative design of a collaborative and new primary healthcare model in rural Australia, the PHCRN:SB program. Findings from our study provide insight into how cross-sector collaboration created a design to tackle an embedded and challenging issue and offer strategies that can be expanded to inform change in other disadvantaged communities in Australia.

Methods

Results

Analysis of the data collected from six participants across three organisations led us to generate three overarching themes: embedded challenges and experimental solutions; building a shared language and understanding; and the role of relationships and trust.

Discussion

This study has provided valuable insights into the reasons that led to the reported cross-sector collaboration and how the leaders from different sectors brought their discipline specific perspectives to enable collaboration, program design and implementation to attempt to address a cycle of disadvantage that was exacerbated by remoteness. It was the deeply embedded and complex issues affecting children and young people that required a cross-sectoral response to challenges that would ordinarily be considered as ‘too hard’ to tackle. Improving educational outcomes alongside social inclusion, access, participation and engagement are described as important to learning success in childhood; a time that is integral to health and wellbeing and for positive future roles in society (Roberts 2017). Our study explored how these changes were managed by executives and senior managers within and across organisations to enable collaboration formation and program design, including policy, structural, and participant experiences of these changes from the perspectives of the three organisations who drove the change. These findings provided, through three overarching themes: embedded challenges and experimental solutions; building a shared language and understanding; and the role of relationships and trust, insight into how the changes can inform the potential transferability of the program to additional communities and school sites, and future approaches to the establishment and maintenance of additional cross-sector collaborations.

The aim to explore cross-sectoral executive and senior management level systems changes that were required to enable the innovative design of a collaborative and new primary healthcare service model in rural Australia, the PHCRN:SB program, demonstrates the first two stages of Lewin’s model that underpin the research: unfreezing and movement. The recognition of a cycle of disadvantage that negatively affected children, young people and their families was evident to organisations such as education, where a child’s attendance might be sub-optimal, developmental challenges apparent and educational achievement lower than their peers. In health, there was a recognition of poorer health outcomes for those with lower levels of educational attainment. These factors led to a desire to unfreeze the ‘status quo’. This is reflected in the first theme: embedded challenges and experimental solutions. Movement, according to Lewin’s Model, occurs when driving forces for change exceed restraining forces. Driving forces in this project included an acknowledgement of the issue, hearing and acting on the voices of the community and progressive leadership amongst executive teams. Re-freezing, through the establishment and implementation of the program, is described in another paper (Jones et al. 2019). The fluidity of a situation plays an important part, and the more fluidity there is (unfreezing) then the easier it is to bring about changes. Lewin noted that unfreezing was a challenging part of a process that tackled the ‘status quo’. That this study reports unfreezing across three organisations, highlights the importance of the processes and achievements, because more often different organisations are at different stages of readiness. The recognition by leaders across the three organisations of an issue of concern, the influence of existing relationships and trust created momentum to improve understanding and work to create sustainable change. Challenges, such as the one described in this paper, often present as problems with many interdependent factors making them feel impossible to solve and therefore are often left to perpetuate. The factors associated with ‘wicked problems’, as embedded and complex challenges are often referred to (Rittel and Webber 1973), are difficult to define, and therefore solving them requires a deep understanding of, and by, the stakeholders involved, and an innovative and somewhat experimental approach to designing a solution (Bryson et al. 2021). The participants in this study provided insights that spoke to poor outcomes across health and education for children and young people who often presented with poor health behaviours in their teens, to unfreezing and the deep understanding that was needed to underpin change. Young people have unique developmental, emotional and social needs that require responsive health systems to support their access to services (Robards et al. 2019). Addressing the embedded challenges through an experimental solution was in part achieved through building a shared language of understanding. The development of effective communication when collaborating between multiple organisations is noted as a skilled endeavour (Tooher et al. 2017). Aligned with the role of relationships and trust, these factors were essential to both identify the opportunities for collaboration that managed to align visions and goals of all partners (Lo and Lockwood 2022). In this case, maintaining the status quo would have meant that poor health and educational outcomes for children and young people would continue perpetuating a lifetime of increased hardships (Sanford et al. 2021). Instead, the findings of this study showed that concerns could be addressed by creating system-level integration characterised by shared goals and frequent communication (McGihon et al. 2018). Understanding the processes and factors that influence cross-sectoral collaboration is noted as vital to ensure continuing success of projects that run across sectors (Tooher et al. 2017). Inter-sectoral collaboration is seen as one of the core principles of primary health care (Chircop et al. 2015). In this case, it may offer an opportunity to address issues of inequity for children and young people and could be considered a step forward in extending key policy drivers, such as the first 2000 days (NSW Health 2019), further into the lifespan where services can be less available particularly in rural and remote areas.

