“It’s all about relationships” – Alaskan adventures and the Nuka System of Care

Written by: Kylie Fagan, PhD Student at the Yunus Centre for Social Business and Health

In May onuka-smallf this year I was fortunate enough to be awarded the Merchants House Magnusson Award, one of thirteen Magnusson Awards given out this year presented in the name of the University’s late Chancellor, the journalist and broadcaster Magnus Magnusson KBE. The annual awards support the ambitions and dreams of students and researchers at GCU. For me, this Award gave a unique opportunity to explore an alternative model of healthcare, one which has been designed by the people it aims to serve and whose focus on person-centred wellbeing weaves biomedicine with more traditional aspects of Alaska Native health and healing. Southcentral Foundation (SCF) is a not-for-profit organisation that operates the ‘Nuka System of Care’ in and around the Southcentral region of Alaska, incorporating the city of Anchorage and serving around 65,000 Alaska Natives across the region. Tasked with radically re-shaping the local health care system, improving the quality of care provided for patients and drastically shifting the balance of power and accountability between service provider and patients, SCF have had some impressive outcomes since the intentional whole system redesign undertaken in the mid 1990’s.  Owned and operated by the local Alaska Native community, the Nuka model has not only dramatically improved health outcomes within the local community  (which were amongst the worst in the U.S) but has also been recognised as a world-leading example of what a successful – and sustainable – locally owned model of healthcare can look like.

I first became aware of the Nuka model whilst working with a local community on an action research project in the Highlands of Scotland. Some of the challenges that Southcentral Foundation were actively tackling through the Nuka model, and the approach that they were taking, was of great interest to the local health services and the wider community. A number of pilot communities are currently in the early stages of taking learning from this international model and putting it into practice within their own local healthcare services – my PhD has focused on how local people across rural Scotland have, and will, engage with this change.

Back in March I was fortunate enough to join a group affectionately known as the ‘Nuka Alumni’ – individuals across Scotland who had visited SCF in prior years, who had met or heard SCF staff talk about the Nuka model and people who had an interest in innovative models of healthcare more generally. During this day event, facilitated by the International Futures Forum, one of the overarching conclusions that really stuck home with me involved envisioning ‘Nuka’ on two levels – one, a hands-on practical approach to tackling health inequalities and the other, a fundamental shift in thinking, a different philosophy on health and wellbeing from the one that had gone before. It is this latter position that really caught my attention and offered me an interesting lens through which to observe how SCF functions across these two distinct levels of action.


Not a bad view from work – at the Alaska Native Primary Care Centre

On a structural level, Southcentral Foundation has some really interesting systems in place. The co-located multi-disciplinary teams are perhaps the most obvious example of how this system operates on a day to day basis. It’s not an approach singularly unique to the Nuka model by any means, the team working approach is one that has gained traction worldwide – and is in practice here in Scotland. However, this way of working has formed the core of SCF’s primary care services since the beginning. The team-based approach has changed over this time, with new roles being incorporated based on the needs of their customer-owners (patients), however the fundamental idea of this integrated team approach remains part of the bedrock of Nuka.  A typical primary care team consists of a provider (GP), a nurse case manager, one or two case management support (administration), a certified medical assistant and these teams share the services of a pool of behavioural health consultants (BHC), pharmacists, midwives and dietitians that make up the wider integrated care team.


