Primary Health Network Needs Assessment Reporting Template

Transcription

1 Primary Health Network Needs Assessment Reporting Template This template must be used to submit the Primary Health Network s (PHN s) Needs Assessment report to the Department of Health (the Department) by 30 March 2016 as required under Item E.5 of the PHN Core Funding Schedule under the Standard Funding Agreement with the Commonwealth. This template should include the needs assessment of primary health care after hours services. To streamline reporting requirements, the Initial Drug and Alcohol Treatment Needs Assessment Report and Initial Mental Health and Suicide Prevention Needs Assessment Report can be included in this template as long as they are discretely identified with clear headings. Name of Primary Health Network Western Sydney When submitting this Needs Assessment Report to the Department of Health, the PHN must ensure that all internal clearances have been obtained and the Report has been endorsed by the CEO. Page 1 of 137

2 Instructions for using this template Overview This template is provided to assist Primary Health Networks (PHNs) to fulfil their reporting requirements for Needs Assessment. Further information for PHNs on the development of needs assessments is provided on the Department s website ( including the PHN Needs Assessment Guide, the Mental Health and Drug and Alcohol PHN Circulars, and the Drug and Alcohol Needs Assessment Tool and Checklist (via PHN secure site). The information provided by PHNs in this report may be used by the Department to inform programme and policy development. Reporting The Needs Assessment report template consists of the following: Section 1 Narrative Section 2 Outcomes of the health needs analysis Section 3 Outcomes of the service needs analysis Section 4 Opportunities, priorities and options Section 5 Checklist PHN reports must be in a Word document and provide the information as specified in Sections 1-5. Limited supplementary information may be provided in separate attachments if necessary. Attachments should not be used as a substitute for completing the necessary information as required in Sections 1-5. While the PHN may include a range of material on their website, for the purposes of public reporting the PHN is required to make the tables in Section 2 and Section 3 publicly available on their website. Submission Process The Needs Assessment report must be lodged to the Grant Officer, George Freeman via George.Freeman@health.gov.au on or before 30 March Reporting Period This Needs Assessment report will cover the period of 1 July 2016 to 30 June 2018 and will be reviewed and updated as needed by 30 March Page 2 of 137

3 Section 1 Narrative This section provides PHNs with the opportunity to provide brief narratives on the process and key issues relating to the Needs Assessment. Needs Assessment Process and Issues ( words) - In this section the PHN can provide a summary of the process undertaken; expand on any issues that may not be captured in the reporting tables, and identify any areas where further developmental work may be required (expand this field as necessary) This initial needs assessment used a rigorous mixed methods approach to identify general population and specific sub-groups in western Sydney. This approach enabled WSPHN to examine the quantitative data and support this with qualitative data by engaging with community, health providers and key stakeholders. This gave WSPHN a deeper understanding of: - The needs of consumers, carers and all service providers - Service gaps, availability, access, quality and suggested service improvements - The capacity of the system in western Sydney - Barriers to services and care, including cultural and language Specific population groups identified as priority groups to assess for need and service provision were child and youth, Aboriginal and Torres Strait Islander, culturally and linguistically diverse and refugee populations and the elderly. Throughout the needs assessment, WSPHN s objectives included designing a data collection and analysis process that would shape and support setting, measuring and achieving long-term improvements in health outcomes for western Sydney. This process will inform work, such as the comprehensive needs assessment, operational plans and commissioning priorities. Data Collection Considerable data was provided by key partners to assist with our work. A formal data sharing agreement has been put in place with the Western Sydney Local Health District and both they and Sydney Children Hospital Network provided significant access to data. Quantitative methods have been used to understand: - Demographic characteristics including growth projections - Special needs groups (e.g. refugee and migrants) and health inequities - Health status, disease/risk factor prevalence and premature mortality. - Health service program use - Service provision and capacity mapping A wide range of quantitative data was collected and analysed from over 55 sources. Data was analysed across the five local government areas (LGS s) of Auburn, Blacktown, Holroyd, Parramatta and The Hills Shire. Online surveys also contributed to quantitative data. Page 3 of 137

4 However, a large range of data were not available at a sub-regional level so could not be meaningfully analysed. The data has been of a wide range of formats to inform the reader. Qualitative data on consumer, carer and service provider needs, access barriers and system capacity issues was captured in a systematic way based on WSPHN s stakeholder strategy, to ensure a broadly representative sample of community members, health professionals and other stakeholders. The methods included several online surveys (with paper surveys options for those without internet access), town hall forums, face-to-face consumer groups, participation at community/stakeholder events and key stakeholder interviews. As will be seen from the data presented, the WSPHN has a long history of seeking to understand consumer, carer provider and other stakeholder needs. This approach will continue through Stakeholder Consultation Core to realising WSPHN s vision is knowing our community and this is reflected in the depth and breadth of stakeholder engagement conducted for this needs assessment, despite the tight timeframe. The methods used included: - Many forums for community stakeholders - Online surveys targeting consumers/carers, service providers and general practices. - Focus groups with patients, consumers, carers and health professionals - Numerous other community and provider events, newsletters and WSPHN communications. The most recent forum was attended by approximately 80 consumers, carers, and service providers. The forum provided an environment for sharing personal experience, how satisfied people were with the care they received, and their experiences navigating the western Sydney system of care. Anonymous feedback collected from the forum participants indicated that most found the sessions informative and believed they allowed sufficient opportunity for their experiences, opinions and thoughts about suggested improvement to be expressed. Needs Assessment Surveys Over the past year online surveys designed for the specific purpose of collecting detailed information on the western Sydney community and providers for this needs assessments have been a routine part of our work. These surveys provide a benchmark from which to design customized surveys to contribute towards WSPHN s ongoing data collection and refinement activities. Page 4 of 137

5 Additional Data Needs and Gaps (approximately 400 words) In this section the PHN can outline any issues experienced in obtaining and using data for the needs assessment. In particular, the PHN can outline any gaps in the data available on the PHN website, and identify any additional data required. The PHN may also provide comment on the accessibility on the PHN website, including the secure access areas. (Expand field as necessary) There is an increasing acknowledgement of the importance of health data available in the PHN website for the healthcare including de-identified data extracted from the clinical management systems for all Primary Healthcare Networks. There is also increasing recognition of the importance of developing simple standards for record components, including clinical and administrative requirements. The advantage of having health data available in the PHN secure site when and where it is required, will impact the improvement of healthcare delivery, accelerate data driven quality improvement and support cost control with economics of scale and sharing of resources. Despite the rich content of this site, some problems were faced during preparation of this needs assessment regarding availability of some of required statistics. Improving the following areas with depicted data needs will make this site a single source of intelligence with all required information: Aged Care Data: Prevalence of chronic condition among people aged 65+ by PHNs, LGAs and SA3 areas, data on dementia Chronic Disease Data: Currently only contains ANDA. Suggested improvements include inclusion of all other chronic conditions including prevalence, distribution by LGAs, and health risk factors Demographic Data: Inclusion of LGBTI report Child and Family Report: Requires additional tab: Children from single parent families, fertility rates, Antenatal Care, Perinatal deaths, IMR, CMR, Children of parents with mental health issues, median age death, and premature death. Aboriginal and/or Torres Strait Islander Data: Additional tab required. The quality and availability of information on Aboriginal and/or Torres Strait Islander people is a bare need. Suggested improvements include a coordinated approach to information on Indigenous peoples in the health, community services and housing sectors. Regular reporting on the health and welfare of Indigenous peoples also needs to be included. Health Workforce Data: Geographical distribution of health workforce in primary care and clinical care, DWS, population workforce ratio for primary care and clinical care. Others: Problems in the provision of care, regions, areas, and health care systems that lag or lead in delivering high quality and efficient care, the cause of unwarranted variation, and the magnitude of public benefit, if problems in care were remedied. Page 5 of 137

6 Additional Comments and Feedback (approximately 500 words) In this section the PHN can provide any other comments of feedback on the needs assessment process, including any suggestions that may improve the needs assessment process., outputs or outcomes, in future (expand field as necessary). No comment. Page 6 of 137

7 Section 2 Outcomes of the health needs analysis Outcomes of the health needs analysis Identified Need Key Issue Description of Evidence Page 7 of 137

8 Outcomes of the health needs analysis Population and projected growth Current population and projected population growthwestern Sydney PHN matches the boundaries of Western Sydney Local Heath District (WSLHD) and comprises of five local government Areas (LGAs) Proportion of Population by LGA WSPHN, 2016 Auburn 10% Auburn (32 square kilometers (km2)) Blacktown (247 km2) The Hills Shire (401 km2) The Hills Shire 21% Holroyd (40 km2) Parramatta 20% Parramatta (61 km2). With a population of ( 2016) projected to increase to 1,052,100 by 2021, western Sydney will see challenges in Increasing demand of healthcare, an increase in chronic conditions, shifting consumer expectations, changing models of care, and redevelopment of major hospitals. Blacktown has the highest projected population rate, expected to raise from residents in 2016, to residents in Population density is unevenly distributed across western Sydney with the population concentrated in the local government areas of Parramatta, Auburn, Holroyd and parts of Blacktown The western Sydney population is younger than that of NSW with a larger proportion of the population aged less than 45 years. 21% of the Blacktown 37% Holroyd 12% Source: Population Projection WSPHN Auburn Blacktown 2021 Holroyd Parramatta 2016 Source: Page 8 of 137 The Hills Shire

9 Outcomes of the health needs analysis Western Sydney population are aged 0-14 years, 14% years, 31% years, 23% years and 11% are persons 65 years and older. It is estimated that in 2025 there will be 49,308 more people aged 65 years and over compared to Approximately 1.5 % of the population ( people) are identified as Aboriginal and/or Torres Strait Islander, with Blacktown as the largest community at approximately 65% of the population. The clans of Bidjigal, Burramattagal, Cannemegal and Wangal of the Dharug language group are acknowledged as the traditional owners of the land within western Sydney The Hills Shire 9% Proportion of ATSI Population by LGA WSPHN, 2016 Auburn 5% Parramatta 13% Holroyd 8% Blacktown 65% Source: Culturally and Linguistically Diverse communities apportion for a significant component of the western Sydney population,with 37% of the Blacktown ( people), 21% of the Hills Shire ( ), Parramatta 20 % ( ), Holrpyd 12 % (48 080) and 10% (39 156) of the Auburn population born overseas. Page 9 of 137

10 Outcomes of the health needs analysis Proportion of Population in Age Groups WSPHN, ERP Yrs 11% Yrs 23% 0-14 Yrs 21% Yrs 14% Yrs 31% Source: PHN Secured Website, Demography, 2014 ERP Page 10 of 137

11 Outcomes of the health needs analysis Population by Age Group WSPHN, ERP Yrs Yrs 55-59Yrs Yrs Yrs Yrs Yrs Yrs Yrs Yrs Yrs Yrs 5-9 Yrs 0-4 Yrs Source: PHN Secure Website, Demography, 2014 Page 11 of

12 Outcomes of the health needs analysis Proportion of CALD Population by LGAs WSPHN, ERP 2016 Auburn 10% The Hills Shire 21% Blacktown 37% Parramatta 20% Holroyd 12% Source: NSW Local Government Area Population. Hosehold and Dwelling Projections Page 12 of 137

13 Outcomes of the health needs analysis Social Determinates of Health (SDH) The links between SDH and the development of diseases such as chronic conditions are complex, although usually associated with access to opportunities and resources such as quality education, adequate and meaningful employment, safe and affordable housing, accessible transport, nutritious food, safe local environments and accessible health services. Income also plays a critical role as it provides flexibility and options, enabling people to access the SDH they need. SDH underpin health and influence the movement of individuals and populations across the Population Health disease continuum All SLA s have great variation when considering the SA1 s within a given SLA e.g.: Blacktown - South-West (890 Overall score) has SA1 s with scores of as low as 480 and a maximum of The Hills Shire - North has the highest SEIFA IRSD Score (1105) but still has SA1 s within the area with scores as low as 874 (up to a maximum 1158). Western Sydney Primary Health Network (WSPHN) Population Health Profiling Report, March Australian Government Department of Employment, February Issues within western Sydney are indicated by: 1. Low Indexes of Relative Social disadvantage (IRSD), indicate a high proportion of relatively disadvantaged people. The IRSD for the WSPHN region is 994 slightly below the Australian Average (1000) and the greater Sydney Average (1011). 2. Unequal distribution of the SDH across the western Sydney population as a driving factor in the health status, creating health inequalities. Page 13 of 137

14 Outcomes of the health needs analysis Unemployment and low income are associated with poor physical and mental health outcomes. Western Sydney has an overall unemployment rate of 6.5%, in comparison to the NSW average of 5.3 %, and 12.0% for young people aged years. Parramatta LGA has an unemployment rate of 6.2%, with youth unemployment of 9.9%, and Blacktown LGS an unemployment rate of 6.0%, with youth unemployment at 12.0%, which is more than twice the NSW average. Blacktown and Parramatta LGA also have the highest rates of total concession card holders, with over 25% of each regions population in receipt of a Centrelink issued concession card. Western Sydney has a wide range of median weekly personal incomes, ranging from $370 in Parramatta South to $740 in The Hills Shire North. Page 14 of 137

