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The integration of people-centred services is key to improving the performance of health systems. This chapter explores the rationale and definitions of integrated and people-centred services, considers frameworks to inform and drive integrated care, and describes common barriers as well as enabling strategies related to values and policy, the engagement of key stakeholders and operational considerations. It highlights the unique role of family practice (also called family medicine) as a community-based and community-oriented discipline, and as a driver of comprehensive integrated people-centred care. It concludes with a description of the key strategies used in the re-organization of primary care services into a family health model by United Nations Relief and Works Agency for Palestine Refugees (UNRWA) in the Near East in 2011.
Edited by
Uta Landy, University of California, San Francisco,Philip D Darney, University of California, San Francisco,Jody Steinauer, University of California, San Francisco
Over the past 30 years, a number of national and international commission reports focus on the future of the health workforce related to availability, accessibility, acceptability and quality factors of human resources for health. Specific to a sexual and reproductive health (SRH) workforce, the World Health Organization (WHO) provides leadership for delivery of essential SRH care by competent health workers around the world. According to the WHO, SRH care goes beyond maternal child health care to include the SRH of men and women throughout their life-cycle, and adolescents of both sexes delivered as integrated services within a primary care system. SRH extends before and beyond the years of reproduction, and it is closely associated with sociocultural factors, gender roles and the protection of human rights. Global and national examples, like the US Ryan Residency Training and Family Planning Fellowship programs, described elsewhere in this book, highlight the policy interventions to align SRH practice, education, and credentialing to address challenges and progress to improving SRH workforce capacity.
This study aimed to explore the ability of sexual health nurses working in the South West of England, to implement new learning within existing sexual health service delivery models. Drawing on Lipsky’s account of street-level bureaucracy to conceptualise policy implementation, the impact of workforce learning on the development of integrated services across this region of the United Kingdom was assessed.
Background
In order to achieve the United Nations’ goal of universal access to sexual health, it is essential for reproductive and sexual health, including HIV provision, to integrate into a single service. This integration requires a commitment to collaboration by service commissioners and an alignment of principles and values across sexual health and contraceptive services. UK health policy has embraced this holistic agenda but moves towards integrating historically separate clinical services, has presented significant workforce development challenges and influenced policy success.
Methods
Employing a qualitative approach, the study included data from semi-structured telephone interviews and focus groups, and longitudinal data from pre- and post-intervention surveys, collected between September 2013 and September 2015. Data were collected from 88 nurses undertaking a workforce development programme and six of their service managers. Data were analysed using thematic analysis to identify consistent themes.
Findings
Nurses confirmed the role of new learning in enabling them to negotiate the political landscape but expressed frustration at their lack of agency in the integration agenda, exposing a clear dichotomy between the intentions of policy and the reality of practice. Nevertheless, using high levels of professional judgement and discretion practitioners managed the incongruence between policy and practice in order to deliver integrated services in the interests of patients. Workforce education, while essential for the transition to the delivery of integrated services, was insufficient to fulfil the sexual health agenda without a strengthening of public health.