Bega Valley Local Government Area

Southern NSW Medicare Local Bega Valley Local Government Area Population Health Sub Regional Profile Pty Ltd ACN 118 337 821 Level 3, 86 Liverpool Street, Sydney, New South Wales, 2000 Phone (02) 9261 3707 Fax (02) 9261 3705 26 July, 2013 Final Version 1

Table of Contents Section Page INTRODUCTION... 1 POPULATION AND COMMUNITY CHARACTERISTICS... 2 2.1 POPULATION CHARACTERISTICS... 2 2.2 BIRTH RATE... 3 2.3 CULTURAL CHARACTERISTICS... 4 2.4 EDUCATION LEVELS... 4 2.5 SOCIO-ECONOMIC CHARACTERISTICS... 4 2.6 EMPLOYMENT... 5 2.7 ABORIGINAL AND TORRES STRAIT ISLANDER COMMUNITY... 6 2.8 HOMELESSNESS... 6 HEALTH RISKS OF THE POPULATION... 7 3.1 HEALTH RISK FACTORS... 7 3.2 ALCOHOL RELATED DOMESTIC VIOLENCE INCIDENCES... 7 3.3 HEALTH SCREENING RATES... 8 3.4 IMMUNISATION... 9 LONG TERM CONDITIONS, CHRONIC DISEASE AND DISABILITY... 12 4.1 PREVALENCE OF CHRONIC DISEASE...12 4.2 MORTALITY...13 4.3 INFECTIOUS DISEASE...14 4.4 DISABILITY...15 HEALTH SERVICE AVAILABILITY... 16 5.1 ACUTE AND DAY SURGERY...16 5.2 GENERAL PRACTITIONERS...16 5.3 ALLIED HEALTH...17 5.4 COMMUNITY HEALTH SERVICES...18 5.5 AGED CARE... 1 HEALTH SERVICE UTILISATION... 4 6.1 PRIMARY CARE UTILISATION... 4 6.2 EMERGENCY... 4 6.3 HOSPITAL ADMISSION... 5 6.4 AMBULATORY-CARE SENSITIVE ADMISSIONS... 5 6.5 HOME AND COMMUNITY CARE... 7

APPENDICES APPENDIX A: APPENDIX B: APPENDIX C: POSTCODE TO LGA/SLA CORRESPONDENCES DATA SOURCES AND LIMITATIONS AMBULATORY CARE SENSITIVE CONDITIONS QUERY

1 Introduction The Bega Valley Local Government Area (LGA) (pop: 31, 949) is a large rural local government area on the New South Wales Far South Coast, with major centres at Bega, Merimbula and Eden, as well as Bermagui-Wallaga Lake, Pambula and District, Tathra-Kalaru and the rural North, South and West Districts. The Yuin-Monaro people are the traditional owners of these lands. Spanning 6,280 square kilometres (2,420 sq mi), Bega Valley is sparsely populated as 75% of the catchment is comprised of National Park and State Forest. Much of the coastal area along the Tasman Sea is strongly oriented towards residential development and tourism, while the rural areas inland are highly productive with dairying as the most notable agricultural industry. Table 1.1 provides general characteristics of the Bega Valley LGA at a glance. Population^ Indicator Table 1.1: Characteristics of the Bega Valley LGA at a glance Value LGA Rank within ML Medicare Local NSW 31,949 4 189,415 6,917,656 Population growth forecast (2011 to 2025) # 20.3% 4 28.2% 20.3% % Indigenous persons # 2.8% 3 3.0% 2.5% Average annual household income^ $56,749 5 $74,094 $80,813 Unemployment # 6.8% 2 4.94% 5.7% % English as primary language^ 97.1% 1 94.1% 72.5% Private Health Insurance coverage # 35.6% 6 45.7% 48.2% Broadband internet penetration # 64.6% 3 66.0% 69.9% Source: ^Australian Bureau of Statistics; # Public Health Information Development Unit and Australian Bureau of Statistics Southern NSW Medicare Local Page 1

