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McMurray, A. & Clendon, J. (2015)

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1 HEAL6012 and HEAL6042 Module 4: Introduction to PHC Principles and Practice
McMurray, A. & Clendon, J. (2015). Community Health and Wellness Primary Health Care in Practice. (5th.ed. pp. 4, 11-16, 62, ). Sydney. Elsevier Australia KEY READING FOR THIS SESSION

2 Environment World Health Organisation Epidemiology
Public Health in New Zealand Environment PHC and Disability Awareness Determinants of Health Health Promotion Local Environmental Health Issues Epidemiology Youth Health New family Sexual Health Application to Nursing

3 Relates to HEAL6012 and HEAL6024 Learning Outcomes:
2.Outline selected national and international health care issues and systems, structures and policies in relation to nursing practice. 3. Examine concepts of Primary Health Care (PHC) and apply to community nursing practice. CHECK THIS lo 2015. See also Conceptual Map of this course

4 Learning Objectives. Part One.
Distinguish between Primary Health Care and Primary Care Outline brief history in development of PHC (WHO) Explain Primary, Secondary and Tertiary Prevention Discuss PHC as a Philosophy: (social justice and equity) as a Strategy, as a Set of Activities and as a First level of Care. Outline barriers to accessibility of PHC and role of the RN.

5 Part Two 6. Outline PHC in New Zealand : The Vision of N.Z PHC Strategy (2001) and the role of PHOs. 7. Discuss development of PHC nursing in NZ and the role of the PHC RN.

6 References. College of Nurses Aotearoa NZ., & New Zealand Nurses Organisation. (2007). Investing in Health 2007: an update to the recommendations of Investing in health: a Framework for Activating primary Health Care Nursing (2003), Ministry of Health. Retrieved from College of Nurses Aotearoa NZ. (n.d.). Nurse Practitioners New Zealand. Retrieved from:

7 Continued: Ministry of Health ( 2001). The Primary Health Care Strategy. Wellington : Author. Retrieved from: Ministry of Health (2008). Nurse Practitioners. [DVD]. Retrieved from:

8 Continued. Ministry of Health (2011). Better, Sooner, More Convenient Health Care in the Community. Author Wellington. Retrieved from Ministry of Health (2014). Care closer to Home. Author .Wellington. New Zealand College of Practice Nurses, NZNO: Linking opportunities inter-professional collaboration: (LOGIC). (3 Issues a year). Retrieved from

9 Waitemata DHB. PHC Plan 2010-2017
Many of you may work for our local Waitemata DHB when you are registered. Check out their Primary Health Care Plan. See pgs. 7-18

10 Stop Press 2014. Who is the new Minister of Health?
Why should you know this? Discuss with your neighbour. Write your answer in your notes.

11 Part One: Obj. 1.Distinguish between Primary Care and Primary Health Care. (see text 12-13)
Primary Care: when people require health care because of illness or injury, the FIRST line of care is primary. It is an element of PHC. May include only one intervention or treatment over a period of time. Primary Health Care (PHC) includes primary or initial care to address a problem, BUT ALSO encompasses the broader activities of govt. and other sectors of society. It is intersectorial. (E.g. Food industry, education, housing, transport etc.). It is a philosophy of care, a strategy, a set of activities and a level of care). 10/60 Know this well, I like to include it in an Exam

12 Goal of PHC is to help communities and the people in them to achieve lasting improvements in the quality of their lives.

13 Obj. 2. History and Definitions: Primary Health Care: (Alma Ata declaration. (1978.WHO).
essential health care that is: Practical, and scientifically sound Socially acceptable Technology universally accessible to individuals and families At a cost country can afford First level of contact Brings health care close to where people live and work First element of a continuing care process. (WHO & UNICEF 1978)

14 Primary Health Care (PHC): Definition from The Ministry of Health (MOH) NZ PHC Strategy (2001).
1.Quality PHC means essential health care based on practical, scientifically sound, culturally appropriate and socially acceptable methods that is: 2. universally accessible to people in their communities 3. involves community participation 4. integral to, and a central function of, NZ’s health system 5. the first level of contact with our health system 8/60

15 Selective versus Comprehensive Primary Health Care
Selective: expressed in language of economics: ‘best investments in health,’ ‘targets’ and ‘outcome focused’. Comprehensive approach: Key ideas include: Underpinned by notion of Social justice Empowerment framework achieved through partnership with populations served

16 The Ultimate Aim of PHC To build community capacity to enable sustainable health and wellbeing. Community capacity is based on fundamental values of: Social justice and Equity Community participation and self determination These all embody human rights and shared social expectations.

