Intentional whole health system redesign: Southcentral Foundation's 'Nuka' system of care

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Southcentral Foundation in Alaska is widely regarded as one of the best examples of health system redesign in the United States and internationally. It delivers state-funded health care to a minority population with high levels of need, with funding and responsibility for services resting with local people. Southcentral is a working example of a ‘multispecialty community provider’ offering expanded and integrated primary and community services.


The case study, with a foreword by Don Berwick, aims to inspire commissioners and providers in the English NHS embarking on whole-system redesign. It analyses the factors behind Southcentral’s achievements and draws lessons for the NHS, focusing on issues with relevance to our system.

Interviews at Southcentral Foundation

As part of his research, Ben Collins interviewed many people at Southcentral Foundation. Seven of these interviews were filmed and can be watched on this site:

Key findings

  • When Southcentral Foundation assumed responsibility for primary, community and mental health services for Alaska Native people in the mid-1990s, the quality of care and outcomes were among the worst in the United States.
  • Southcentral’s improvement journey began when it was given control of a single budget and responsibility for a broad range of services. It delivered transformation entirely from within rather than in response to external stimuli.
  • This is an example of ‘intentional’ whole system redesign: engagement with the community, leading to a vision and principles that informed the development of a clear operating model for services.
  • The model for the new system has broken down barriers between primary care, community services and mental health services, and between these services and hospital specialists. Staff work in effective multidisciplinary teams that can offer co-ordinated, whole-person care.
  • Southcentral’s success hinges on its leaders’ commitment and the strong links they forged with their community. Service users actively share responsibility for their health and are engaged in the governance of their system.
  • Continued effort across multiple dimensions – vision, values, supporting infrastructure and investment in the workforce – is needed to sustain high performance at scale and over time.