15 Outcomes of the health needs analysis Page 15 of 137

16 Outcomes of the health needs analysis 3. Variable rates of full time school attendance across western Sydney.With higher education associated with higher levels of employment, and as a protective factor for young people reducing risk of substance misuse, incarceration, social exclusion and poverty, Western Sydney has overall participation rates of 80.5%, there is variability between LGAs with The Hills Shire with participation rates of 86%,Blacktown SouthWest 72.4% and Parramatta South 69.4% Page 16 of 137

17 Maternal and Child Health Antenatal Care Antenatal care has been found to have a positive effect on the health outcomes for both mother and baby. Between 2009 and 2012 the WSPHN population had the highest rate of antenatal visits in Australia during the first trimester (97.7%). Fewer Aboriginal mothers receive their first antenatal care within the recommended antenatal period compared to nonaboriginal mothers. Fertility rates in western Sydney indicate the projection of increased births at a higher rate than other PHNS. 1. Epidemiological Profile WSLHD Residents Feb 2016 p Total fertility rate 2014, PHN comparatives Total Fertility Rate 2014, PHN Comparatives Far West Western NSW Murrumbidgee Southern NSW Mid North Coast Northern NSW Hunter New England Central Coast Northern Sydney Nepean Blue Mountains Western Sydney Illawarra Shoalhaven South Eastern Sydney South Western Sydney Sydney Sydney South Western Sydney South Eastern Sydney Illawarra Shoalhaven Western Sydney Nepean Blue Mountains Northern Sydney Central Coast Hunter New England Northern NSW Mid North Coast Southern NSW Murrumbidgee Western NSW Far West Page 17 of

18 Maternal and Child Health Address rates of smoking in pregnancy Low birth weight is a risk factor for neurological and physical disabilities, and low birth weight babies may also be more vulnerable to illness throughout childhood and adulthood. Risk factors include maternal smoking, socioeconomic disadvantage, the weight and age of the mother, poor antenatal care and illness during pregnancy.16 Blacktown South-West and South-East has high proportions of mothers smoking during pregnancy 13.4%). These two SLAs also have the highest proportion of low birth weight babies. 1. Smoking during pregnancy By LGAs, WSPHN % Smoking during Pregnancy By LGAs, WSPHN 2008 to Auburn Blacktown Holroyd 13.4 Parramatta The Hills Shire Source: Page 18 of 137

19 Maternal and Child Health The rate of Child Mortality Rate is very high in Blacktown and Parramatta LGAs of WSPHN. Average Annual Infant Death is also very high in Blacktown, Parramatta and Auburn LGA. 1. Child Mortality rate by LGAs, WSPHN, Child Mortality Rate by LGAs. WSPHN 2008 to 2012 Rate per 100,000 To understand reasons for high rates of child mortality and average annual infant death Auburn Child Mortality Rate (1 to 4 yrs) per 100,000 Average Annual Infant Death Rate IDR Blacktow n Holroyd Source: PHIDU Page 19 of Parramat ta The Hills Shire

20 Maternal and Child Health To decrease premature mortality rate In Australia, as in most developed countries, the vast majority of premature deaths occur at older ages, while among younger ages external causes of deaths (injury, accidents, suicides) are more common. Though the summary mortality statistics are less reflective of the patterns of deaths in younger age group, there were 49,692 premature deaths were reported in Australia in Total 4,907 premature deaths were reported in WSPHN between years 2008 to Premature mortality by LGAs, WSPHN , Average annual SDR per 100,00 Premature Mortality by LGAs, WSPHN 2009 to 2012 Average Annual SDR per 100, Auburn Blacktown Holroyd Parramatta The Hills Shire Premature Mortality of Person (0-74 Yrs) Standard Death Rates Premature Mortality of Females (0-74 Yrs) Standard Death Rates Premature Mortality of Males (0-74 Yrs) Standard Death Rates Source: PHIDU 2011 Page 20 of 137

21 Healthy Children Address the high rates of child and family adversity as precursors to poor health, developmental disability and/or delay Child health is an important indicator of the health of a community.13 The importance of the early years and the impact they have on a child s health and development is acknowledged in the Key National Indicators Framework by AIHW. This framework brings together all of the determinants of children s health outcomes and includes safe communities and environments, family circumstances, exposure to risk and protective factors, learning and development, health child development and access to health and social services.14 Australian Early Development Index (AEDI) The Australian Early Development Index (AEDI) provides a snapshot of how Australian children are tracking against national benchmarks. Data is collected every three years with the teachers of children who are in their first year of school completing measures in five key domains (Physical Health and Wellbeing, Social Competence, Emotional Maturity, Language & Cognitive Skills and Communication Skills & General Knowledge). There is a social gradient in children s physical health, social-emotional wellbeing and academic learning. 1 Percentages of Children Vulnerable on one or more domains of the AEDI are higher than the national average of 22% and the NSW average of 20.2% in four out of five LGAs: Auburn 27.3%, Blacktown 22.8%,Holroyd 28.8%and Parramatta 24%. The Hills Shire slightly lower at 17.6%) The National average is 22% Adverse Child Experience (ACE) increases the risk of poor health and social outcomes over the lifespan and contributes to intergenerational transmission of poor health.2 Interventions need an approach that is longitudinal, ecological and targeted (proportionate universalism). The aim is sustained system change over at least 5-10 years.3 1. Western Sydney Primary Health Network (WSPHN) Population Health Profiling Report, March The same LGAs are higher than national (11.1%) and NSW (11.8%) averages for two or more domains with Auburn 11.8%, Blacktown 11.6%, Holroyd 13.2% and Parramatta 11.6%. The Hills Shire is lower than the NSW average at 8.4% Higher than National and state averages of one or more domain\ins of the AEDI 3. AEDC data 2015 & Marmot M. The Health Gap. The challenge of an unequal world Bloomsbury. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction too many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine. 1998; 14(4): Restacking the Odds: Path to Sustained Outcomes Murdoch Children s Research Institute; SVA social ventures Australia; Bain & Company. Melbourne Page 21 of 137

22 Children developmentally vulnerable on 1 or more domains (LGA specific), 2015 Children developmentally vulnerable on 1 or more domains (LGA Specific), Year Auburn Blacktown Holroyd The Hills Shire NSW Average Australia 27.30% 22.80% 28.80% 22.00% 24.00% 20.20% 17.60% Parramatta 11.10% 11.80% 11.60% 13.20% 11.60% 9.60% 8.40% Vulnerable on one or more domains of the Vulnerable on Two or more domains of the AEDI AEDI Source: Page 22 of 137

23 Address food insecurity and nutrition among children and their families across areas of relative social economic disadvantage A significant percentage of populations in the WSLHD are food insecure, with Aboriginal Australians overrepresented. Factors contributing to this include low incomes, inadequate cooking facilities, difficult access to major retail areas, fewer food choices in local stores and poor knowledge of nutrition. Address the high rates of childhood obesity Obesity reduces child wellbeing and increases risk for lifelong ill health The Mapping food Environments Australian Localities (MEAL) Project (2014) Epidemiological Profile WSLHD Residents Feb 2016 From the NSW Population Health Survey it has been estimated that less than % of children, aged 2 15 years, In WSLHD consume the recommended amount of vegetables for good health. Less than 30% of children aged 5-15 years in WSLHD engage in adequate physical activity the challenge is to find effective ways of promoting healthy eating, drinking and exercise. This includes reduction in sedentary occupations such as recreational screen time. 1. Public Health Information Development Unit (PHIDU) Social Health Atlas of Australia: Primary Health Networks published However, estimates of sedentary behavior by children in WSLHD have decreased; in , 40.5% of children in WSLHD spent more than 2 hours per day engaging in sedentary leisure activities (compared to 60.1% in ).- WSLHD Epidemiological profile, 2016 Percentage of children aged 5-15 years who engage in adequate physical activity or more than 2 hours per day of sedentary leisure activities, WSLHD and NSW, Page 23 of 137

24 Source: NSW Population Health Survey. Centre for Epidemiology and Evidence. Health Statistics New South Wales. Sydney: NSW Ministry of Health. Produced by: Epidemiology, WSLHD ( Note:*Adequate physical activity was defined as 1 hour of physical activity outside of school hours each day. Page 24 of 137

25 To protect and provide support to a larger % of children identified at risk of significant harm (ROSH) in WSLHD Incidence of abuse and neglect is highest in the first year of life,2 brain development in the first 4 years of life is particularly vulnerable to abuse.3 Sustained health home visiting may reduce abuse and improve parenting skills.4 A large proportion of children and young people at risk of significant harm do not receive a face to face visit from Family and Community Services caseworkers and therefore are not referred onto Health care services Gilbert R, Widom CS, Browne K, et al. Burden and consequences of child maltreatment in high-income countries. Lancet 2009; 373: Australian Institute of Health and Welfare. Child Protection Australia Canberra. Australian Government Perry BD. Examining child maltreatment through a neurodevelopment lens: clinical applications of the Neurosequential Model of Therapeutics. J Loss Trauma 2009; 14: Mc Donald M, More TG, Goldfield S. Sustained home visiting for vulnerable families and children. A literature review of effective programs. February Prepared for Australian Research Alliance for Children and Youth. Parkville, Victoria. 5. Joint Child and Family Steering Committee minutes. Page 25 of 137

26 To strengthen the developmental surveillance and screening rates of children in Western Sydney for vulnerable sub populations across the WSPHN It is well recognized that often the most vulnerable sub populations have the lowest usage rates of developmental surveillance and health monitoring. 1 One systematic review sought to identify the prevalence of parental concerns about their children s development, as measured by the PEDS, along with identifying associated risk factors. 37 studies were ultimately included in the review, with over 210,000 subjects in total. Nearly 14% of parents raised concerns associated with high developmental risk and overall more than 31% raised concerns associated with either high or moderate risk of developmental problems. A variety of individual, family and service level risk factors were identified Screening and surveillance in early childhood health: Rapid review of evidence for effectiveness and efficiency of models. Murdoch Children s Institute A systematic review of the prevalence of parental concerns measured by the Parents Evaluation of Developmental Status (PEDS) indicating developmental risk (2014) Children aged 4-15 years at substantial risk of developing a clinically significant behavioural problem by LHD, NSW Source: Page 26 of 137

27 Access to trauma informed care, treatment, and services for traumatized children and their families To reduce the prevalence of children and young people exposed to domestic and family violence across the WSPHN Trauma experienced in childhood is increasingly being recognised as one of the primary social determinants of health and wellbeing. Blacktown is characterised by particularly high prevalence rates of domestic violence. The witnessing of violent acts and abuse between parents and/or caregivers is recognised as a form of child abuse because of its serious emotional, psychological, social, behavioural and developmental impacts on children. In fact, evidence shows that children who witness violence experience the same level of negative psychosocial outcomes as children who directly experience physical abuse In 2010, police data shows that Blacktown was ranked 24 out of the 141 NSW local government areas with populations greater than 3000 people for domestic violence assaults per 100,000 residents 2. In 2005, ABS data showed that around 1,000,000 children in Australia were affected by domestic violence. The number has been on an upward trend since then. 3. Kitzmann, K.M., Gaylord, N.K., Holt, A.R. & Kenny, E.D. (2003). 'Child witnesses to domestic violence: a meta-analytic review', Journal of Consulting and Clinical Psychology, vol. 71, issue 2, pp Improve outcomes for children living in families with parental substance misuse It is well established that children raised in families with parental substance abuse misuse often have poor developmental outcomes 1 1. Dawe, S. Improving outcomes for children living in families with parental substance misuse: What do we know and what should we do, Australian Institute of Family Studies No Children with low birth weight, high temperamental risk, limited supportive relationships, poor coping skills, and an absence of other protective factors have been found to have a heightened vulnerability to the effects of parental drug dependency. *National surveys that collect data to monitor drug use trends across Australia do not collect information on parental status or child care responsibilities of substance users. 1. Wall L, Higgins D, Hunter C. Trauma informed care in child/family welfare services. Child Family Community Australia, CFC Paper No. 37 February The principles of trauma informed care need to underpin all interventions. 1 Page 27 of 137

28 Stable Housing Children without a stable home are in fair or poor health twice as often as other children, and have higher rates of asthma, ear infections, stomach problems, and speech problems. Homeless children also experience more mental health problems, such as anxiety, depression, and withdrawal. They are four times as likely to have delayed development.1 1. Better Homes Fund Housing NSW (2010), Annual Report 2009/10, NSW Government: Sydney One in three applicants for public housing in NSW is a single parent with dependent children.2 Increase the capacity for both private and public child and adolescent psychiatry There is a significant market failure with respect to accessing child and adolescent psychologists and psychiatrists in the WSPHN region (Dr Michael Fasher G.P) 1. 70% of people in OOHC were estimated to be there because of either their own mental illness or the mental illness of their parent/s. (Parents with mental health issues: Consequences for children and effectiveness of interventions designed to assist children and their families. Department of Community Services 2008 Page 28 of 137