% of total population 2 Population and community characteristics Headlines A higher proportion of older residents aged 50 and above, compared to the ML Second lowest birth rate among sub-regions in the ML Average household incomes are lower than the ML average with approximately 75.7% of the population earning $71,500 or lower Higher unemployment than the ML NSW averages Higher rate of homelessness than the ML 2.1 POPULATION CHARACTERISTICS Residents aged 50 years and above account for almost half of the population (47.5%) of the Bega Valley LGA. In contrast, Bega Valley has a relatively low proportion of residents aged 20 to 39 (15.5%) in comparison to the overall ML (20.6%) and NSW (27.2%) 1 due to young residents leaving the community to pursue education and employment opportunities. 2 Figure 2.1: Population profile (by age) versus ML and state comparators, 2011 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85 Bega Valley (A) Southern NSW New South Wales years + Source: Public Health Information Development Unit and Australian Bureau of Statistics (2012) Population estimates to 2025 are provided in Figure 2.2. Forecasted population growth for Bega Valley LGA is expected most predominantly in the 65+ age ranges; however, population growth will be generally lower than the ML overall. Overall migration to Tura Beach-Mirador, Bermagui-Wallaga Lake and to a lesser extent, Merimbula-Berrambool, is concentrated in retiree age groups. 3 1 Public Health Information Development Unit and Australian Bureau of Statistics (2012) 2 Bega Valley 2030 Community Engagement Report, Accessed 14 February 2013: http://www.begavalley.nsw.gov.au/cp_content/resources/csp_communityengagementreport_adopted%281%29.pdf 3 http://forecast2.id.com.au/default.aspx?id=354&pg=5000. Accessed 17 February 2013. Southern NSW Medicare Local Page 2

Births per 1,000 population % populations growth (2011 to 2025) Figure 2.2: Forecast population growth (2011 to 2025, by age) versus ML and state comparators, 2011 to 2025 100% 80% 60% 40% 20% 0% -20% 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85 Growth Growth years + (all ages) aged 65+ Bega Valley (A) Southern NSW New South Wales Source: Public Health Information Development Unit and Australian Bureau of Statistics (2012) With an historical flow of new residents from the Victorian, Canberra and Sydney regions, the largest amount of new planning and development is expected in Merimbula-Berrambool, Rural West and Bermagui-Wallaga Lake. By contrast, relatively smaller amounts of new dwellings are anticipated in Pambula & District and Tathra-Kalaru. 4 2.2 BIRTH RATE The birth rate in Bega Valley is 9.8 births per 1,000 population. This rate is the second lowest in the ML catchment and is 13% lower than Southern NSW rate of 11.3 births per 1,000 population and 28% lower than NSW rate of 13.7 births per 1,000 population 5. 16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 Figure 2.3: Comparison of Birth Rates across the ML and state, 2011 0.0 Upper Lachlan /Goulburn Mulwaree Yass Valley/Palerang Queanbeyan Eurobodalla Bega Valley Monaro Southern NSW NSW Source: Australian Bureau of Statistics (2011) Figure 2.4 shows the percentage of births with young mothers aged 15 to 20. Bega Valley has the second lowest proportion of young mothers (0.5%) compared to the other regions in Southern NSW ML. 4 http://forecast2.id.com.au/default.aspx?id=354&pg=5520. Accessed 17 February 2013. 5 Australian Bureau of Statistics (2011) Southern NSW Medicare Local Page 3

% of total population % of all births Figure 2.4: Comparison of births with mothers aged 15 to 20 across the ML, FY 2011/2012 1.4% 1.2% 1.0% 0.8% 0.6% 0.4% 0.2% 0.0% Upper Lachlan/ Goulburn Mulwaree Queanbeyan Eurobodalla Bega Valley Monaro Source: Provided by Southern NSW LHD, Data received 12 Feb 2013 2.3 CULTURAL CHARACTERISTICS As shown in Figure 2.5, 97.1% of the Bega Valley population identify English as the primary language spoken at home which is higher than the overall ML rate of 94.1% and the NSW rate of 76.5%. Figure 2.5: Primary language spoken at home versus ML and state comparators, 2011 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% English Northern Europe Eastern Europe Southern Europe Southern Asia Southeast Asia Eastern Asia Middle East Australian Indigenous Other Bega Valley Southern NSW New South Wales Source: Australian Bureau of Statistics (2011) 2.4 EDUCATION LEVELS Within the Bega Valley LGA, 47.4% of the population left school at Year 10 or below, and 34.8% went on to complete Year 12 or equivalent, compared with 49.7% and 34.5% respectively for regional NSW. 6 Data available from PHIDU indicates that secondary school participation at age 16 is slightly higher in Bega Valley (81.6%) than the Southern NSW ML overall (79.2%) and across NSW (80.1%). The proportion of school leavers from Bega Valley that go on to pursue higher education qualifications (9.9%) is lower than the overall ML (14.0%), but is significantly lower than NSW (26.6%). 2.5 SOCIO-ECONOMIC CHARACTERISTICS The Socio-Economic Indexes For Areas (SEIFA) index score for socio-economic advantage and disadvantage in Bega Valley is 951, which places it in the 47 th percentile of Socio-Economic Advantage and Disadvantage 7 for NSW, and is ranked the second lowest within the Southern NSW 6 Profile Id: Bega Valley, (2012), accessed from http://profile.id.com.au/bega Valley/ 7 Australian Bureau of Statistics (2006) Southern NSW Medicare Local Page 4