We are mindful that this study took place in a remote context where it is common to have long-standing collaborations between key organisations. As such, it may be considered that enabling a cross-sector collaboration to explore a solution to a ‘wicked problem’ that resulted in a new service being developed and innovation was enabled because of the remote setting, and is thus a limitation. We contend that our findings describe skills and attributes that are likely to be evident in any other context and thus the new service described here is a scalable entity. Key factors were reciprocity, mutual benefit and listening to community stakeholders, and were described through building a shared language and understanding and through relationships that were based on trust that allowed what Lewin describes as movement, when the forces for change outweigh resistance. The trust was such that it allowed space for disagreements between the advocates in each organisation, but because the focus could be brought back to improving outcomes for children and young people, energy was created to find a meaningful solution and thus embedding Local Health District-employed registered nurses into schools to provide support for children (Sanford et al. 2021).

Strategies could be employed to elicit change in other contexts. Our study acknowledges that the actions described developed over several years and had been cultivated during that time span. Successful change is noted to build on a series of phases that usually occur over a considerable time frame and that skipping steps leads to less successful outcomes (Kotter 1995). Retention of key senior staff, as noted in our study’s findings, is a crucial factor to achieve sustained change in Kotter’s view and is a strategy that has been explored by others (Herlitz et al. 2020). Leadership in our study has demonstrated skills that enabled movement from the program itself to the systems level. This movement is multi-faceted and cut across individual siloed organisations by building bridges across sectors to create relationships that were maintained over several years (Bryson et al. 2021). The innovation described in our study shows how leadership support at the executive level of all three organisations empowered staff in senior management positions to be active stakeholders thus creating a powerful platform for progress (Heathfield 2016). These elements are crucial for collaborative and cross-sectoral teams to be successful and, as Chircop et al. (2015) noted, this may be one example of how future research can build on studies such as ours by focussing on the successes of systems change to effect improvement in equity for children and young people rather than focussing on outcomes alone.

Other factors that contributed to the success of this program were funding and community literacy. Failure to embed positive health messages early, and not providing support to meet health needs of young people, have been shown to increase risk for chronic conditions (Houtepen et al. 2020). The World Health Organization’s Innovative Care for Chronic Conditions Framework (World Health Organization 2002: p. 65) highlights the importance of consistent financing. Often, if supported at all, new initiatives attract short to medium-term funding that impacts negatively on sustainability. Providing funding to make this program core business, through the health chief executive officers’s actions to commit to nursing positions, was a major factor in making this program sustainable and enabling its continuation even after staff instrumental in its design and rollout left the organisations. However, funding cannot always overcome workforce shortages, because it can be harder to attract staff to rural and remote regions. Without the vision and leadership that led to consistent financing of this innovation, it may not have survived, and this is a crucial factor that others should consider. Furthermore, drawing on community skills, knowledge and resources, which Jones et al. (2020) named community literacy, are critical to the design, delivery and adaptation of healthcare policies and services to meet community needs. We contend that this is another important factor to affect long-term and sustainable change of embedded challenges to the health and educational outcomes of children and young people.

Conclusion

Understanding context is important when implementing change. This study took place in a remote community in far west NSW. The uniqueness of the site was expected to describe how a new primary healthcare model that involved cross-sectoral contributions from three organisations was developed. What also emerged from the data were factors that were linked to leadership, vision and skills to effectively manage change. These factors, we conclude, offer other rural and remote communities opportunity to implement a similar model to address health, social, educational and economic outcomes thus reducing inequity for children and young people.

Data availability

The data that supports this study cannot be shared due to ethics approval constraints.

Conflicts of interest

The authors declare that they have no conflicts of interest.

Declaration of funding

This research did not receive any specific funding.