17 Brief History of PHC. Primary Health care approach conceptualises health as:
Fundamental right Individual and collective responsibility An equal opportunity concept Image:

18 Continued Essential component of socio/economic development.
Image: https://www.google.co.nz/search?q=Popular+images+of+Mother+and+children+from+1940s&client=firefox-

19 Brief History of the development of PHC. WHO
Alma Ata Ottawa Charter Jakarta Declaration Bangkok Charter /

20 Why adopt a PHC approach?
Inadequate management systems were not creating healthier societies. Response by the World Health Organisation (WHO) to address the issues of unjust suffering was/is occurring world wide, especially in the poorer countries.

21 Obj. 3. Primary, Secondary and Tertiary Prevention
Primary: is to promote health by removing the precipitating caused and determinants of ill health. What are some of the strategies of Primary prevention? Immunisation etc. Education re healthy life styles: nutrition, exercise etc. Secondary Screening for early detection and treatment Tertiary is restorative Vaccination, health education re healthy life-styles, nutrition, exercise, companionship, protection of the physical environment. E.g. clean air and water etc. Secondary: steps taken to recover from illness and guard against any deterioration in health, E.g. Screening for early detection and treatment of disease. Tertiary prevention is restorative: rehabilitation, transition to community care, Learning to love with a disability etc. E.g. walking programmes for people with cardiac condition Metaphor of waterfall: Upstream: Primary: develop educational materials to portray benefits of nutrition or regular exercise etc. See posters riround room. Teaching healthy lifestyles. AND LOBBYING govt for improved living conditions: E.g. RN who lobbying for new bus service, more playgrounds for children to play, . Secondary: as above

22 Examples of Primary, Secondary and Tertiary Prevention in PHC.
Primary prevention: strategies to maintain health and wellbeing and prevent illness. Secondary prevention: treating and limiting illness or injury Tertiary prevention: rehabilitation or restorative actions. For SDL, identify 2 examples for each of the above.

23 Obj. 4. PHC as Philosophy, Strategy, Set of Activities and Level of Care. (must know)
Emphasis on principles of: Social justice, equity, community participation, socially acceptable and affordable technology. The provision of services on the basis of needs of the population, health education and work to address the root causes of ill-health. Emphasizes working WITH people to enable them to make decisions about their health. PHC philosophy uses approaches that are accessible, affordable, and appropriate (cultural sensitivity) to local needs and are therefore sustainable. 15-60. Give 2 mins to read

24 So what is Social Justice?
Social justice implies equal rights for all, regardless of gender, race, class, ethnicity, citizenship, religion, age or sexual orientation. It implies economic justice – which means governments must take active steps to alleviate poverty and redress past injustices. . Social justice provides the foundation for a healthy community. It grows out of our sense that each person — each created being — has value. Only as we recognize the value and dignity of each person can we build a healthy community, so it's a slow, painful process of learning and growing. To help the process along we develop attitudes of respect for one another. We also shape policies and patterns of behaviour to protect and enhance the worth of each person. We do this by building governmental and economic structures, educational and religious institutions, and all the other systems that provide for health and social welfare. This justice is not a goal that we'll ever reach, but a process, a struggle in which we can be engaged through all the pain and all the joy. - Doug King, editor and WebWeaver, The Witherspoon Society of the Presbyterian Church USAc. The principles (or values) of social justice and equity underpin both public health and the Millennium Goals. In your own words, explain what these terms mean? Give an example to support your answer. (5 marks). Answer: Social justice is also a concept that some use to describe the movement towards a socially just world. In this context, social justice is based on the concepts of human rights and equality and involves a greater degree of economic egalitarianism. There are many aspects to justice and the creation of a just world. These include social and economic factors as well as the principles of equity and equal rights. “Social justice” has been defined in a variety of ways. Amongst them, they incorporate concepts of basic rights, the realisation of human potential, social benefit, a healthy planet, an equitable distribution of resources, equal opportunities and obligations, security, and freedom from discrimination. Economic justice really forms a part of social justice. It seeks the equitable distribution of world’s natural and intellectual wealth so that everyone is able to gain a fair share. Social justice means equal rights for all, regardless of gender, race, class, ethnicity, citizenship, religion, age or sexual orientation. It implies equal rights for women and girls in workplaces, homes and public life. It implies economic justice – which means governments must take active steps to alleviate poverty and redress past injustices. Any reasonable answer that identified these basic ideas. Must include something about the notion of fairness. Equity refers to the social application or expression of social justice. This is exemplified in the Millennium Goals specific attention to alleviating poverty, the rights of women and children to maternal and child health and education. (ADD TO THIS FROM Book of Readings).

