The primary recommendation of the Study focused on the preferred service model for the CA region. However, the implementation of the service model will occur against the background of a several key overarching factors. Accordingly, a supplementary recommendation of the Study is the need to take into account seven overarching considerations that are central to enabling the primary recommendation, and must underpin the implementation plan.
- Prevention effort must be part of the suite of activities - Noting the identification, by primary care and renal services, of almost 600 people with CKD Stages 3 to 5, and evidence suggesting these cases represent a fraction of the actual number with CKD in the cross-border region, an integrated approach to CKD prevention should be implemented. The approach to preventions should include interventions across the life course, including primary prevention, early intervention and evidence based management of risk factors for CKD and progression of disease.
- Services need to be shaped in ways which recognise social and cultural determinants of treatment uptake, adherence and outcome - Practical approaches to developing appropriate health service structures and modes of delivery are crucial for implementation. Considerable evidence attests to the significance of proximity to care, availability of transport, welcoming physical spaces and meaningful roles for Aboriginal and Torres Strait Islander people.
Given that treatment close to home will not always be possible in the CA region, respite dialysis services and return to country programs should be provided as part of an integrated, coordinated regional renal service and priority should be given to addressing accommodation and social support issues for patients and their families.
- Jurisdictional drivers must be accommodated within a Tri-State service model - The CA region is a multi-jurisdictional region, which presents governance challenges. Any recommendations and/or implementation plans will hinge on a united response from all jurisdictional governments. This clearly implies the need for accommodation of the separate needs of the jurisdictions, and agreement of an appropriate mechanism for governance and coordination across the region. As a minimum, a Tri State Agreement and process addressing:
- Coordinated regional planning in harmony with jurisdictional service planning.
- Development of the funding model as a basis for resource allocation.
- Agreed status of renal services on the lands/communities.
- Protocols for dialysis treatment closer to home in the particular circumstances of the CA region must be agreed and formalised – Safe and sustainable renal service provision in remote communities requires specification of a broad range of well-documented environmental factors, including location, services, design, construction, water, electricity, drainage and management of bio-hazardous waste. Access to safe and secure housing for patients returning to remote communities for ongoing dialysis were also articulated. It is not possible to supply a checklist of community characteristics required to sustain the provision of dialysis services, and decisions regarding sites for services will require consideration of locally-specific detail about community. However, as part of coordinated regional implementation, the criteria will need to be formalised and agreed, in order to ratify them as protocols.
- The full suite of safety and quality requirements must be built in, although they will require customisation – The National Service Guidelines for the Management of Dialysis and Kidney Transplantation in Remote Australia can be utilised to develop an agreed, evidence-based set of standards to measure the performance of renal services. As a threshold issue, harmonised treatment protocols should be developed and agreed across jurisdictions. The process will be challenging, given that it will require the engagement of clinicians, governments and communities. Implementation of a workable cross-jurisdictional service model requires consistency in assessment and treatment.
- Addressing workforce requirements of the service delivery model must be a priority - Renal services require multidisciplinary teams with highly skilled staff. Quite apart from clinical and specialist skills, English is not the first language for many renal patients in the CA region. Recruitment, retention and high turnover for the remote area health workforce is well documented. These problems are not specific to renal services. Renal service delivery in remote communities across the CA region shares common challenges with other rural and remote health services in building and maintaining an appropriately skilled multidisciplinary workforce. A combination of recruitment/retention, up-skilling and alternative workforce strategies will need to be pursued. In addition, the provision of renal services in the CA region will be best served by a collaborative and inclusive approach across public, private and non-government sectors.
- Strategic monitoring and evaluation should be a core component of implementation - With the expansion of service delivery and the establishment of new models of care, ongoing monitoring and evaluation are essential to ensure that implementation is sustainable, and that transitions in service options are appropriate.