Bridging the divide: the growing role of school-based integrated care in regional Australia

Introduction

Inequitable paediatric healthcare access is globally significant. School health models have been widely adopted as a solution.¹ These programmes improve healthcare access for priority populations by aligning with community values, and leveraging multisector partnerships.^{1 2} International examples are demonstrated in table 1.

Table 1. Examples of school health programmes by United Nations geographical regions.

United Nations geographical regions	Country/name of school health programme	Description of school health programme
Africa	Tunisia/School Health Programme	Government-led where doctor/nurse team work alongside schools to develop and implement school policies that align with the programme One study showed that knowledge and behaviours regarding tobacco use, physical activity and a healthy diet improved after accessing the programme
	Southern Africa/Schools as Centres of Care and Support	Developed through multisector partnerships in rural and impoverished communities to improve access to health and social services Implemented in about 1000 rural schools Improved school attendance and access to health and social services High community, school and stakeholder support for model Increased awareness by teachers of social circumstances affecting students
Americas	Brazil/Health in School Programme	Government-led health promotion programme, for example, healthy eating, physical activity and disease and infection prevention Emphasis on staff education and community partnerships to ensure access to healthcare services
	USA/School-Based Health Care	Over 2300 programmes across the country Often provide services to underserved children Generally on-site healthcare delivered by a multidisciplinary team Improves physical health, mental health and education outcomes, advances social equity and economic benefits
Asia	Indonesia/Usaha Kesehatan Sekolah/Madrasah	Mandatory and government-led Promotes health and well-being 10-component programme including mental health screening, immunisations, teacher training, embedding health education within education curriculum
	India/Integrated Child Development Scheme and other programmes	Government-led Health promotion Parent and community engagement Mental health services
Europe	Europe/School Health Services	Physical health screening and health promotion Model requires re-design to include psychosocial well-being and holistic care
Oceania	New Zealand/School-Based Health Services (SBHS)	Model of care ranges from referrals made by school to drop-in clinics Government funded for low socioeconomic communities School-funded or partnering with local health services in other communities Comprehensive SBHS associated with lower student-reported depressive symptoms, emotional and behavioural difficulties and suicidality

Across Australia, school-based integrated care (SBIC) programmes have developed based on international principles, the benefits of which are described in an urban setting.³ Compared with urban centres, regional Australian communities experience poorer health and educational outcomes. Wait times for paediatricians and allied health therapists can be up to 6 years, resulting in delayed diagnoses and inability to access early intervention. Novel solutions are needed to bridge this gap in healthcare. This viewpoint article discusses SBIC programmes in regional Australia, providing transferable knowledge for implementation in other similar contexts.

School health models: the international context

The WHO Health Promoting Schools guidelines describe the positive impact school health models have on health, education and social outcomes.¹ The guidelines include eight standards and an implementation guide. Programme examples are outlined in table 1. The ‘Schools as Centres of Care and Support (SCCS)’ programme, has components that could be translatable to regional Australia.⁴

The SCCS programme was developed in southern Africa through multisector partnerships in rural and impoverished communities, improving access to health and social services. A hub-and-spoke model was used, a strategy which may be useful for regional Australia. At each central site, a multidisciplinary ‘School Support Team’ led programme implementation and promoted resource-sharing. New roles included a ‘Learner Support Educator’ and counsellor, who were trained to provide psychosocial support to students.⁴ Other implementation strategies were strengthening school and community relationships, capacity-building, shared leadership, identifying ‘champions’ and understanding the community. Challenges included limited access to more intensive psychological support, establishing cross-sector partnerships, monitoring progress, being perceived as increasing workloads and transport to some regions—concepts that resonate with regional Australia. Overall, the programme was associated with better access to health and social care, community connectiveness, reducing stigmas, promoting life skills, positive peer relationships, improved school attendance and achievement, as well as strengthened cross-sector relationships. Through system-level endorsements, SCCS has been implemented in about 1000 rural schools within southern Africa.⁴

In the USA, school-based healthcare (SBHC) programmes are well established with over 2300 programmes across the country. SBHC plays an important role, providing services to underserved populations of youth. The programmes vary but generally comprise on-site healthcare delivered by a multidisciplinary team. Most provide medical assessments, preventative care, counselling and sexual health and reproductive counselling.^{2 5} US models have evolved over time with recent alignment and integrated care concepts addressed through the ‘Whole School, Whole Community, Whole Child (WSCC)’ model (figure 1).⁶ The WSCC model emphasises the importance of a child’s psychosocial and physical environment on their well-being, and the need for strong collaboration between community, education and health sectors.⁶ These concepts can be drawn on when designing similar programmes to meet the needs of regional Australia.