25 Social Justice Continued
The principles (or values) of social justice and equity underpin Public Health, Primary Health Care and the Millennium Goals. Implies a commitment to fairness or equity of access to health opportunities for all members of society. ‘Equity for all’ must supersede individual goals(notion of greatest good for the greatest number: Unitarianism) Is the collective expression of equity. Means governments must stand for the benefit of all members of society. Poverty is the single most important determinant of health, BUT relative poverty is also significant See Wikipedia for explanation of utilitarianism

26 Equity. Defined as striving to reduce systematic disparities in health between more and less advantaged social groups within and between countries. Some health disparities are unfair, social characteristics such as disparities in wealth, put some at a disadvantage and lack opportunities to be well. E.g. unemployed, low wage, mental illness.

27 Equity continued Is about the degree of sharing available resources in order to provide fair access. Means that some may require additional support. E.g. isolated communities may need transport, childcare, or culturally sensitive programmes. Examples to address this include the Plunket Bus, Marae based, and Pacifika health facilities.

28 PHC as a strategy for organising care.
When the philosophy of PHC is implemented, the organisation of health care reflects a : Balanced system of illness treatment with Rehabilitation and Disease prevention and Health promotion (How does the NZ PHC Strategy measure up?) 20/60 ?pg

29 PHC as a set of activities.
The Alma Ata (WHO 1978) highlights a minimum set of activities: Education of prevailing health problems, prevention and control Promotion of food supply and proper nutrition Provision of adequate safe water supply and basic sanitation Provision of maternal and child health care including family planning Immunisation against the major infectious diseases Prevention and control of locally endemic diseases Appropriate treatment of common diseases and injuries Provision of essential drugs How well are we doing in New Zealand?

30 PHC as a LEVEL of care Is often described as the first point of contact with the health system. BUT Cannot be described as a PHC unless the service offered is comprehensive AND is underpinned by the Principles of PHC. including collaboration with other health and welfare workers to deal effectively with health issues in their local area (see also slide on PHC as Strategy). 25/60. READ PG. …..(? …..). 27/30

31 Obj. 5. But: Many people experience barriers to accessing PHC
Obj. 5. But: Many people experience barriers to accessing PHC. Some barriers are: Multiple and include: Poverty, socio/economic status. Wealthy usually have better access to food and a better lifestyle. Need to provide services that are responsive to poor and help then cope and avoid the worst effects of poverty Cultural minorities. Cultural bias can provide a barrier to appropriate health care Geographical Stigma Lack of education

32 Nurses role : Accessibility
Act as entry point for access Identify and facilitate use of resources Provide health information Care should be appropriate in content and amount to satisfy essential needs of people Must be delivered in a culturally sensitive and appropriate way

33 How can you as a RN improve Access? Questions to ask yourself. Include:
How does the client get here? How much does it cost? Are the services and programmes available in the appropriate language? Are the hours user friendly? How much do the drugs cost? Can they afford to fill the prescription. Are there cheaper choices of drugs? Is the site wheel-chair accessible?

34 PART TWO. Objectives 6. Outline PHC in New Zealand : The Vision of N.Z PHC Strategy (2001) and the role of PHOs. 7. Discuss development of PHC nursing in NZ and the role of the PHC RN.

35 PART TWO. Obj. 6. PHC in New Zealand : Two Key MOH documents
Ministry of Health. (2002).The New Zealand Health Strategy. Author. Aim is to reduce inequalities in health and improve the overall health status of the population. Retrieved from: The Primary Health Care Strategy (2001) sets out how this will happen in a primary care setting. These 2 documents inform the health goals set by the then government which were set at 3 levels of detail, goals, objectives and targets. The objectives and targets are measured against specific criteria at regular intervals and reported to the Ministry of Health which then informs the Minister of Health and are published in the annual Ministry of Health Report to the Minister.

36 PHC Strategy(2001).The Vision
People will be part of local primary health care services that improve their health, keep them well, are easy to get to and co-ordinate their ongoing care. Primary health care services will focus on better health for a population, and actively work to reduce health inequalities between different groups. Ministry of Health (2010) Primary Health Care Strategy. p vii. Wellington. Author.

37 NZ PHC Strategy: Old and New PHC Strategies (see p. 6
NZ PHC Strategy: Old and New PHC Strategies (see p. 6. PHC Strategy 2001). Old Focus on individuals Provider focused Doctors principle providers Fee for service Service delivery monocultural Providers tend to work alone New Population based Community/people focused Education and prevention important Teamwork-nursing too Needs based funding for population Cultural competence Connection to other health and non-health agencies 34/60…pg. No. 2006/7……….. Refer pg.?53 in Bk Readings in Primary Health Care Strategy doc.

38 PHC Workforce: Team Work: Image: http://www. health. govt

39 Structure of the Health System
A reminder of how our health services are structured (building of NZ Society).

40 What are Primary Health Care Organisations (PHO’s)?
The DHBs over see the Primary Health Organizations established throughout the country. These were first set up in July, 2002, with a mandate to focus on the health of communities. They are funded by DHBs, and are required to be entirely non-profit, democratic bodies that are responsive to their communities' needs. Almost all New Zealanders are enrolled in a PHO, as there are financial incentives for the patients to become enrolled.