29 Appropriate care for adolescents and young adults Health and social factors differ for young people aged 5-14 and young adults Percentage of children aged 0-15 years who spent at least one night in hospital in the previous 12 months, by local health district, 2012 It is estimated that in 2012, 8.1% of children (0-15 years) spent at least 1 night in hospital in the previous 12 months (11.8% in NSW).It is estimated that in 2012, 19.8% of children (0-15 years) presented to an Emergency Department in the previous 12 months (26.6% in NSW).In 2011, 10.2% of persons aged years in WSLHD were not attending an education facility and had no occupation, compared to 9.6% in NSW Appropriate health and social care including transitional care to service s for young people. Source: NSW Population Health Survey. Centre for Epidemiology and Evidence. Health Statistics New South Wales. Sydney: NSW Ministry of Health.Available at: Page 29 of 137

30 Immunisation Improve immunisation Coverage in 1, 2 & 5 years age group A. Improve childhood immunisation coveragetimeliness & completeness Age appropriate vaccination has the strongest evidence base for effectiveness of any intervention to promote health in childhood. ACIR data reveals that some WentWest areas have achieved herd immunity (95%), most have not; there is a social gradient; no area has achieved age appropriate timeliness. 2,3 The impact of the Commonwealth policy no jab, no pay has yet to appear in the data. Data indicates that Western Sydney childhood immunisation coverage rates for all children including Aboriginal and/or Torres Strait Islander children are below the national average for both age cohorts of 12 - < 15 months & 24 - < 27 months. Data reveals that Western Sydney children are just slightly higher for the 60-<63 months.1 Data presented in the Healthy Communities: Immunisation rates for children in reported that Mt Druitt (86.2), Parramatta (85.7) and Auburn (85.4) are in the bottom 10 with the lowest percentages of all children aged 1 year fully immunised in our region in Table: As of 31 December 2015, per cent fully immunised by age cohort. WSLH WSLHD Immunisation D Indigeno rates All NSW National NSW us December 2015 childre Children n (12-<15 Months) 88.6% 92.2% 91.3% 85.7% % (24-<27 Months) 87.5% % 85.8% 88.5% % (60-<63 Months) 92.4% % 95.2% 95.3% % Source: ACIR & MyHealthyCommunity, December 2015 Nation al 87.7% 86.7% 93.5% 2. Achieved herd immunity Children aged 5 years who were fully immunised, Blacktown North- 95.1% 3. Aboriginal and/or Torres Strait Islander children aged 1 year who were fully immunised, , St Marys 95% Page 30 of 137

31 Percentage of Children Fully Immunised at age cohort of 1,2 and 5, WSPHN SA3, Percentage of Children Fully Immunised at age cohort of 1, 2 and 5, WSPHN-SA3, Parramatta Merrylands - Guildford Carlingford Auburn St Marys Mount Druitt 5 Year Age Group Blacktown - North 2 Year Age Group Blacktown 1 Year Age Group Rouse Hill - McGraths Hill Hawkesbury Dural - Wisemans Ferry Baulkham Hills Source: National Health Performance Authority Page 31 of 137

32 Improve immunisation Coverage in 1, 2 & 5 years age group in ATSI Population Data indicates that Western Sydney childhood immunisation coverage rates for all children including Aboriginal and/or Torres Strait Islander children are below the national average for both age cohorts of 12 - < 15 months & 24 - < 27 months. Data reveals that Western Sydney children are just slightly higher for the 60 - < 63 months. Data presented in the Healthy Communities: Immunisation rates for children in reported that Mt Druitt (86.2), Parramatta (85.7) and Auburn (85.4) are in the bottom 10 with the lowest percentages of all children aged 1 year fully immunised in our region in Western Sydney Local Health District Australian Childhood Immunisation Register (ACIR) Consultations at the Western Sydney Immunisation Committee Percentage of Children Fully Immunised at age Cohort of 1,2 and 5, ATSI, ALLPHNs Percentage of Children Fully Immunised at age cohort of 1, 2 and 5, WSPHN-SA3, Parramatta Merrylands - Guildford Carlingford Auburn St Marys Mount Druitt Blacktown - North Blacktown Rouse Hill - McGraths Hill Hawkesbury Dural - Wisemans Ferry Baulkham Hills 5 Year Age Group 2 Year Age Group 1 Year Age Group Page 32 of

33 5. Percentage of Children Fully Immunised at age cohort of 1, 2 and 5, ATSI, All PHNs, Year Old age group Indigenous 2 Year Old age group Indigenous 5 Year Old age group Indigenous Source: National Health Performance Authority Page 33 of 137

34 Improve School Based Vaccinations coverage In 2014 data reveals that in WSLHD 86% received the HPV dose 1 subsequent doses have dropped off significantly with only 71% of eligible population receiving HPV does 3.1 Improve Influenza and pneumococcal disease immunisation Influenza/pneumonia hospitalisation rates increased ( to ) in WSLHD residents (2.5 and 2.9 more hospitalisations per 100,000 per 2-year period in males and females, respectively) but not in NSW.3 Most common types of respiratory disease contributing to these hospitalisations in WSLHD in were influenza and pneumonia, 29.8% of all respiratory disease hospitalisations (18.8% in NSW); COPD, 14.0% (16.5% in NSW); and asthma, 13.5% (9.8% in NSW). 3 Table: Immunisation Coverage by school, year and vaccine type Immunisation Coverage by school, year and vaccine type Eligible School Students, WSLHD, Year 2011 to 2014 HPV Varic HPV HPV dtpa dtpa Hepatit Hepatit (Year 7) ella Year (Year 7) (Year 7) - (Year 7) - (Year 10) is B - is B - Dose Dose Dose 1 Dose 3 Dose 1 - Dose 1 Dose 1 Dose % 76% 71% 77% 66% 48% 64% 59% % 84% 76% 80% 67% 50% 67% 60% % 82% 80% 82% 59% 66% 59% % 83% 71% 87% 46% Source: hn_trend 1. Health Stats NSW 2. National Health Performance Authority My Healthy Communities 3. Centre for Epidemiology and Evidence. Health Statistics New South Wales. Sydney: NSW Ministry of Health 1. Page 34 of 137

35 Influenza and Pneumococcal disease immunisation WSLHD, Influenza and Pneumococcal Disease Immunisation WSLHD, Year 2002 to Influenza (Per cent) Pneumococcal (Per cent) Source: Influenza and Pneumococcal disease immunisation by Local Health Districts, persons aged 65 years and over, NSW 2014 Page 35 of 137

36 Source: Page 36 of 137

37 Ensure secure vaccine supply and efficient use of vaccines for the NIP and continue to enhance vaccine safety monitoring system Lack of awareness of the cost of vaccine wastage and cold chain maintained in practices. Through stakeholder consultations it was identified that power failure represents 45% of the reasons of vaccine wastage within WS. The total value of vaccines wasted reported in the Sydney West Immunisation Strategy was approximately $274,000 in 2008 and $299,000 in Reasons for vaccine wastage, Source: Public Health Unit (WSIC), Western Sydney Local Health District. Jan 2008 Sept 2015 Page 37 of 137

38 Strengthen monitoring and evaluation of the National Immunisation Program through assessment and analysis of immunisation register data Over 10,000 children five years and under in WSPHN are overdue for vaccination. Auburn followed by Parramatta LGA are the lowest coverage rates and the highest percentage of overseas migrants and refugees. Planning & reporting of vaccination catch up of overseas born children are both time consuming and challenging for GPs and general practice staff. Documented transmission glitches between general practice software and ACIR which subsequently impact on the childcare/school enrollment and Centrelink benefits for those children recorded as being overdue on ACIR. Data cleansing activities of overdue children on ACIR have stopped the cessation in 2013 of general practice immunisation incentive GPII and its accompanying report of overdue children. This was compounded by the removal of ACIR field officers who provided technical support to general practices to manage ACIR issues. 1. Periodic consultations with WSIC 2. Public Health Unit 3. ACIR review Page 38 of 137

39 Maintain and ensure community confidence in the National Immunisation Program through effective communication strategies Ensure an adequately skilled immunisation workforce through promoting effective training for immunisation providers Availability and proper distribution of Immunisation Enrolment Toolkit for Child Care centres and Primary Schools. Availability of IEC materials for bilingual community educators (BCE). Lack of Immunisation IEC materials in multiple languages for CALD community. The implementation and operation of a reminderrecall system. Identify children five years and under within the boundaries of WSPHN who are overdue for vaccination and follow up through immunization providers or by contacting their parents with the aim of bringing them up-to-date with immunisation. Support general practices in planning, providing and reporting catch-up immunisations for overdue children especially those born overseas. Help practices with workforce training and orientation who have large numbers of overdue children to clear their backlog. 1. A 92.9% level, at 1 year age is achieved in Blacktown North area. However, on average this level is not achieved across WSPHN which has a current level of 88.6%. Parramatta LGA (85.7%), Auburn LGA (85.4%), and Mount Druitt LGA (86.2%) have the lowest rates in WSPHN which are below the NSW State Average (91.22%) year old Immunisation Bike Competition - a communication strategy by Western Sydney PHN has involved record number of practices and 999 children were immunized successfully through this campaign. 1. Improving Childhood Immunisation in Western Sydney though Overdue Children follow up A collaborative project between Western Sydney PHU and WentWest Primary Health Network. Page 39 of 137

40 Adult Health Hepatitis B In , Western Sydney had the highest notification of Hepatitis B in NSW, western Sydney HBV can lead to cirrhosis of the liver, liver failure, liver cancers, and other co-morbidities 1. Hepatitis B notifications by Local Health District, age and sex, NSW Source: Page 40 of 137

41 Adult Health Prevention and screening for breast, cervical and bowel cancer screening to lower mortality rates due to cancer Western Sydney has low screening rates of breast cancer and the rate of premature mortality due to breast cancer for females is higher than the Australian Average. Auburn and Blacktown have the lowest screening participation rates out of 5 LGAs in Western Sydney are below the state average rate with Blacktown South-West and Inner Parramatta having very low screening participation rates.5 The WSPHN population has one of the very lowest bowel screening rates in the country ranking 56 out of Mammography screening is proven to reduce mortality and morbidity attributable to breast cancer, by detecting early-stage breast cancer in women between the ages of 50-69years. BreastScreen Australia. Australia Evaluation: Mortality Study WSPHN participation rate for all women aged is 45% (as of December 2013) which is below the state average of 51.7%. Cancer Institute: Reporting for Better Cancer Outcomes Report 2014 The rate of premature of mortality of breast cancer in females in western Sydney (18 per 100,000) is higher than the Australian average (17 per 100,000). Parramatta NW and Blacktown SW have very high rates (more than 50%) of premature mortality due to Breast cancer in women. PHIDU Social Health Atlas of Australia: Primary Health Networks 2014 Auburn and Blacktown LGA have the lowest screening participation rates within WSPHN. Data Source: Epidemiology and Surveillance. Biennial breast Screening participation rate for NSW women aged by LGA, Western Sydney Medicare Local, Page 41 of 137

42 Adult Health Source: Branch, NSW Ministry of Health Biennial cervical screening participation rates for NSW women aged 20-69, WSPHN ranked second lowest at 51.4% compared to 56% in NSW. PHIDU Social Health Atlas of Australia: Primary Health Networks 2014 Page 42 of 137

43 Adult Health Map: Western Sydney Cervical Cancer Screening 2014 Source: Public Health Information Development Unit (PHIDU). Social health atlas of Australia: Primary Health Networks published 2014.Available from The WSPHN populations has one of the very lowest bowel screening rates (31.9%) in the country ranking 56 out of 61 for participation in screening. All SLAs in Blacktown and Parramatta South have high rates of premature mortality due to bowel cancer, and all are above the Australian average (ASR 9.6 per 100,000). PHIDU Social Health Atlas of Australia: Primary Health Networks 2014 Page 43 of 137

44 Adult Health Chronic Disease Address the lifestyle risk factors of chronic diseases Western Sydney has a high incidence of chronic disease risk factors, placing them at a higher risk of developing chronic diseases. The LGA of Mt Druitt, Blacktown and South Granville have been identified as areas of food deserts. These are areas of socioeconomically disadvantage with a high percentage of households (>25%) without access to a car. Additionally there was no supermarket, grocery store or green grocer but did have at least one takeaway option within 500m from home. The existence of food deserts places residents at a significantly higher risk of developing chronic disease 1. Risk Factors include: % of adults overweight (not obese) 25.8% of adults obese 7.7% adults consume recommended veg intake (2014) 53.4% adults consume recommended fruit intake (2014) 6.3% children 2-15 years old consume recommended veg intake (2014) 62.2%children 2 15 years old consume recommended fruit intake 54.1% adequate physical activity in adults (2014) 28.6% children aged 5-15 adequate physical activity ( % children 5-15 sedentary behaviours (2014) Less than 10% of people aged 16 years and over in WSLHD are consuming the recommended amount of vegetables and recommended fruit consumption is just over 50%. 3 Page 44 of 137

45 Adult Health Source: The Mapping Food Environments in Australian Locations (MEAL) project final report, 2014 Note: high disadvantage and >25% without a car, with a 500m buffer Page 45 of 137

46 Adult Health Recommended fruit and vegetable consumption(%), persons aged 16 years and over, WSLHD and NSW, 2002 to 2014 Source: Centre for Epidemiology and Evidence. Health Statistics New South Wales. Sydney: NSW Ministry of Health. Produced by: Epidemiology, WSLHD Page 46 of 137