Figure 1. Whole School, Whole Community, Whole Child model.

Evidence for school health programmes

Despite local evidence for school health programmes (table 1) comprehensive reviews are mainly limited to the USA. One review demonstrated SBHC programmes improved access to mental health services, with students displaying high-risk behaviours more likely to use SBHC services.⁷ For chronic health conditions such as asthma, food allergies and diabetes, having direct access to school nursing and other health services has been associated with improved health and academic outcomes.⁸ SBHC programmes are popular among students, effectively reducing health disparities and emergency department presentations.⁹ SBHC enhances health equity by providing healthcare to children from priority populations, improving educational and health outcomes.¹⁰ An economic evaluation of SBHC demonstrated a positive benefit–cost ratio ranging from 1.38:1 to 3.05:1.¹¹

An international systematic review showed that school health services were effective in supporting autism, depression, anxiety, obesity, dental caries, visual acuity, asthma and sleep.¹² An Australian rapid review showed SBHC promoted healthy eating, physical activity and mental health improvements in adolescents while being acceptable, accessible and affordable.¹³

The Australian context

School health programmes were introduced in Australia in the 1970s, but only a few health services were co-located within schools. Recently, there is growing recognition of the importance of schools supporting the community’s educational, health and well-being needs.¹⁴

In 2017, a General Practioner-led ‘Doctors in Secondary Schools’ integrated service model was established in Victoria. Key to the success of the model was collaborative partnerships between the school and allocated general practice, co-design with youth, guidelines and shared professional development.¹⁵

In urban Sydney, a co-designed SBIC framework with Aboriginal elders called Kalgal Burnbona, meaning to surround family, provides holistic and multidisciplinary assessments to students. The framework describes stakeholders developing a shared understanding of goals, processes, evaluation and resources required to support the child and their family, as well as practical understanding of sector roles, expected outcomes and sustainability. Evaluation showed that students attending the programme had multiple unmet health and social needs. The model was acceptable, improved accessibility and resulted in significant teacher-reported behavioural improvements.³ Communication between teams, guidelines, interprofessional interactions and shared professional development sessions were critical in developing effective integrated care teams.³

Another urban Sydney school designed a holistic and integrated model to support the education, health and development of children and their families. Evaluation of the model showed that in the 2 years since inception there were improvements in student and family well-being, attendance and academic performance.¹⁶ Similar approaches have been established in different schools within regional Australia with one such school-based hub facilitating access to services by removing cost and transport barriers while establishing connections to community and cross-sector partnerships.¹⁴ Additionally, school-based health has been strengthened through a nurse-led programme where primary healthcare services are delivered at schools.¹⁷

Implications

The success of SBIC programmes is built on partnerships between schools, health professionals and community. Each model is based on local needs and health workforce availability, demonstrating the powerful impact of local collaboration and systems integration.

For regional areas, where sustainability challenges exist due to workforce and resource limitations, successful international school programmes can be drawn on.^{1 4} As programmes expand, ongoing monitoring and evaluation enable evidence-based practice, efficiency and knowledge-sharing to optimise outcomes.

SBIC programmes can overcome long waiting lists and accessibility issues. However, sustainability of these programmes requires careful consideration of local policy and funding environment. For instance, the Australian government’s National Disability Insurance Scheme (NDIS) funds costs associated with disability for eligible Australians. The NDIS is undergoing review, and a tiered approach to disability support is being developed. Systems are changing, with generalised disability support provided outside of NDIS, including foundational supports such as capacity building and early childhood intervention. Existing Australian SBIC programmes can deliver these supports; however, the Australian Medicare funding model does not cover the costs of care. This results in clinicians charging gap fees, which are out of reach for many priority groups. Clinicians could be paid a retainer or allocated block funding to assist in the management of complex cases. Furthermore, virtual care consultations by therapists or specialists may improve service accessibility.

Summary

Children living in regional Australia experience inequities accessing healthcare and early intervention. This detrimentally affects long-term health, education and social outcomes. SBIC programmes play a growing role in bridging the divide of inequitable access to care. Successful implementation requires coordinated, integrated approaches with community stakeholders and these concepts are translatable in similar communities worldwide. Integrating healthcare into education settings shows promise to address complex health problems in regional communities.