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Working well: Tailoring a workforce development model to deliver sustained improvements in community controlled healthcare

‘Working Well’ aimed to develop evidence-informed, tailored workforce systems and processes to support sustained improvements in Aboriginal and Torres Strait Islander community-controlled primary healthcare service provision with a demonstration project at Gurriny Yealamucka Health Service (Gurriny), Yarrabah, Queensland.

Background
This research responded to a need identified by Yarrabah’s Gurriny Yealamucka community controlled health service to better elucidate their workforce model. Gurriny assumed control of primary healthcare services from Queensland Health on 1 July 2014 and is now the only primary healthcare service for 3,472 Yarrabah clients. Since transition, the numbers of staff have increased and mix of workforce skills required to maintain service delivery has changed. Gurriny has achieved optimal practitioner to client ratios and workforce stability in some areas.

Employment of local people has increased by more than 75% in three years (Gurriny Yealamucka Health Service, 2015) with 83% positions filled by Indigenous people in 2014-15. While local health professionals are deemed essential to client engagement and the delivery of culturally safe care, the workforce model required revision in relation to community demand, Indigenous leadership, capacity, competencies, strengths, wellbeing, roles/professions, coordination, responsibility, control, accountability, liability, performance, retention, progression, underpinning systems, and impact.

Research aim
This research aimed to identify how an Aboriginal community controlled primary health care service developed and implemented its workforce model to deliver sustained improvements in health care service provision.

Research method
The research comprised three steps:

  1. Systematic scoping review of the literature to determine the enabling conditions strategies and impacts of Indigenous primary healthcare service workforce models in Canada, Australia, New Zealand and the United States (CANZUS nations)
  2. Mapping of annual growth and change in workforce and workforce systems since transition to community control
  3. Informed by 1 and 2, grounded theory analysis to develop a workforce model based on interviews/focus groups with staff and key stakeholder groups to identify what worked well, what did not, and how improvements could be made.

Outcomes and key achievements
Systematic scoping review
The systematic scoping review of the literature found 28 studies that described or evaluated models and systems that support the sustainability, capacity or growth of the Indigenous PHC workforce to provide effective PHC provision. No study reported a “one size fits all” model of workforce development in Indigenous PHC.

Studies reported enabling conditions for workforce development as government funding and appropriate regulation, support and advocacy by professional organisations, community engagement, PHC leadership, supervision and support, and practitioner Indigeneity, motivation, power equality and wellbeing. Strategies focused on enhancing recruitment and retention, strengthening roles, capacity and teamwork, and improving supervision, mentoring and support.

Only 12/28 studies were evaluations, and these studies were generally of weak quality. These studies reported impacts of improved workforce sustainability, workforce capacity, resourcing/growth and healthcare performance improvements.

The review concluded that PHCs can strengthen their workforce models by bringing together healthcare providers to consider how these strategies and enabling conditions can be improved to meet the healthcare and health needs of the local community. Improvement is also needed in the quality of evidence relating to particular strategies to guide practice.

Workforce mapping
The numbers of staff and mix of workforce skills required to maintain service delivery under Gurriny’s current model of care has grown considerably since the organisation’s transition of PHC services to community control. Overall, staff numbers increased by 71% from 44.5 FTE in 2013-14 to 61.5 FTE in 2014-15, 54 FTE in 2015-16 and 76.0 FTE in 2017-18. Gurriny has actively recruited local Yarrabah health professionals and operational staff. The proportion of local people employed has been maintained at high levels, with 58/76 (76%) positions filled by Indigenous people in 2017-18. The composition of the Gurriny workforce has also changed. The focus of additional positions has been in management, drivers, administrative/clerical, cleaning, health worker, medical, nursing, drug and alcohol worker, health promotion and health trainee positions.

Interviews with Gurriny Staff
Interviews were conducted with 17 Gurriny staff members from various positions in the organisation. They provided staff members’ perspectives on what is working well and what could be working better to build a strong workforce. The conditions, strategies, enablers and barriers of Gurriny’s workforce development were identified.

Key conditions, or contextual factors that influenced Gurriny’s workforce development included macro societal-level factors such as broad political and economic systems, and health and social inequities experienced by Indigenous people in Australia and internationally. Conditions also operate at community, PHC service, and individual levels. For example, the transition of primary healthcare services in Yarrabah to community control has led to significant organisational growth with a large increase in employment, including of local Yarrabah community members, and the provision of a wide array of comprehensive PHC services and programs. These changes, while enabling, building and strengthening Gurriny and its workforce, have also brought challenges such as changes in the workforce culture and a degree of change fatigue, especially among local staff who have been with Gurriny throughout the transition process and beyond.

The core process for Gurriny’s workforce development was identified as growing a stable, capable and cohesive/collaborative workforce that is responsive to community health needs. Four key strategies or actions that are taken, and could be extended, to help strengthen this core process were identified. They were strengthening workforce stability, having strong leadership, growing capacity and working well together. Each of these core strategies contain further sub-strategies that outlined the specific ways in which Gurriny supports its workforce well, and the ways this could be improved.

Impact
The top challenges listed by Indigenous primary health care services nationally in Online Services Report (OSR) to the Australian Institute of Health and Welfare in 2014-15 were staffing levels, retention and turnover. The National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework 2016–2023 also recognised the need to build a strong and supported health workforce with appropriate skills to provide culturally-safe and responsive health care. Six strategies were identified, but these require tailoring for local services.

This research project developed a collaborative and evidence-based workforce model to inform Gurriny practice and advocacy for sustained healthcare improvements to Australia’s largest discrete Indigenous community. The case of Gurriny provides useful documentation for other community controlled primary healthcare services of the enabling conditions and strategies required for a best practice workforce model, and how they are negotiated.

Next steps
The project team were successful in 2018, in partnership with Gurriny Yealamucka and 2 other primary healthcare services, in attaining a NHMRC-funded project in “systems approaches to improve the mental health of Indigenous children”. This project has workforce implications and will allow us to further explore improvements in workforce development. Particularly for mental health/ social and emotional wellbeing staff.

Related resources:
Project leader

Dr Janya McCalman

Administering institution:

Central Queensland University