47 Adult Health Tobacco smoking continues to be Australia s largest preventable cause of death and diseases. It increases the risk of a coronary heart disease, stroke, peripheral vascular disease, lung cancer, COPD and a variety of other diseases and conditions. There is strong correlation between smoking rates and disadvantage, with people living in areas of most disadvantage more likely to smoke daily compared with those living in areas of lease disadvantage (23% to 10% nationally).4 Page 47 of 137

48 Adult Health Alcohol is a central nervous system depressant, with alcohol consumption associated with a range of diseases and conditions including cardiovascular disease, cancer, diabetes, obesity, fetal alcohol spectrum disorder, liver disease, depression and anxiety. Alcohol attributable hospitalisations in western Sydney ( )were significantly higher overall than other PHN areas, specifically in males, at a rate per 100, 000 of for males (3785). NSW Combined Admitted Patient Epidemiology Data and ABS population estimates (SAPHaRI). Centre for Epidemiology and Evidence, NSW Ministry of Health Page 48 of 137

49 Adult Health High rates of chronic disease prevalence amongst western Sydney residents The complex nature of the western Sydney demographic presents significant issues with regards to the prevalence of chronic diseases and associated risk factors. Although the overall western Sydney figures for chronic disease prevalence are comparable to national data for some diseases, the inclusion of data for the Hills region may be a contributing factor to reduced figures. Additionally, chronic diseases are major causes of death across western Sydney. 1 Deaths by category of cause, WSLHD, Source: Centre for Epidemiology and Evidence. Health Statistics New South Wales. Sydney: NSW Ministry of Health. Produced by: Epidemiology, WSLHD ( Note: *Designated as Malignant neoplasms in Health Statistics New South Wales; **Designated as Circulatory diseases in Health Statistics New South Wales; ***Endocrine diseases includes diseases other than diabetes, which is the major endocrine disease in Australia; **** All other causes of death may be the consequence of chronic disease, for example, death from end stage kidney failure can arise from complications associated with diabetes. Page 49 of 137

50 Adult Health Improved management of cardiovascular diseases and risk factors, including coronary heart disease and heart failure is required in western Sydney Cardiovascular disease and its associated risk factor is complex due to the differing diagnosis, contributing factors and potential impact on quality of life if the condition is not managed well. Data shows that rates of cardiovascular diseases throughout western Sydney are higher than the NSW average indicating the need for better management of the condition and its associated risk factors Epidemiology and health analysis report conducted by western Sydney Local Health District. Produced February Cardiovascular disease hospitalisation by sex in WSLHD and NSW to Source: Centre for Epidemiology and Evidence. Health Statistics New South Wales. Sydney: NSW Ministry of Health. Produced by: Epidemiology, WSLHD ( Note:*Cardiovascular disease includes ICD-10-AM classifications I00-I99, Diseases of the Circulatory System. Page 50 of 137

51 Adult Health 3. Cardiovascular disease hospitalisation by LGA, to Source: Centre for Epidemiology and Evidence. Health Statistics New South Wales. Sydney: NSW Ministry of Health. Produced by: Epidemiology, WSLHD ( Page 51 of 137

52 Adult Health 4. Estimated population %, aged 18 years and over, with high blood cholesterol, ASR per 100, LGAs Estimated population %, aged 18 years and over, with high blood cholesterol, ASR per 100, LGAs Auburn Blacktown Holroyd Parramatta The Hills Shire Source: PHIDU PHIDU data showing rate of elevated blood pressure within western Sydney Coronary heart disease mortality rates are higher in western Sydney (10.6% in males; 18.1% in females) compared to NSW.1 Page 52 of 137

53 Adult Health Heart failure hospitalisation rates have increased in male western Sydney residents (2.8 more hospitalisations/100,000/2 years) but not in NSW. 2 Heart failure mortality rates increased in male western Sydney residents (0.4 more deaths/100,000/2 years) but not in NSW.1 Cardiovascular disease mortality rates are highest in the Blacktown LGA. In , the cardiovascular disease mortality rate by LGA were: 3 Blacktown: deaths per 100,000 Parramatta: deaths per 100,000 Auburn: deaths per 100,000 Holroyd:142.1 deaths per 100,000 and The Hills Shire: deaths per 100,000. CHD death rates were consistently higher in western Sydney compared to the NSW average. Average male death due to CHD was 10.6% higher in western Sydney compared to NSW and 18.1% higher for female deaths compared to NSW % adults across western Sydney have high cholesterol. This is broken down by LGA (ASR per 100) into:4 Auburn: 30.9 Blacktown: 31.3 Holroyd: 31.1 Parramatta: 31.5 The Hills Shire: % of adults across western Sydney have high BP.5 Page 53 of 137

54 Adult Health Early diagnosis of diabetes and intervention for the management of poorly controlled diabetes Western Sydney has been identified as a diabetes hotspot with a diabetes risk of across most of the region.1 In addition to the high rates of diabetes, the rate of undiagnosed diabetes is a major concern. This highlights the issue of managing not only people diagnosed with diabetes but identifying those who may have undiagnosed diabetes or prediabetes. The prevalence of diabetes is increasing in both western Sydney and NSW residents.3 The incidence of gestational diabetes increased by 0.9% of births per year in western Sydney residents and 0.5% of births per year in NSW. 4 There is scope for improvement in the management of diabetes across primary care in western Sydney. 1. Map of diabetes risk across the western Sydney region Source: Taking the heat out of diabetes hotspot, 2016 Page 54 of 137

55 Adult Health Taking the heat out of diabetes hotspot, 2016 Findings of a HbA1c testing in Blacktown ED pilot revealed: % of patients tested were diabetic 32.2% had undiagnosed diabetes and 27.4% were pre diabetic Epidemiology and health analysis report conducted by western Sydney Local Health District. Produced February Gestational diabetes incidence in WSLHD and NSW Source: Centre for Epidemiology and Evidence. Health Statistics New South Wales. Sydney: NSW Ministry of Health. Produced by: Epidemiology, WSLHD ( Page 55 of 137

56 Adult Health 5. Hospitalisation where diabetes is a comorbidity in WSLHD Vs NSW Source: Centre for Epidemiology and Evidence. Health Statistics New South Wales. Sydney: NSW Ministry of Health. The type 2 diabetes hospitalisation rate is 17.9% higher in western Sydney residents compared to in , the rate of hospitalisations where diabetes is a comorbidity is 16.4% higher in male western Sydney residents and 25.9% higher in female western Sydney residents, compared to NSW.5 6. Estimated population, aged 18 years and over, with diabetes mellitus, ASR per 100, LGAs western Sydney Page 56 of 137

57 Adult Health Estimated population, aged 18 years and over, with diabetes mellitus, ASR per 100, LGAs Auburn Blacktown 6.8 Holroyd Parramatta The Hills Shire Source: PHIDU 7. Diabetes-related mortality rates are higher in western Sydney residents compared to NSW (24.3% higher in males; 37.1% higher in females). 3 Page 57 of 137

58 Adult Health Enhanced respiratory disease management including Asthma and COPD Asthma is a growing issue across Australia, in particular in western Sydney due to the demographics of the region. The rate of asthma among Indigenous Australians is almost twice as high as that of non-indigenous counterparts. Additionally, asthma is more common in people living in socioeconomically disadvantaged areas. 1 In addition to the high hospitalization rates, western Sydney s death rate due to asthma is higher than the NSW average. 4 Another key respiratory disease which is a concern in western Sydney is COPD. As with asthma, the incidence of COPD amongst Indigenous Australians is 2.5 times higher than the non-indigenous population.5 8. Incidence of diabetes in western Sydney is 7.9%. This is likely due to the low incidence of diabetes in the Hills Shire, (4.7 ASR per 100) bringing down the region s overall average. Incidence of diabetes across the region (ASR per 100) is as follows: 6 Auburn: 10.8 Blacktown: 7.8 Holroyd: 8.2 Parramatta: 6.8 The Hills Shire Asthma foundation: Estimated population (western Sydney) with Asthma by LGA Estimated population with asthma, ASR per 100, LGAs Auburn Blacktown Holroyd Page 58 of 137 Parramatta The Hills Shire

59 Adult Health Source: PHIDU Epidemiology and health analysis report conducted by western Sydney Local Health District. February Asthma hospitalisations by sex in WSLHD Vs NSW, to Source: Centre for Epidemiology and Evidence. Health Statistics New South Wales. Sydney: NSW Ministry of Health. Produced by: Epidemiology, WSLHD ( Page 59 of 137

60 Adult Health 4. Asthma deaths in WSLHD Vs NSW to Source: Centre for Epidemiology and Evidence. Health Statistics New South Wales. Sydney: NSW Ministry of Health. Produced by: Epidemiology, WSLHD ( Page 60 of 137

61 Adult Health COPD hospitalisations (people aged 65 years and over) by sex in WSLHD Vs NSW, to Source: Centre for Epidemiology and Evidence. Health Statistics New South Wales. Sydney: NSW Ministry of Health. Produced by: Epidemiology, WSLHD ( Page 61 of 137

62 Adult Health 7. Estimated Western Sydney population with COPD by LGA, Estimated population with COPD, LGAs ASR per Auburn Blacktown Holroyd Parramatta The Hills Shire Source: % of western Sydney residents have asthma. By LGA this is broken down to (ASR per 100):2 Auburn: 6.7 Blacktown: 8.7 Holroyd: 7.8 Page 62 of 137

63 Adult Health Parramatta: 8.1 Hills Shire: 8.4 Only 20% of people aged 15 and over have a written asthma action plan, this is even lower in western Sydney.1 Asthma hospitalisation rates are 21.6% and 18.6% higher in male and female western Sydney residents, respectively, compared to NSW residents. 3 In addition to the high hospitalization rates, western Sydney s death rate due to asthma is higher than the NSW average.4 The COPD hospitalisation rate is 13.1% higher in male western Sydney residents 65 years of age and over compared to their NSW counterparts. 6 In western Sydney it is estimated that 2.4 ASR per 100 are diagnosed with COPD. This is broken down into (ASR per 100):7 Auburn: 2.1 Blacktown: 2.6 Holroyd: 2.5 Parramatta: 2.4 The Hills Shire: 2.1 Page 63 of 137

64 Culturally And Linguistically Diverse (CALD) Health Culturally appropriate health services Western Sydney is culturally diverse with 42.7% born overseas and 45% speak a language other than English at home compared to 35.2% in Greater Sydney. Several of the western Sydney LGAs display high concentrations of overseas born persons from particular countries. Consumers and community identify key issues being, lack of information on culturally appropriate health services available, lack of integration between Commonwealth and State funded services, and lack of coordination between sectors e.g. Mental Health and Aged Care.1-5 Reluctance for CALD populations to access both hospital and primary health services within the community. 7 Stigmatisation towards mental health by the CALD community % of people in Auburn, Blacktown Southwest and Parramatta South report high or very high levels of psychological distress, compared to 11.8% for Metropolitan Sydney.9-10 Low cancer screening within CALD population Australian Bureau of Statistics, Census of Population and Housing, 2006 and 2011 Auburn the largest overseas born group is form China (8341 persons), Blacktown is home to persons in the Philippines. Holroyd and Parramatta both had a large Indian born population (7433 and respectively). New South Wales State and Local Government Area Population, Household and Dwelling Projections: WESTIR Cultural and Linguistic Diverse in Western Sydney WSPHN Community & Consumer Forum WSPHN Primary Healthcare Survey for Community Providers The RACGP Curriculum for Australian General Practice Policy and Implementation Plan for Healthy Culturally Diverse Communities Ministry of Health WSPHN Primary Healthcare Survey for Community Providers 9. Federation Ethnic Community Council of Australia - Mental Health and Australia s Culturally and Linguistically Diverse Communities Primary Health Care Research & Information Service (PHC RIS). 11. Cancer and Culturally and Linguistically Diverse Communities: Federation of Ethnic Communities Councils of Australia 2010 Page 64 of 137

65 Culturally And Linguistically Diverse (CALD) Health Address the high rates of disease prevalence amongst CALD populations in western Sydney Higher prevalence of some disease for specific CALD populations. Because of their experiences and sometimes their region of origin, they may be at increased risk of under immunisation. A large number of refugees have been found to be nonimmune to Hepatitis B. There is a lack of education and support for Asian communities to understand and de-stigmatise HBV.1-2 People from a culturally and linguistically diverse background are at high risk for Type 2 diabetes, including those of Melanesian, Polynesian, and Mediterranean, Middle Eastern and Asian (especially Indian subcontinent) background. Many of these ethnic groups develop diabetes at lower levels of obesity and at a younger age than people of European descent Westerns Sydney is one of 2 LHDs with the highest crude rates of HBV in NSW, with Auburn having the overall highest rate due to residents born in high prevalence countries China, Vietnam, Philippines, Fiji and Korea. NSW Hepatitis B Strategy Consultation with Community Service Providers for Hepatitis B in 2015 identified that there is lack of understanding in how HBV is contracted and hence stigma is often associated with the disease. Australian Diabetes Council, 2012 Diabetes is higher across many areas of western Sydney. Compared with a national diabetes prevalence of 5.4%, the rates in Holroyd (7.6%) Blacktown (7.2%), Auburn (6.7%) and Parramatta (6.4%) are high. Four out of five Western Sydney local government areas have a rate of diabetes above NSW and national rates. National Diabetes Services Scheme, Diabetes Australia Map 2013 Source: Diabetes Australia, Australian Diabetes Map Page 65 of 137

