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Table 10 Examples of comments on delivery system design

From: Describing and analysing primary health care system support for chronic illness care in Indigenous communities in Australia's Northern Territory – use of the Chronic Care Model

Weaknesses/threats (negative) Strengths/opportunities (positive)
Delivery system design
"Irregularity of doctors is a big factor in this clinic. Sometimes there are none, and if there is, they are always changing – people don't like that – no one likes that, not in any community, people like to go to the same doctor, that doctor may not be very good, but people go with longer term relationship, with someone who knows them". Clients are reminded by appointment cards (delivered by the driver the day before a visit is due). A list of clients is prepared and the driver goes to pick up everyone. Aboriginal Health Workers know if the person is at home or not. "People won't attend if not picked up – and it is a good thing in the heat to pick up the old people especially but also pick up the young people".
"From October to February a new nurse came every 5 weeks. People don't want to have anything to do with them. They don't know them. These staff never really got to know the place or the people and therefore were only partly effective". The health centre has both male and female practitioners and consulting spaces. Well men's screening has been carried out since the arrival of a male Aboriginal health worker. Men use the back door for screening – a separate male entry so that they don't have to sit with the women. The Aboriginal health worker is thought of very well by his colleagues – "He is the backbone of men's health and shows up to work every day. The Yolngu* know that with him confidentiality is 100%".
"Annual diabetic eye checks are delivered by an external team located in nearby town. When people go to the town they have to wait up to 5 hours then they leave and don't wait and then don't get the service and have to wait another year". A dosette system has been set up to increase medication compliance. The dosette boxes are filled at the health centre, then are delivered to people's homes and picked up by health centre staff.
The male AHW was working as a plumber and then heard via another male AHW that the health system was looking for a male AHW who was literate and numerate. He was trained but felt that the course didn't prepare him for working in a health centre. The course also contained little on chronic disease care. "If someone has to have a fasting blood sample the health centre will open early to accommodate that person's needs on any day of the week. Samples are spun down if necessary, and put into the cold box. Courier picks up before mid-day each day – results fax back as soon as they are processed. The result goes through to GP's in-tray and he signs it as sighted. Then to doctor's out-tray (may have comments such as follow-up required). Nurse on call reads all results and files in Doctor's out-tray, and checks that action has been taken before they can be filed".
Health centre staff reported that a lack of training in health promotion, prevention or brief intervention was affecting the performance of staff in delivery of chronic illness care. The registrar has been assigned the position of managing the chronic disease program. There are two team members who have a specific role for supporting chronic disease program.
The clinic manager has the assumed position of managing the chronic disease program. There is no team member who has a specific role or responsibility for the chronic disease program. "When staff are regular there are weekly meetings and chronic disease issues are addressed, in broad terms i.e. recall, reminder and follow-up for due clients".
The Aboriginal Health Workers are across issues concerning chronic disease, but have no responsibility. The health centre staff consider their team as cohesive – they have meetings every morning, they each go through the case loads, they discuss any recall reminders and they solve problems with systematic follow-ups.
Communication among team members may be an issue – internal meetings are supposed to be held monthly but these have been sporadic because of staff changes and if health workers are not there then it is not possible. The recall and follow-up system is functioning well because of the team approach and everyone is aware of who is due to come, for what and who is responsible.
Chronic disease coordinator position is not recognised locally or by the system. The work between the doctor, nurses and Aboriginal workers is currently not well coordinated. The health centre provides a place of work and the opportunity to work as a team. Administration officer is an active member of the team and coordinate care between the nurse, Aboriginal health worker and doctor. The doctor is a "good member of the team, good team player, cleans his own instrument, and gets them himself off the trolley."
  1. * Aboriginal people inhabiting the north-eastern Arnhem Land of Australia