41 How does Whanau Ora(2010)relate to Primary Health Care?
Supports Maori aspirations to lead own health development. Govt. is working with collaboratively with whanau, hapu and iwi. Strengthening families and participation. Recognises real needs of families. Will be delivered through Maori PHOs and other Maori health care providers. Whānau Ora is an inclusive approach to providing services and opportunities to whānau across New Zealand. It empowers whānau as a whole, rather than focusing separately on individual whānau members and their problems. Whānau Ora will work in a range of ways, influenced by the approach the whānau chooses to take. Whānau Ora is not a one size fits all approach. It is deliberately designed to be flexible to meet family needs. Some whānau will want to come up with their own ways of improving their lives, and they may want to work on this with a hapū, iwi, or a non-government organisation (NGO). Other whānau will want to seek help from specialist Whānau Ora providers, who will offer them wrap-around services tailored to their needs. Whānau will have a practitioner to work with them to identify their needs, develop a programme of action to address them and broker their access to a range of health and social services. From:T Puni Korkore: Ministry of Maori Development (2010). More of this in T H I paper with Liz and Lesley.

42

43 Obj. 7. Development of PHC nursing in NZ
Obj. 7.Development of PHC nursing in NZ. Government MOH with New Zealand Nurses PHC Nursing is critical to implementing the PHC Strategy. The NZ Govt. realizes that nurses have a critical role in the development of health policy at all levels and has developed a: MEMORANDUM of UNDERSTANDING (MOU) (2001) between the MOH and NZ Nursing Organisations. Objectives of MOU include, leadership and nursing perspectives in health policies, and facilitation of the development of nursing profession to improve health and well being of New Zealanders. MOU A legal document outlining the terms and details of an agreement between parties, including each parties.

44 What is needed to develop the PHC Nursing Workforce?
Greater population focus and wider range of services, will increase need for well-trained PHC nurses Will have generalist knowledge and skills plus: developing advanced skills in particular areas of practice. 57/60

45 Some key roles: New Zealand Community Nurse’s in PHC delivery.
Key Community Nurses who Provide PHC include: Nurse Practitioners (p begins ½ way down p.95) Rural Nurse specialists (p. 99 see bottom of page). Home visiting: Highlight role of District Nurse (p. 105) Practice Nursing (p. 103) Plunket Nurse ( top of p. 111) Public Health Nurses(top of pg.111) School Nurse. (begins bottom of pg ) Community Mental Health Nurse( p. 117) Occupational Health Nurses (121) 59/60 Hurry up

46 Your turn. In groups of 3 Select one of these Community based RNs.
First select one person in your triad to feed back to the class. You have 5 minutes to read your section in your text. Note as many key points about this role as you can. Feedback to the rest of the class. (I suggest as people feed back, that you all take brief notes about each of these roles). Go back and re-read Chapter 5 for SDL today). TO HERE)

47 Evolving Models of PHC Practice. Two examples.
The Hub. Youth Health in Waitakere AND Public Health Nursing.

48 Continued Nurse Led Clinics. (E.g. Youth Health)
Nurse Practitioners.(see DVD next slide) Their shared goal is to provide primary health care based on PHC philosophy.

49 Chief Nurse at the Ministry
DVD clip: Nurse Practitioners. (2008). Focus: Primary Health Care.

50 The next 3 slides are for Interest Only: what do Nurses Earn?
Check this out: See the priorities of the NZNO for the 2014 election:

51 LOGIC. The journal of the NZ College of Practice Nurses
Note the Position Statement in the Guest Editorial June 2012 Journal. In particular also note; The strong political statements about the RN role and how you can be an effective advocate. Check out the College at:

52 What do I need to Know? Definition of PHC.
Distinguish between PHC and Primary Care Discuss PHC as a philosophy, of care including social justice and equity, accessibility, affordability and appropriate care and give examples. PHC as a set of activities, as a Strategy and as a first point of care. Identify barriers to accessibility and describe the nurses role to improve accessibility. Compare and contrast he old and new approaches to PHC. Whanau Ora and PHC. The community nurses role in PHC delivery

53 Don’t know about the OECD? Then check this out.
Go to Search window on Ministry of Foreign Affairs and Trade, type in OECD This will give you a one page history and NZ involvement

54 Health Improvement and Innovation Centre NZ. PHC
Check this site for regular updates in NZ PHC

55 NZ Primary Care Handbook 2012.
This resource is intended for Medical practitioners, but also useful for Nurse Practitioners and Practice Nurses. For your interest only. See Rheumatic Fever.

56 MOH Update: 2011. Better, sooner more convenient Health Care in the Community
This is for interest only. NB. Type in ‘PHC Better sooner’ in search window, select community document. (Note story about man’s wife dying from influenza)


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