66 Culturally And Linguistically Diverse (CALD) Health Note: Estimates of known diabetes from National Diabetes Services Scheme and undiagnosed diabetes from Ausdiab survey Improve language barriers and health literacy amongst CALD populations in western Sydney Language barriers influence stress levels and incidences of self-reported poor health.1-2 Low levels of health literacy correspond with poor health outcomes resulting in poor access and utilisation of healthcare, less effective communication in patient provider relationships and self-ability to self-manage conditions. 3 The provision of culturally appropriate services (e.g. mental health and other key government departments). Literacy and comprehension of particular services for CALD communities Top country of birth for Western Sydney LGAs according to 2011 shows that many of the ethnicities highlighted by Australia Diabetes Council as being at high risk of developing Type 2 Diabetes are spread across the region. Linguistic Disparities in Health Care Access and Health Status among Older Adults. Ponce et al 2001 All LGAs in Western Sydney have a higher percentage of people with English not identified as a main language with Auburn at a high of 71%. Bowers E (2011) Health literacy and primary healthcare PHCRIS research roundup issue 19 WSPHN Primary Healthcare Survey for Community Providers 2016 identified a need for health resources to be translated, better access to interpreters. Difficulty in finding local health providers that speak the language. Page 66 of 137

67 Culturally And Linguistically Diverse (CALD) Health Appropriate health services for refugee and asylum seeker migrants Complex or multiple health problems suffered by newly arrived refugee background migrants. 1-2 Experiences of torture and trauma by refugee background migrant. Common refugee experiences include torture or civil unrest, the loss of family and friends through violence and prolonged periods of depravation. These experiences have major implications on a person s health status and on the delivery of healthcare. 3-4 Refugee migrants present with incomplete immunisation records. Migrants and refugees are often susceptible to many of the vaccinepreventable diseases included on the National Immunisation Strategy, yet there is no catch-up immunisation available, and may be at increased risk of under immunisation. A large number of refugees have been found to be non-immune to Hepatitis B.5-6 Higher rates of mental health issues amongst refugee including anxiety and depression. 7 Unique health issues for refugee children. 8 Approximately 400 children (0-16years) are being seen at a special clinic for refugee kids in Westmead Children s Hospital. Since 2005, the majority of clients have been from African Newly arrived refugee patients can have complex or multiple health problems. Inadequate reimbursement to general practitioners for the additional time required to provide medical care for patients with special needs can provide a disincentive for providing comprehensive care. Problems Refugees Face When Accessing Health Services. NSW Public Health Bulletin pp Top 5 LGAs, out of 15 LGAs for refugee settlement in NSW, fall within the Western Sydney Boundaries. For the 2009 to 2014 period, refugees were taken in by Western Sydney LGAs in the following numbers: Auburn 1669, Blacktown 1365, Holroyd 745 and Parramatta 1243.PHIDU (2013). Social Health Atlas of Australia. Data by Medicare Locals. Published 2013: May 2013 Release. Each year, some 4000 people who have experienced persecution or other serious human rights abuses settle in NSW. Western Sydney had the second largest intake of humanitarian arrivals to NSW at 31.7% with a large share of this stream settling in Blacktown. PHIDU (2013). Social Health Atlas of Australia. Data by Medicare Locals. Published 2013: May 2013 Release. NSW Refugee Health Services: An overview Oct 2012 NHMRC Centre for Research Excellence in Immunisation - Protecting Australia closing the gap in immunisation for migrants and refugees 2014 NSW Refugee Health Services: An overview Oct 2012 PHIDU (2013). Social Health Atlas of Australia. Data by Medicare Locals. Published 2013: May 2013 Release. Sydney Children s Hospital Network Health Assessment for Refugee Kids (HARK) Clinic Page 67 of 137

68 Culturally And Linguistically Diverse (CALD) Health countries with more recent migrations from Middle East and South East Asia. Common health problems associated with refugee children are growth and development issues, malnutrition, under-immunisation, poor oral health, poor vision, Vitamin D/Iron deficiency and infections includingtuberculosis, HIV/AIDS, Hepatitis B, Schistosomiasis, Leishmaniasis and Parasitic infections. Page 68 of 137

69 DISABILITY Further understanding and planning for the high growth of participants in the National Disability Insurance Scheme (NDIS) in Western Sydney Demand for disability services is expected to increase as a result of population growth, population ageing and change in service usage and service delivery of the NDIS. 1. PHIDU 2015 Rates of profound or severe disability across our region are generally higher than the State average of 2.6/100. All of our 5 LGA s sit above this, with the rates being Holroyd (5.1), Parramatta (4.9), Blacktown (4.6), Auburn (4.5) and The Hills Shire (2.8). 1 Profound or severe disability is more common amongst people 65 years and older (18.3% in NSW). The prevalence amongst this cohort in our region ranges from 13.0% in the Hills Shire to 26.7% in Auburn Data indicates that there are approximately 8,700 people in Western Sydney currently in receipt of specialist disability support through the NSW Government. At full scheme, in June 2019 Western Sydney is forecast to have 16,800 NDIS participants, representing an annualized growth of 25 per cent. Source: NDIS March 2016 :NSW Market Position Statement Western Sydney is expecting to see the highest growth in the population of individuals aged 65+ over the next 15 years with 120% compared to the rest of NSW. The data indicates there is a growing need for disability services due to population growth and aging population. Source: NDIS March 2016 :NSW Market Position Statement As part of its growing capability, the NDIS is now able to forecast growth in demand for NDIS supports at the LGA level and for the Western Sydney LHD. The LGAs with the highest demand growth in 2018/19 are: Blacktown (3,800 to 7,300), followed by Parramatta (1,900 to 3,700), The Hills Shire (1,100 to 2,200), Holroyd (1,100 to 2,100) and Auburn (800 to 1,500). Source: NDIS March 2016 :NSW Market Position Statement Page 69 of 137

70 DISABILITY Improved access, navigation and communication of the roll-out of the NDIS The Community reports that navigating an increasingly complex disability service is a significant barrier to access. Service providers, consumers and carers reported concerns about the potential impact on accessibility of services for people living with a disability with the implementation of the NDIS including: elderly parents that have always cared for their child change for service providers from a focus on service delivery to negotiating with clients and families Provide support to the growing diverse community seeking appropriate disability services in Western Sydney Demand for culturally appropriate disability services is expected to increase as a result of population growth and the growing prevalence of complex and chronic conditions amongst the CALD population There are also a high number of families with complex needs, including where the parent is a person with disability and needs support to care for their children, or elderly parents from culturally and linguistically diverse (CALD) backgrounds caring for their adult child with a disability.1 1. Official NDIS rollout for Western Sydney is July 2016 however I was told at one forum that we may not get contacted until early 2017 I was also told that Local Area Coordinators have not even been recruited yet as they are having trouble finding people with the required skill set! Source: Consumer Statement, WentWest Community Forum March 2016, consumer forum report 1. 1.Source: NDIS March 2016 :NSW Market Position Statement) 2. Western Sydney PHN is culturally diverse with 42.7% born overseas and 45% speak a language other than English at home. Source: New South Wales State and Local Government Area Population, Household and Dwelling Projections: Western Sydney is a diverse community, with extensive cultural and linguistic diversity (there are approximately 16 per cent of current Western Sydney disability clients, compared with 10 per cent in NSW). Page 70 of 137

71 Aboriginal And/Or Torres Strait Islander Health Health systems effectiveness The main center of Indigenous populations is Blacktown with 8,194 people. Blacktown south-west has the highest Indigenous community at 4.6%, higher than any proportion of community in Sydney. The Aboriginal population is younger than the nonaboriginal population, with a much higher proportion of the Aboriginal population aged less than 20 years and relatively few people aged over 65 years compared to the non-aboriginal population % of western Sydney population identified as Aboriginal and/or Torres Strait Islander (14,407 people), compared to 2.6% of the NSW population. Due to the transience of the community, with a sensitivity to completing the census, it is suggested that the Aboriginal & Torres Strait Islander population in western Sydney is closer to 16, ,000. WSPHN Aboriginal and Torres Strait Islander Population per LGA WSPHN Aboriginal & Torres Strait Islander Population per LGA Identification as Aboriginal and/or Torres Strait Islander, and receipt of culturally appropriate care, with variable or an absence of understanding of the Close the Gap Program , 9% 734, 1918, 13% 1126, 8% 9419, 65% Auburn Blacktown Holroyd Parramatta The Hills Shire Source: Page 71 of 137

72 Aboriginal And/Or Torres Strait Islander Health Based on Australian Bureau of Statistics population estimates. State of New South Wales through Planning & Infrastructure Aboriginal persons by age and sex: count of residents of western Sydney 2011 WSLHD Source: 2011 Census, ABS data used with permission from the ABS ( Produced by: Epidemiology, ( Note: * Comprised of Aboriginal, Torres Strait Islander, and both Aboriginal persons. Page 72 of 137

73 Aboriginal And/Or Torres Strait Islander Health Maternal health and parenting Fewer Aboriginal and/or Torres Strait Islander mothers receive their first antenatal care within the recommended period. The gap between Aboriginal and non-aboriginal mothers is greater in western Sydney than in NSW.1 The proportion of mothers smoking during pregnancy is 2-3% higher in western Sydney than NSW. Aboriginal and/or Torres Strait Islander mothers are more likely to smoke during pregnancy (49.5 % in 2014; 6.3% for nonaboriginal mothers).2 Preterm births are increasing in western Sydney and not in NSW, and are common among Aboriginal and/or Torres Strait Islander mothers. 3 Low birth weight babies are common among Aboriginal and /ortorres Strait Islander mothers and are increasing in western Sydney but not in NSW Epidemiological Profile of Western Sydney Residents In 2014, the proportion of Aboriginal mothers who had their first antenatal visit to a clinician prior to 14 weeks or 20 weeks of pregnancy was less than for non-aboriginal mothers. This difference was greater in WSLHD than in NSW. The proportion of mothers in WSLHD who had their first antenatal visit prior to 14 weeks of pregnancy was 36.5% and 55.1% for Aboriginal and non-aboriginal mothers, respectively. The proportion of NSW mothers who had their first antenatal visit prior to 14 weeks of pregnancy was 54.4% and 59.9% for Aboriginal and non-aboriginal mothers, respectively. 2. Page 73 of 137

74 Aboriginal And/Or Torres Strait Islander Health First antenatal visit before 14 or 20 weeks or pregnancy by mother s Indigenous status, WSLHD and NSW, 2014 WSHPN Aboriginal and Torres Strait Islander Family Structure 2011 WSPHN Aboriginal & Torres Strait Islander Family Structure URP 2011 Parramatta Holroyd Blacktown Baulkham Hills % children aged less than 15 yrs in Aboriginal jobless families % Aboriginal single parent families with children <15 yrs Page 74 of % Aboriginal jobless familes with children aged <15 yrs % Aboriginal low income families Auburn

75 Aboriginal And/Or Torres Strait Islander Health Source: PHIDU release of the Aboriginal and Torres Strait Islander Social Health Atlas of Australia has been produced by Indigenous Areas (Australian Bureau of Statistics (ABS) 2011 Australian Statistical Geography Standard (ASGS) Indigenous relative socioeconomic outcomes index 2011 Indigenous Relative Socioeconomic Outcomes Index LGA Index Score Aboriginal population (2011 URP) 3. Auburn Baulkham Hills Blacktown 59 8,219 Holroyd Parramatta 31 1,394 NSW ,949 Australia ,368 Smoking during pregnancy is associated with a variety of health risks for both the mother and the foetus including premature birth, impaired placental development, low birth weight and stillbirths. Rates of smoking during pregnancy decreased substantially in NSW in the past two decades, from 21.3% in 1996 in NSW (Health Statistics NSW, NSW Ministry of Health). The proportion of mothers smoking during pregnancy continued to decline and in 2014, 7.2% and 9.4% of mothers in WSLHD and NSW, respectively, reported smoking during pregnancy Page 75 of 137

76 Aboriginal And/Or Torres Strait Islander Health 4.. Percentage of mothers smoking during pregnancy, WSLHD and NSW 2011 to 2014 Source: Centre for Epidemiology and Evidence, Health Statistics New South Wales. Sydney: NSW Ministry of Health. Produced by: Epidemiology WSLHD ( 5. Rates of smoking during pregnancy prior to 2011 are not shown since the question asked at data collection changed in this year and therefore data prior to 2011, although a reliable estimate of smoking rates, is not directly comparable to recent data. Smoking during pregnancy by mother s Indigenous status, WSLHD and NSW, 2014 Page 76 of 137