photo-26-09-2016-13-14-01-1The co-located team all look after a panel of around 1400 patients with individuals seeing the same nurse, GP or medical assistant on each and every visit, enabling a continuity of care that SCF feel is vital to the development of healthy relationships between the healthcare providers, the patient and their family. The role that has perhaps captured particular interest here in Scotland is the role of the behavioural health consultant. This role spans psychology to social work in terms of its remit and individuals would normally be qualified to Master’s level in one of these subjects to fill the role. The role of the BHC has recently been expanded by Southcentral Foundation and during my time in Alaska this was one of the areas that really came across as fundamental to the success of the model. Many of the issues that providers would come across in their daily consultations with patients would have a strong behavioural and/or social component or root. Therefore, having a co-located BHC on the team enabled the provider to quickly link their patient with this service – normally by paging a BHC and bringing them directly in to the consultation. This immediacy, they found, encouraged patients to use the BHC service much more widely and helped to destigmatise behavioural health appointments by bringing them into the day to day normality of GP services.  They see this position as ‘breaking down the roles between traditional mental, behavioural and physical health’ and whilst reflecting on lessons learned during the development of the Nuka model, a senior executive of SCF highlighted the importance of behavioural health to the system, stating that “if they had to do it again, they would seriously consider building the system around the behavioural health role and putting it at the heart.”[1]

The practical aspects that Southcentral Foundation employ – the innovative primary care roles, multi-disciplinary team working, co-located teams and impressive dedication to staff development have impact in their own right. However, these structures are all designed to feed from, and build into, an underpinning philosophy centred on the idea of people, communities and ‘being in relationship’ with one another.

photo-27-09-2016-20-22-41“It’s all about relationships”[2]– Katherine Gottlieb, CEO of Southcentral Foundation

This is perhaps the defining feature and message that underpins the whole of the Nuka System of Care and Southcentral Foundation more widely. The notion of ‘being in relationship’ echoes throughout the whole system, from CEO Katherine Gottlieb to administrative staff on the frontline of the service, the language and ethos remains consistent. One of the most striking aspects, I found, was the unswerving devotion to the founding principles and values of the organisation – they were echoed time and time again and were used as a tool by the organisation as a way to ‘check in’ and see if what they were doing or how they were working remained consistent to their mission statement. This can, at times, feel ever so slightly ‘cult-like’ – so much so that it’s regarded as a bit of a tongue-in-cheek running joke amongst staff, however, this impressive dedication to their vision of “[A] Native community that enjoys physical, mental, emotional and spiritual wellness”[3] appears to enable the staff to feel like they are all working towards the same, tangible goal. This ‘togetherness’ seems to be valued and encouraged by the SCF leadership both between staff and their teams and within the wider relationship between care teams and customer-owner. This change in relationship is perhaps most starkly demonstrated by eschewing the term ‘patient’ for the use of ‘customer-owner’ to reflect the change in dynamic from paternalistic provider/patient relationship to one of active participation in the co-creation of wellbeing. The term customer-owner highlights an important aspect of this relationship – one of shared ownership, responsibility and decision-making. One of the key goals of this system is to build capacity within their community to the point at which the customer-owner can meet providers in the middle, question the authority of the provider and engage in real discussion and debate over the direction of their health, and what they need to achieve wellness. One customer-owner reflected that there had been a huge shift from her parent’s generation to her children’s generation in terms of their relationship to their healthcare provider, with her son happy to give negative feedback and highlight what he felt he needed from the system. The extent to which this had impact was unclear to me (it was never elucidated whether her son got the change he requested) but for her it was a fundamental shift towards something her parent’s did not have, the confidence to “[have] a say in our own healthcare”.[4]

This sense of ownership over the system was evident in a range of ways with one of the most powerful manifestations of this for me revolving around the notion that the primary care centre itself was seen as a local-owned community space. The beautifully designed Alaska Native Primary Care Centre more closely resembled an art gallery or the lobby of a boutique (rustic) hotel than a healthcare setting with local people playing traditional music and stalls selling handmade Alaska Native crafts in the lobby of the centre. It was seen as a space for community wellbeing beyond the need to access health services and this is an idea that I can see being implemented outwith the context of indigenous Alaskan healthcare to promote the integration of health services into the local community and breaking down barriers between the traditional provider/patient roles.