77 Aboriginal And/Or Torres Strait Islander Health Source: Centre for Epidemiology and Evidence. Health Statistics New South Wales. Sydney: NSW Ministry of Health. Produced by: Epidemiology, WSLHD ( 6. Aboriginal mothers in WSLHD and NSW have more preterm births compared to nonaboriginal mothers. From 2001 to 2014, the proportion of births by Aboriginal mothers in NSW that were preterm remained stable at approximately 12% (compared to 7%-8% for non-aboriginal mothers). However, during this period there was an increasing trend in the proportion of Aboriginal mothers in WSLHD who were delivering premature infants. Preterm births by mother s Indigenous status, WSLHD and NSW, 2001 to 2014 Page 77 of 137

78 Aboriginal And/Or Torres Strait Islander Health Source: Centre for Epidemiology and Evidence. Health Statistics New South Wales. Sydney: NSW Ministry of Health. Produced by: Epidemiology, WSLHD ( Note: * Births for which gestational age was less than 37 weeks were classified as preterm. Data include all births (stillbirths and live births) Page 78 of 137

79 Aboriginal And/Or Torres Strait Islander Health 7. Analogous to the trend in preterm births, between 2001 and 2014, the proportion of Aboriginal newborns with low birth weight (<2,500 grams) increased in WSLHD but decreased in NSW (see figure). In 2014, in WSLHD, the proportion of Aboriginal and non-aboriginal newborns with low birth weight was 13.8% and 6.6%, respectively. Low birth weight newborns by mother s Indigenous status, WSLHD and NSW, 2001 to 2014 Source: Centre for Epidemiology and Evidence. Health Statistics New South Wales. Sydney: NSW Ministry of Health. Produced by: Epidemiology, WSLHD ( Page 79 of 137

80 Aboriginal And/Or Torres Strait Islander Health Note: *Low birth weight is birth weight <2,500 grams. Data include all births (stillbirths and live births). These data have not been adjusted for gestational date of birth Healthy adults, Healthy ageing and the improvement of health literacy and lifestyle through community health promotion Improving overall health literacy through education and community health, closely related to influencing better lifestyle choices in nutrition, substance abuse and exercise. 1 Hospital admissions overall are lower, but are markedly higher for specific preventable conditions that could have been managed through primary and preventive care measures. Overall death rates are higher, and are higher for specific causes including deaths from lifestyle factors (nutrition and exercise), social and mental health problems,, ear and eye infections, and illness/injury or deaths from the local environment (e.g., pollution, respiratory illness, water sewerage etc.). and deaths from the physical environment.2 1. Lifestyle choices observed amongst at-risk groups in diet, substance (alcohol and tobacco) abuse and a lack of physical exercise reflect low health literacy and a need for ongoing promotion. As data on the health of Aboriginal people at the community level is limited due to transience, social exclusion and unreported and untreated health concerns and conditions. Extensive consultations with the Close the gap team, members of the Aboriginal and Torres Strait Islander community and the health professionals that service the ATSI community indicate, that the Issues of chronic and complex/multimorbidity, commonly triple diagnosis mental health, drug and alcohol, physical illness and risk factors impact on the accessibility, presentation and usage of culturally appropriate services. Low income, Trauma, Stolen generation, Loss, Mental Health indicates prevalence in Substance Abuse (Drug and Alcohol), physical health, healthy eating, lack of finances to afford good nutritional foods all contribute to ongoing issues and barriers faced within the Aboriginal and Torres Strait Islander community in western Sydney. Page 80 of 137

81 Aboriginal And/Or Torres Strait Islander Health Source: Page 81 of 137

82 Aboriginal And/Or Torres Strait Islander Health Median Age at Death of WSPHN Aboriginal Population Median age (years) Person Median age (years) Female Median age (years) Male 0.0 NSW Parramatta Holroyd Page 82 of Blacktown Baulkham Hills Auburn 90.0

83 Aboriginal And/Or Torres Strait Islander Health Affordable and culturally appropriate health services Health services are associated with costs, transport and a required level of health literacy an ability to navigate a complex health system. Groups where poor health lifestyle and adverse social situations including financial and transport barriers are evident especially where mental health issues are also present. 1. Economic challenges include lower incomes and are reliant on public health services, difficulty affording and gaining access to private allied health service, and challenges using and affording transport services. Table: indicates the prevalence of co-morbidities of clients accessing Close the Gap services in western Sydney comparable to the ATSI community as a whole. Table: WentWest Aboriginal health team patient data: 1st July th March 2016 WentWest - Aboriginal health team patient data: 1st July th March 2016 PRESENTING ISSUES NUMBER OF PATIENTS Alcohol and Drug Use Disorders 16 Amputee 6 Anger Issues 3 Anxiety Disorders 21 Arthritis 24 Asthma 184 Back injury/pain 23 Bipolar 10 Cancer 47 Cardiovascular Disease Cataracts Chronic Kidney Disease COPD Page 83 of

84 Aboriginal And/Or Torres Strait Islander Health Dementia 3 Depression 60 Diabetes 230 Epilepsy 13 Hearing issues Hep C Hypertension High Cholesterol 11 Liver Disease 12 Obstructive Sleep Apnoea 38 Note: Data collected from Case file management system Penelopev4: Athena software Source: Aboriginal and/or Torres Strait Islander clients WSPHN Close the Gap team, Case file management system - Penelopev4: Athena software Page 84 of 137

85 Aboriginal And/Or Torres Strait Islander Health Education Indigenous residents of WSLHD on average reported having a lower educational attainment compared to non- Aboriginals 1. Indigenous residents (23.1% of Indigenous people had completed Year 12 or equivalent compared to 59.2% of non-indigenous people) Similar levels of educational attainment were reported for Indigenous people of NSW. Highest year of school completed by Indigenous status: per cent of residents of WSLHD aged 15 years and over who are no longer attending primary or secondary school, 2011 Source: 2011 Census, ABS data used with permission from the ABS ( Produced by: Epidemiology, WSLHD ( Page 85 of 137

86 Aboriginal And/Or Torres Strait Islander Health Support and equality of access post incarceration With multiple correctional facilities within western Sydney, there is a high incidence of the Aboriginal and Torres Strait Islander community released into the community. Currently there is an absence of planning and collaboration around integration back into the community and into health services and general practice care. NSW Inmate Census 2014 Page 86 of 137

87 Older Persons Health Further understanding of and planning for an ageing population including access to coordinated care and support of healthy independent living. Although western Sydney has a proportionally younger demographic compared to the rest of NSW, the expected population growth indicates that the proportion of the population aged 65 years and over will increases substantially to 49,308 more people in 2025 than in Variability within the health status of older persons, access to health services such as GPs, allied health and specialist. 4. Projections indicate the proportion of the population aged 65 years and over will substantially increase from 2015 to 2025, with an estimated 49,308 more people aged 65 years and over in WSLHD in By 2031 the population aged 65 years and over will have increased by 82,414 compared to Agency for Clinical Innovation, Building Frameworks: A partnership for Integrating Care for Older Persons with Complex Health Needs, 2014: data/assets/pdf_file/0003/249483/building_partners hips_framework.pdf 6. New South Wales Aging Strategy Source: HealthStats NSW; NSW Ministry of Health: data/assets/file/0011/257276/1282_adhc_nswageingstrategy_web.pdf Page 87 of 137

88 Older Persons Health Reduced avoidable hospital presentations 1. Admitted Patient Data Collection, SAPHaRI. Centre for Epidemiology and Evidence, (NSW Ministry of Health). Hospital admission financial year shows a total of 2,210 were Australian born and 2,631 were overseas born patients with an age greater than 65 years, were admitted in hospital comprising around 13% of total hospital admission for that period. Whereas, child admission was only 0.1% for same time period Rate of preventable hospitalisations in persons over 65 years in western Sydney are higher than the NSW average. Epidemiological Profile of WSLHD Residents 51% of were category 4 and 5 presentations to WSLHD emergency departments Presenting Problem - Top Encounter 10 s Pain, limb lower / hip 883 Care - patient review 823 Pain, abdominal 646 Unwell 535 Pain, back 410 Cellulitis suspected Pain, limb upper / shoulder Falls Wound infection Injury - upper limb 229 Group Total 4614 Grand Total 9041 Page 88 of 137

89 Older Persons Health Patient LGA - Top 10 Blacktown (C) Parramatta (C) Auburn (C) The Hills Shire (A) Holroyd (C) Penrith (C) Bankstown (C) Fairfield (C) Hornsby (A) Encounter s Liverpool (C) 24 Group Total 8704 Grand Total 9041 Significant rate (51% of all presentations over 65 years old) of WSLHD emergency department presentations were Category 4 or 5. Trend of increasing rates of hospitalisation for influenza and pneumonia in people 65 years and older in WS against relatively stable NSW rates. 3,6 From to COPD hospitalisation rates decreased in male populations, however increased by 0.9% in female populations to 1,430.8 hospitalisations per 100,000.4 Cellulitis, urinary tract infections and COPD were responsible for 32.8% of potentially preventable hospitalisations in COPD, congestive heart failure and cellulitis were responsible for 40.3% of potentially preventable bed days in Page 89 of 137

90 Older Persons Health In males and females, these rates were 33.7 and28.5 more hospitalisations per population per 2 year period respectively, from to In males and females, these rates were 33.7 and 28.5 more stable NSW rates. The COPD hospitalisation rate in males aged 65 years and over was 13.1% higher in Western Sydney (2,304.8 per 100,000) compared to NSW ( 2,037.3 per 100, 000). 7. Epidemiological Profile of WSLHD Residents. Influenza and pneumonia hospitalisations (people ages 65 years and over by sex, WSLHD and NSW, to Source: Centre for Epidemiology and evidence. HealthStats NSW. Sydney: NSW Ministry of Health. Produced by: Epidemiology, WSLHD ( Page 90 of 137

91 Older Persons Health 8. Epidemiological Profile of WSLHD Residents. COPD Hospitalisation (People aged 65 years and over) by sex, WSLHD and NSW, to Source: Centre for Epidemiology and evidence. HealthStats NSW. Sydney: NSW Ministry of Health. Produced by: Epidemiology, WSLHD ( Page 91 of 137

92 Older Persons Health Improved access for clients of Residential Aged Care facilities to Primary Health Care services, including GPs, Allied Health, medical specialists. Consultations held with local Residential Aged Care facilities (RACFs) identified the overall barrier for RACFS and their clients was in accessing safe, continuous and integrated health care across visiting GPS, after hours GPs, various Emergency Departments (EDs) allied health professionals, specialists and local mental health services Western Sydney Medicare Local, Aged Care Report 2013 Aged Care in Western Sydney. Care Compassion and Dignity (whitepaper). Demographic Overview: The Hills Western Sydney PHN Consumer and Community Stakeholder forum and consultations report, Less ambulant, frail and unwell clients, barriers in access to transport and external health services were indicated. Access to GP care is variable, with only a portion of RACFS having established working relationships with GPs, whilst others struggle from a shortage of GPs able to service RACF clients. 1-2 Pain Management, Palliative care and medication review management The shortage of continuous GP coverage impacts on clients with ongoing severe pain requiring restricted analgesia, the availability of palliative care services impedes implementation of person centered care Western Sydney Medicare Local- Aged Care Report 2013 Consumer and Community Stakeholder forum and consultations report, Western Sydney Primary Health Network, Agency for Clinical Innovation, Building Frameworks: A partnership for Integrating Care for Older Persons with Complex Health Needs, 2014 NSW Aging Strategy, data/assets/file/0011/257276/1282_adhc_nswageingstrategy_web.pdf Page 92 of 137

93 Older Persons Health Mental Health Care Integrated and person centred Care and support for carers and clients with Dementia and other chronic and complex conditions Improve awareness of targeted preventive health promotion campaigns amongst vulnerable groups in WSHPN. Limited access to mental health support services for management of ageing clients with complex mental health problems including dementia and acute presentations of Psychosis, self-harm and depression. Acute management of mental health clients is perceived as poorly supported and raised as a critical access barrier. Early Intervention and diagnosis of Dementia and chronic and complex conditions. Early diagnosis for dementia is critical for the early identification of reversible aetiologies, to delay progression of dementia and to potentially reduce the patient and caregiver burden. 1. Projections in Western Sydney is by 2025 there will be significant growth in the 65+ population from 5.7% to 7.6% of total population. Falls are a major cause of harm to older people and fall-related injuries impose a substantial burden on the health care and aged care systems Western Sydney PHN Consumer and Community Stakeholder forum and consultations report, Western Sydney Medicare Local- Aged Care Report 2013 NSW Health, 2011, Implementation Plan for the NSW Dementia Services Framework Agency for Clinical Innovation, Building Frameworks: A partnership for Integrating Care for Older Persons with Complex Health Needs, 2014 Western Sydney Dementia Strategy Implementation Group 2016 Western Sydney Local Health District Strategic Plan July Western Sydney PHN Consumer and Community Stakeholder forum and consultations report,, HealthStats NSW. Clinical Excellence Commission Falls Prevention In , 96,385 people aged 65 and over were hospitalised for a fall-related injury three and a half times as many cases as year olds. Of these, 65,965 (68%) were women compared with 30,420 (32%) men. Injuries also proved more serious for older Australians, with 29 per cent of cases considered life-threatening for those older than 65 compared to 16 per cent for younger Australians. Australians over 65 were most likely to fall from slipping, tripping or stumbling, while only 1.7 per cent fell down stairs. Source: AIHW: Hospitalised injury in older Australians, Page 93 of 137

94 Older Persons Health Fall-related hospitalisations by age group, Source: AIHW National Hospital Morbidity Database. Table B.1 Page 94 of 137

95 Section 3 Outcomes of the service needs analysis This section summarises the findings of the service needs analysis in the table below. For more information refer to Table 2 in 5. Summarising the Findings in the Needs Assessment Guide on Additional rows may be added as required. Outcomes of the service needs analysis Improve Coordination of Care The WSPHN and WSLHD share the same geographical boundaries, covering an area of 766 square kilometers with an estimated population above 946,750 people. Together with the Sydney Children s Hospital Network (SCHN) a productive, formal working partnership has been established. Agreed shared priorities include Aboriginal health, aged care, mental health, improving access to afterhours GP services, child and family health initiatives, population health and planning and ehealth. These priorities are closely aligned with the priorities set for Primary Health Networks by the Commonwealth. A provider and service overview WSLHD Workforce numbers and distribution Western Sydney has a large workforce with facilities largely clustered in the south eastern section of the WSLHD/WSPHN catchment. Although this broadly aligns with both population density and areas of greatest need, it does create access issues for populations in the north and west of the catchment. Source: Western Sydney Local Health District Year in Review Page 95 of 137

96 Outcomes of the service needs analysis There are a range of workforce and general operational related needs identified in the WSLHD Workforce Strategic Framework that need to be addressed during the planning period and considered as part of the WSPHN Needs Assessment as they will have associated impacts in primary care and care coordination. Western Sydney Local Health District Workforce Strategic Framework *Health Professionals Workforce Plan Key demands identified: *Health Workforce Australia HW 2025 Vol. 2, 2012 Increasing demand the increase in population number is magnified as people are living longer and presenting with more complex conditions. This challenge is reflected in multiple sections of this document. Increase in chronic conditions creates a greater need for primary and preventive care and a generalist workforce with skills and knowledge to manage patients with a broad range of conditions. The central issue here is the need for WSPHN to work with all primary care providers to optimise practice capability and capacity to manage chronic and complex patients to minimise transitions into acute care settings and minimise unnecessary hospital presentations. Page 96 of 137

97 Outcomes of the service needs analysis Shifting consumer expectations - more is expected from health and other public services. Effective partnership activity will be required to fully understand these evolving patient, consumer and community needs and will further leverage an already successful partnership between WSLHD, WSPHN and Health Consumer NSW. Additionally there will be a need to develop and support ehealth solutions to allow patients and carers to access relevant health information that support and enhance selfmanagement. Changing models of care there is a belief that more effective care can be provided by integrating hospital and primary care services Response to this will include working to agree on and implement these models, and collaborate to ensure effective alignment and integration of implementation to foster improved primary care capability and capacity. Early joint work on the NSW Integrated Care Demonstrator and insights derived will be highly informative in this regard. Page 97 of 137

98 Outcomes of the service needs analysis Re-development - the large scale redevelopment is impetus to consider how care is provided in the future WSPHN will need to be an effective advocate for the needs of primary care in this redevelopment period and a positive partner in minimising any impacts during this phase. Workforce shortages Health Workforce Australia* anticipates a likely continuation of health workforce shortages up to 2025 for doctors and nurses across Australia WSPHN is facing similar challenges around an ageing workforce in primary care and a disproportionate number of single handed GPs and this will create a greater need for collaboration across primary and acute care settings to optimise available human resources. An anticipated future policy Commonwealth reform of primary care and introduction of a Health Home model will have significant implications for the primary care workforce. The likely demand for primary care nurses and allied health professionals will potentially mean intensified competition for clinical and support staff in western Sydney. Page 98 of 137

99 Outcomes of the service needs analysis It is assumed that labour force shortages in specialist services will also continue to be problematic and impact patient access and waiting times. Changing technology - with potentially huge benefits to the patient experience and ability to connect health care delivery requiring retraining and orientation for all professionals This reflects some of the needs that are emerging around joint efforts to implementing ehealth across primary and acute care with an attendant need for impactful change management and meaningful use. There will need to be a greater focus on systems connectivity across primary, secondary and tertiary settings to better facilitate communication and improve the patient experience. Focusing resources so that we are ready to direct our resources in the areas that matter the most, to ensure we have the patient at the right place with the right workforce The need here is to, where possible, act as if there were one system funder to ensure the most beneficial impact of resource (re-) allocation with a focus on the Quadruple Aim across health care in western Sydney. Page 99 of 137

100 Outcomes of the service needs analysis This will include further refinement and implementation of the HealthOne model as a key vehicle for care integration and coordination. Sydney Children s Hospitals Network The Sydney Children s Hospitals Network is the largest network of hospital and services for children in Australia. Each year the services manage: 51,000 inpatient admissions 92,000 Emergency Department presentations Over 1,000,000 outpatient service visits The Children's Hospital at Westmead and Sydney Children's Hospital, Randwick, provide care for children locally, across the state, nationally and internationally. The Newborn and Paediatric Emergency Transport Service (NETS), the Pregnancy and the Children s Court Clinic (CCC) are also part of the Sydney Children s Hospitals Network providing key specialised services. Regarding care coordination real opportunities exist for the partnership to collaborate to: 1. Support effective transition of care for children and adolescents between SCHN, WSLHD and primary care 2. Work to address the high number of category 4 and 5 presentations in both SCHN and WSLHD ED s that could be managed in primary care and by the patient s GP. Page 100 of 137

101 Outcomes of the service needs analysis 3. Collaborate to provide more effective care coordination and support across the system for children with complex needs through the Kids GPs Integrated Care Model. 1 SCHN Count of presenting problems Triage Grand Total Source: Sydney Children s Hospital Network Page 101 of 137

102 Outcomes of the service needs analysis Primary care workforce and distribution Practices by number and distribution of GPs WSPHN contains a total of 1,159 GPs and associated clinical and support staff in 334 practices, approximately 1,500 private allied health professionals and 200 pharmacies. Mentioned earlier was the likely increasing focus on a team-based care approach within primary care and the potential implications for workforce composition and numbers. Currently a breakdown of data on practice numbers in WSPHN reveals that 41% of all WSPHN practices are single handed and 82% of all practices are in the 1-5 FTE GP range. Based on the data opposite there is a GP to Practice Nurse ratio ranging from 2.7 to 3.5 per LGA. This does not take account of full or part-time working, and as such possibly overstates the ratio. When analysing the ratio of GPs to patients, marked variation is observed with a very clear link between the LGA with the highest SEIFA rating and generous ratio of 660 Practices in WSPHN 2016 Corporate - National 15 Corporate - Private Group 3 Large Group (6-10 GPs) 34 Over 10 GPs 8 Small Group (2-5 GPs) 135 Solo (1 GP) 139 Total Practices in WSPHN 334 Source: WSPHN Chilli database extract March 2016 Practices GPs by Nurses by per LGA LGA LGA Auburn Blacktown Hills Holroyd Parramatta Total in WSPHN Source: WSPHN Chilli database extract March 2016 GPs by LGA Total GP Population Population 2016 Ratio Auburn Blacktown Hills Holroyd Parramatta Total in WW Source: WSPHN Chilli database extract March 2016 Page 102 of 137

103 Outcomes of the service needs analysis patients to each GP. In contrast, the Holroyd LGA is one of significant disadvantage and a patient/gp ratio of 1052:1. Considering other workforce issues there is a low overall number of Practice Nurses (46% practices) against an estimated 63% of practices nationally who employ a Practice Nurse based on the AMLA / APHCR General Practice Nurse National Survey Report, When considering other workforce issues affecting general practice, GPs report the allied health professionals considered to be most important to their work are psychotherapists, psychologists, dieticians and diabetic educators. Page 103 of 137

104 GPs also stated that they have most difficulty referring or informing patients because of shortages in allied health professionals, with the top four being speech pathologists, social workers, exercise physiologists and occupational therapists. Conversely, GPs reported that in terms of availability and access speech pathologists, exercise physiologists and social workers are the roles in shortest supply. Page 104 of 137

105 Outcomes of the service needs analysis Provider and organisational relationships The table opposite based on a 2013 survey of 131 GPs undertaken by Outcome Services for WSPHN explored the dimensions of and working relationship between General Practice and acute care settings. GPs completing the survey were asked to rate their overall satisfaction with the performance of the hospitals they routinely refer to in the public sector in western Sydney. The respondents were asked to rate from 1-5 their satisfaction with the service areas. Access to emergency services was the highest rated satisfaction parameter. In terms of transitions of care, there is clearly scope for improvement in terms of advising GPs of patient admissions and subsequent treatment with a rating of The survey was also part of a benchmarking study across a number of former Medicare Locals and these results were comparable to the findings from other participating jurisdictions. Within the primary care arena, despite increasing focus on team-based coordinated care, many practices in WSPHN are not persuaded of the need for Practice Nurses. GPs who do not employ a Practice Nurse cited the following reasons in the WSPHN 2013 GP Needs Survey: Cannot afford it Not enough space Tried but difficult recruiting Performance area All Local Hospitals Overall satisfaction 3.25 Access to emergency services 3.34 Access to urgent outpatient services 2.64 Access to non-urgent outpatient services 2.50 Advising you of a patient s admission or treatment 2.53 Sharing clinical information on your patients 2.80 Quality of discharge summaries provided 3.02 Timeliness of discharge summaries provided 2.86 Regarding you as part of the treating team 2.71 Page 105 of 137

106 Outcomes of the service needs analysis See no need Not enough work to justify Only 46% of WSPHN practices employ one or more Practice Nurses compared with 63% nationally. Furthermore, this is a relatively inexperienced and unstable workforce. As an initial step in understanding the needs of primary care nurses WSPHN conducted a comprehensive needs assessment with 157 local nurses in 2015/16. The needs assessment highlighted the capacity and support needs amongst primary care nurses as outlined below: 46% of respondents reported they only have 1-2 nurses working in their practice 40% of nurses had been employed at the practice for less than 1 year 27% of nurses had been working as primary care nurses for less than 1 year and 19% for 1-2 year. This equates to a total of 46% of nurses working as primary care nurses for 2 years or less. Nurses in a 2015 survey reporting on the least satisfying aspects of their role listed: a) poor remuneration, b) time constraints, c) lack of space, d) lack of respect or recognition, e) funding models and health policy, and f) limiting the nurses role. Page 106 of 137

107 Outcomes of the service needs analysis Thus a key resource in optimizing coordination of patient care is underutilized and potentially undervalued. Other allied health providers surveyed in both 2012 and 2013 on the quality of the relationship between general practice and themselves rated communication reasonably highly on a rating scale of 1-5 but had greater concerns about the sense of being part of the treating team. Data presented in the section on efficiency and effectiveness will demonstrate the potential under utilisation of allied health professionals in patient care. Source for data below: 2015 Primary Care Nurse Workforce Survey. ce-capturingtrendsinprimaryhealthcarenursing.pdf Source: WSPHN Allied Health Needs Assessment Survey Page 107 of 137

108 Outcomes of the service needs analysis Aged Care Challenges are apparent across all service areas, whether in aged care accommodation facilities or in at-home support services. Provision and coordination of aged care services is currently impacted by a rapid growth in aged care services demand versus an overall workforce, facility and services shortfall. Consultations with RACF s have revealed high levels of staff turnover, shortages of GPs able to support aged care facility and home visits, and community support services facing long service delays. Overall needs to support and improve comprehensive coordination of care and services are captured in the model opposite. Page 108 of 137

109 Outcomes of the service needs analysis Patient Access to Care 78% of patients in western Sydney report that they have a preferred GP although it is not clear if they can routinely access this GP. Relatively few patients report seeing an allied health professional as part of their care and this reflected in the data in later sections regarding MBS and SIP claims. In western Sydney patients can generally access a GP relatively easily, with 62% of respondents in a WSPHN health consumer survey reporting they could get an appointment on the same day. A surprising 35% of patients interviewed reported seeing a specialist in the last 12 months. Page 109 of 137

110 Outcomes of the service needs analysis Page 110 of 137

111 Outcomes of the service needs analysis Coordination of care for Aboriginal and Torres Strait Islander people Home to the largest urban Aboriginal population in Australia the pressing health needs of Indigenous people in WSPHN are captured in other sections of this document. In terms of effective coordination of care for indigenous people this is impacted by a shortfall in appropriate health services for Aboriginal clients, especially in mental health and younger people. Set out opposite is an outline of the service capacity analysis needed to address care coordination in a meaningful and integrated way. Care discontinuity between hospital, community health, and dedicated Aboriginal health services is exacerbated by a reduced capacity amongst Aboriginal clients to navigate mainstream health service requirements. Preventative screening of at-risk Aboriginal populations is impacted by cost, transport and access barriers in common with other low income and socially disadvantaged groups. Overview of Aboriginal Health Service Capacity - Western Sydney Systems Capacity Service Capacity Workforce Capacity Community Capacity System-wide resourcing of Aboriginal health needs Developing userfriendly clinical pathways Strengthen Aboriginal health mgmnt skills in general prac ce Addressing health literacy & lifestyle gaps Con nuity of care across systems Leveraging exis ng community services Strengthen Aboriginal mental health services Strengthening links with community support groups Screening & preven on gaps Aligning services to meet community needs Strengthen communitybased service capacity Shi ing from acute care to lifestyle management Adapted from Transcultural Rural and Remote Outreach Project Report, NSWCC 2012 Accessing and utilising non-aboriginal health services is challenging due to referral inefficiencies and an absence of common treatment pathways and service information. Page 111 of 137