Many towns and villages are only accessible by plane or boat

Perhaps due to my particular interest in rural health here in Scotland I was keen to see how they managed to operate healthcare services across villages and islands that truly deserve the title of ‘rural and remote’. Serving far flung communities such as St George Island, located in the Bering Sea approximately 200 miles southwest of mainland Alaska, is vastly different from their main primary care facility in Anchorage. Many of these communities rely on people from the local area who are trained up by Southcentral Foundation to operate village clinics. I chatted to a SCF staff member who lived and worked in one such remote community over lunch one day and he told me he dealt with everything from bumps, bruises and accidents to acting as a midwife during childbirth (his most memorable day at work!). There were significant challenges in this approach, he told me, some of which I’ve heard echoed from similar ‘First Responder’ type schemes in rural Scotland, but without this system in place, he was certain that the community would suffer. The support structure behind this approach, however, was evident with extensive training, advanced telehealth systems and paid (rather than voluntary) positions being vital to the provision of these rural services. There was also extensive support through the use of ‘flying doctors’, visiting clinicians from the main primary care centre who operate out of these rural clinics on a revolving basis. The interesting experience of one such SCF doctor was recently published here and is well worth a read.

What was evident from my time with Southcentral Foundation is that there are still flaws in the system, it’s not a perfect static service but instead truly embodies the meaning of ‘Nuka’ itself – the notion of a great, living thing. From the recent co-location of psychiatric services in primary care to the ongoing development of a new rehabilitation and addiction treatment facility, this system is ever changing and evolving. And it needs to. The issues that were pertinent to Alaska Natives twenty years ago when the system was designed are being tackled – and successfully – however new challenges constantly emerge and the system must adapt to address these. How it operates with other providers and care services also appeared, at times, disconnected. The discordance between the SCF primary care services and the local Alaska Native hospital was all too apparent on one occasion during my time in Anchorage with a patient seeming to ‘fall through the cracks’ in the system. The leadership team, however, acknowledge the complexity of negotiating primary/secondary care provision and, it appears, that this is something they are still working to constantly improve and develop.


Reflecting on Nuka around the firepit with fellow visitors to Southcentral Foundation

Since returning from Alaska I have taken some time to reflect on my time with Southcentral Foundation and the Nuka System of Care. I’ve spent the past few weeks being asked many questions by interested colleagues, family and friends and I think at times I’ve struggled to capture and succinctly express my experience in Alaska. Whilst they may not have all the answers as yet, I came away from my time in Alaska with an idea of how a health system could be designed by, and accountable to, the local people it serves, whether that be the Alaska Native population in Anchorage or a community in the Highlands of Scotland. They recognised that to have real impact on the complex health issues facing their population they needed to design a system that put the focus on the underlying behavioural and social determinants of health rather than the symptoms of ill-health itself. This is a narrative that is already firmly embedded within a range of health and social care policies and practices here in Scotland; however, I think it is fair to say that the rhetoric has not perhaps always matched the reality in terms of putting this into practice. There is, I believe, a real desire and will behind the movement here in Scotland to look at what we can do better, and taking learning from innovative models such as Nuka may be one of these. My experience in Alaska simultaneously challenged my naïve understanding of this model from afar and gave me hope it is possible to put such a radical shift in thinking about health and wellbeing into practice. It is my task now to take this experience, made possible by the Magnusson Award, and feed it forward into the local communities I will be working with over the course of my PhD and for many years to come.

I would like to extend my sincerest thanks to Merchants House of Glasgow and the Magnus Magnusson Award for this opportunity – I would not have been able to do this without your support and the experience I had in Alaska is one that I will never forget.

[1] Site Visit Presentation – 26th September 2016, Southcentral Foundation, Anchorage, Alaska

[2] Katherine Gottlieb, ‘Welcome address’ 26th September 2016, Southcentral Foundation, Anchorage, Alaska

[3] Southcentral Foundation, ‘Introduction to Integrated Care Teams in the SCF Nuka system of Care’, 26th September 2016, Anchorage Alaska

[4] Customer-Owner Panel, Site Visit Day 1, 24th September 2016, southcentral Foundation, Anchorage, Alaska

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