112 Outcomes of the service needs analysis A major issue is the need to strengthen the development of culturally appropriate and affordable clinical pathways in mainstream services, which will support more effective interaction across service providers. As increasing proportions of at-risk Aboriginal clients seek mainstream health services, redesign of service delivery will be required to address care costs and transport barriers. Provision of culturally appropriate care is currently impacted by a reliance on dedicated primary care services and under utilisation of mainstream services. Appropriate mental health services, especially for younger clients, are not readily available with uptake impacted by a strong community stigma with mental illness. Page 112 of 137

113 Outcomes of the service needs analysis Coordination of care for children and families The complexity of the existing service systems can result in a mix of services that are multi-layered and fragmented, and services may be provided by Commonwealth, State or local government, as well as NGO s. Additionally, services may be delivered to Aboriginal Australians via Aboriginalspecific services or mainstream programs. This can be confusing for the community. Doonside Services report that they find it difficult to identify and reach clients, given their invisibility in services and in the community. Many also found the complexity of client needs and circumstances presented challenges to engagement, including family breakdown, homelessness, and lack of education, family violence and substance use. Work with the Service Delivery Reform (SDR) network has identified the 100 Lives, a significant priority for high need clients and their families. Page 113 of 137

114 Outcomes of the service needs analysis Increase efficiency and effectiveness of care Western Sydney is a diverse community and with this comes a range of complex health needs and social circumstances. The 2016 edition of the WSPHN Population Health Atlas shows that some sub-regions of western Sydney have poor health compared to those in other parts of NSW. Many communities have high rates of chronic disease (e.g. diabetes and mental health issues). This is underscored by high rates of obesity and smoking, low rates of cervical and breast cancer screening, and a high impact of social determinants of health and inequity. Immunisation rates are also below average. Hospital activity in western Sydney is rising significantly faster than population growth with a projected 2% CAGR in population and 4.7% increase in hospital activity. Key drivers of this growth are chronic disease, with close to an estimated 10,000 avoidable hospitalisations in , and escalating demand for acute mental health and drug related services. This increase in chronic disease is impacting nationally and locally as can been seen from the quote below from the report, Better Health Outcomes for People with Chronic and Complex Health Conditions: Report to Government on the Findings of the Primary Health Care Advisory Group, December Page 114 of 137

115 Outcomes of the service needs analysis Patients with chronic and complex conditions are high users of health services. Very high general practice (GP) attenders saw three times as many different general practitioners (GPs) compared to low attenders (4.8 compared to 1.5). Just one third (34%) of very high and frequent GP attenders combined saw three to four GPs in , while a further 36% of very high and frequent GP attenders saw five or more. Currently, primary health care services in Australia for this patient cohort can be fragmented, and often poorly linked with secondary care services, making it difficult for patients to be confidently engaged in their care as evidenced by the experience of patients that can be found in the Appendices. Most patients with multiple chronic conditions receive treatment from many health providers: most of them working in different locations, and often working in different parts of the health system. As a result, effective communication between the health team can be challenging and may be inconsistent. This leads to concern regarding the quality and safety of patient care. These challenges place a premium on forging a system that is both cost effective and efficient in terms of delivering the right care at the right time in the right setting. Provision of high quality primary care is currently not identified or rewarded. Although WSPHN has high levels of bulk billing, this has limited translation into quality of care. Page 115 of 137

116 Outcomes of the service needs analysis An analysis of care provision by CareTrack* published in the MJA in 2012 illustrated that chronic disease patients only receive appropriate care approximately 50% of the time, with wide variation across the conditions reviewed. Chronic heart failure patients received what was assessed to be appropriate care 76% of the time, with asthma only 38% of the time and obesity 24% of the time. WSPHN is in a diabetes hot spot and the CareTrack data reported that in clinical encounters diabetic patients received appropriate care on only 63% of encounters. Page 116 of 137

117 Outcomes of the service needs analysis This is particularly concerning as a recent pilot study undertaking HbA1c screening during ED encounters at Blacktown Hospital showed a high prevalence of diabetes and one that exceeds current forecasts in the general population in western Sydney. Page 117 of 137

118 Outcomes of the service needs analysis Page 118 of 137

119 Outcomes of the service needs analysis WSPHN has the highest level of GP attendances that were bulk billed in NSW in Page 119 of 137

120 Outcomes of the service needs analysis These attendances also resulted in high MBS expenditure values per attendance. Page 120 of 137

121 Outcomes of the service needs analysis Analysis of Pen Clinical Audit Data for 35 WSPHN practices in shows some encouraging trends but in 2014 only 30% of GPMP s had been reviewed and 34.5 % in Increase in numbers of total care plans is the result of data cleansing work and increased focus on diabetic patient identification. Although there are a significant number of chronic disease GP management plans being created there is still less than optimal ongoing patient review to monitor and support improved outcomes. Diabetes SIP Items WSPHN, 2015 Micro-albuminuria (12 mon) 1504 Indicators of less than optimal care are the very low levels of foot and eye checks indicated via SIP claims as a percentage of the total identified patient population of diabetics. Foot Exam (6-12 mon) Foot Exam (6 mon) 150 WSPHN, in partnership with WSLHD, thus need to address high and rapidly growing levels of chronic disease driving large numbers of (10,000) potentially preventable hospitalisations. Although patients have relatively little difficulty accessing a bulk billing GP, the quality of care provided is in many instances sub-optimal with often little proactive follow up and review. Eye Exam (24 mon) Total Diabetes Type The current primary care system, driven by fee for service, is therefore focused on volume rather than ongoing quality of care, thus impacting system efficiency and effectiveness. Page 121 of 137

122 Outcomes of the service needs analysis Coordination between and integration of services Supporting quality improvement, connectivity and innovation ehealth Although WSPHN has made major efforts to improve the connectivity of care providers, patients and consumers in western Sydney work still remains to be done. Uptake of ehealth in general practice remains slow with only 57% of practices currently ehealth ready. The need is to further drive the penetration and uptake of ehealth and associated enablers with an ultimate goal of effective primary, secondary and tertiary care integration with efficient data and care plan sharing that has minimal impact on provider workflow and potentially delivers workflow efficiencies. Further work is also required to support the uptake of both My Health Record and the WSPHN developed LinkedEHR electronic shared care planning tool. This tool works seamlessly with the My Health record but significantly improves its functionality and will provide an automated My Health Record patient shared health summary update whenever the patient record has been changed in any of the SHS fields. Page 122 of 137

123 Data driven improvement Although tools such as the Pen Clinical Audit Tool provide some insight into quality of care in practices, there is currently no standard approach to this nationally or agreed data sets. Consequently there is no consistent, effective mechanism to identify high quality care nor identify and address poor quality care. Tools to be deployed to assist GPs in providing quality care also need to support effective patient risk stratification to allow targeting and delivery of cost effective and timely interventions. This needs to include simple to use dashboards that allow easy tracking and use at a practice and aggregated regional level. There is a need to develop a range of measures that are agreed and pursued and WSPHN is proposing the use of the Quadruple Aim. The Quadruple Aim focuses on: Improved population health outcomes (including physical and behavioural health) Better experience of health care and support for people Better satisfaction for our clinical partners, especially GPs, their practice team and the local network of providers Improve value for money, whilst meeting the needs of health consumers Measures within the quadruple aim framework could include an adaptation of the Healthcare Effectiveness Data and Information Page 123 of 137

124 Set (HEDIS) measures developed by the US-based National Committee for Quality Assurance to assess performance on important dimensions of care and service. Currently HEDIS consists of 81 measures across 5 domains of care. Clinical Pathways Within HealthPathways, over 230 pathways have been localised and deployed by WSPHN and currently enjoy usage by over 4,000 new and returning users. The ongoing need is to both build the number of localised pathways to over 500 in the next two years and to expand and support a community of users to ensure delivery of appropriate best practice care within the local context. Access to evidence-based assessment, management and referral information will continue to be a critical requirement in minimising variability of care and improving health system connectivity and response with the right care from the most appropriate provider in the right setting. Variability in care and the current funding environment A Model for Australian General Practice : The Australian Person-Centered Medical Home, Discussion Paper 2015, EY, Menzies Centre for Health Policy and WSPHN In seeking to understand this wide variability in patient care and how the current funding environment may impact this, GPs interviewed as part of the discussion paper on the future of General Practice in November 2015 reported their following concerns around the current funding model and ongoing challenges in general practice: Page 124 of 137

125 The current Fee-For-Service (FFS) funding model does not serve chronic disease Patients FFS does not reward quality practice, it rewards high throughput medicine FFS is gamed and aggravated by Federal Government policies such as freezing of rebates, but is useful for patients with acute care needs There is increasing international evidence about the benefits of a blended payment system mixing fee for service, pre-payment and pay for performance with salaried arrangements. Standing Council on Health. National Primary Care Strategic Framework. April High rate of bulk billing in the area makes it difficult to wean patients off it due to expectations and the culture has been set for a long time. Patients tend to delay appropriate treatment if they have to pay, making it more complex when they finally present to healthcare providers Older cohort of GPs providing traditional provision of care getting close to retirement, will be replaced by the younger GPs who tend to practise in large corporate centres, potentially losing the culture of continuity and comprehensiveness of care Hard to attract and recruit young GPs, especially in the areas outside of District Workplace Shortage (DWS) A different model is needed to address growing pressures on the system and support a shift from volume to value. The growth in demand for and expenditure on health care is exacerbated by the current fee for service model which can be characterised as: While [fee for service] is a practical way of reimbursing service providers for isolated episodes of care, it does not provide incentives for the efficient management of care delivered to patients requiring ongoing health care. Primary Health Care Advisory Group. Discussion Paper (2015) Page 125 of 137

126 Unmanaged growth in volume and the potential duplication of services Growing financial and professional challenges for GPs Patients experiencing disconnected care and an increasing level of co-payments. Undefined variation in the quality or type of care delivered through General Practice and primary care and lack of a mechanism to reward providers for delivering high-quality care. Little is known about the variety of operating cost models that underlie General Practice and how to best support General Practice to achieve optimal patient outcomes. Need for new models of care To care for the 35% of Australians that have one or more chronic and complex conditions, the recently published report of the Primary Health Care Advisory Group (PHCAG) proposes the implementation of a Health Care Home: a setting where they can receive enhanced access to holistic coordinated care, and wrap around support for multiple health needs. Better health outcomes for people with chronic and complex health conditions, Report to Government on the Findings of the Primary Health Care Advisory Group, December 2015 Page 126 of 137

127 Key features of this model would be: Voluntary patient enrolment with a practice or health care provider to provide a clinical home-base for the coordination, management and ongoing support for their care. Patients, families and their carers as partners in their care where patients are activated to maximise their knowledge, skills and confidence to manage their health, aided by technology and with the support of a health care team. Patients have enhanced access to care provided by their Health Care Home in-hours, which may include support by telephone, or videoconferencing and effective access to after-hours advice or care. Patients nominate a preferred clinician who is aware of their problems, priorities and wishes, and is responsible for their care coordination. Flexible service delivery and team based care that supports integrated patient care across the continuum of the health system through shared information and care planning. A commitment to care which is of high quality and is safe. Care planning and clinical decisions are guided by Page 127 of 137

128 evidence-based patient health care pathways, appropriate to the patient s needs. Data collection and sharing by patients and their health care teams to measure patient health outcomes and improve performance. Key elements of the recommended model were strongly supported by the feedback from the consultation processes undertaken by PHAG with: 77% of respondents indicated that they support patient enrolment with a Health Care Home for people with chronic and complex conditions. 92% of respondents supported team based care for people with chronic and complex conditions. 90% of respondents agreed that it is important to measure and report patient health outcomes. These findings are consistent with work WSPHN has been undertaking with practices in western Sydney over the last two years. Good progress has been made with a number of practices in attempting to move to a more comprehensive health care home or patient centered medical home (PCMH) based on the model developed opposite. This has been combined with a focus on the Page 128 of 137

129 wider medical neighbourhood through alignment with and implementation of the NSW Integrated Care Demonstrator in partnership with WSLHD. The overall vision for this work is set out in the model opposite developed in consultation with a wide range of GPs and other stakeholders. In seeking to address the key PHN objectives of: Increasing the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes Improving coordination of care to ensure patients receive the right care in the right place at the right team WSPHN has set out in the diagram opposite a summary of how it feels it can best support the achievement of the PHN national priority areas around mental health, Aboriginal and Torres Strait Islander health, population, health workforce, digital health and aged care. As illustrated in the diagram this will require effective operation and collaboration with all players across primary and acute settings as well as state and federal government levels. Source: A Model for Australian General Practice : The Australian PersonCentered Medical Home, Discussion Paper 2015, EY, Menzies Centre for Health Policy and WSPHN Page 129 of 137