% of all industry sectors Percentile ML. 8 Bega Valley s relative socio-economic advantage rating within the overall ML is illustrated in Figure 2.6. Figure 2.6: Comparison of SEIFA* Advantage and Disadvantage percentiles across the ML, 2011 100 90 80 70 60 50 40 30 20 10 0 Upper Lachlan/ Goulburn Mulwaree Yass Valley/Palerang Queanbeyan Eurobodalla Bega Valley Monaro (Bombala, Cooma-Monaro, Snowy River) Advantage and Disadvantage percentile within NSW Source: Australian Bureau of Statistics (2011) Note*: Mean SEIFA score was used for sub-regions with more than one LGA The distribution of household incomes in Bega Valley include a greater proportion of households earning lower incomes in comparison to the ML with approximately 75.7% of the population earning $71,500 or lower. 9 2.6 EMPLOYMENT The top five industry sectors of employment in Bega Valley are shown below in Figure 2.7. Health Care and Social Assistance is ranked the highest accounting for 13.1% of jobs held by residents and is similar to the ML (13%) but higher than NSW (11.6%), followed closely by Retail (12.3%) and Accommodation and Food Services (11.1%), which are both higher than the ML and NSW. Accommodation and Food Services is considerably higher than the ML (45%) and NSW (66%) and can be attributed to the large number of tourists who visit the coastal towns in Bega Valley. Together, these five industries employ 54.6% of the population, which is higher when compared to the ML (48.2%) and NSW (44.4%). 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% Figure 2.7: Top five Industry Sector of Employment versus ML and state comparators, 2011 0.0% Health Care and Social Assistance Retail Trade Accommodation and Food Services Manufacturing Construction Bega Valley Southern NSW New South Wales Source: Australian Bureau of Statistics (2011) 8 Public Health Information Development Unit and Australian Bureau of Statistics (2012) 9 Australian Bureau of Statistics (2011) Southern NSW Medicare Local Page 5

Persons per 1,000 Unemployment in Bega Valley (6.8%) is higher than the ML average (4.9%) and NSW (5.7%) and could be related to the casual and seasonal nature of retail and tourism jobs in the region. 10 2.7 ABORIGINAL AND TORRES STRAIT ISLANDER COMMUNITY Aboriginal Australians comprise a total of 2.8% of the total population of the Bega Valley LGA, which is slightly lower than the percentage of total residents for the ML (3.0%), but higher than the percentage of total residents in NSW (2.5%). The majority of the Aboriginal population in Bega Valley is young with 52.6% of the population aged 0 to 19. 11 There is also a larger proportion of Aboriginal residents aged 65 (4.8%) compared to the ML and NSW (4.2%). Although it is widely recognised that the Aboriginal population has poorer access to health care services and poorer overall health status, indicators that describe the health of Indigenous persons at a LGA level were not available for the purposes of this project. Analysis of acute patient-level activity data may help to provide some insight into the health issues facing Indigenous persons in Bega Valley. 2.8 HOMELESSNESS Homelessness data published by the Australian Bureau of Statistics shows that the per-capita rate of homelessness in Bega Valley (4.9 persons per 1,000) is 50% higher than the ML (3.2 persons per 1,000) and 43% higher than NSW (3.4 persons per 1,000), as shown in Figure 2.8. Bega Valley has a higher proportion of people living in improvised dwellings (1.3 persons per 1,000), living in severely crowded dwellings (1.4 persons per 1,000) and crowded dwellings (1.82 per 1,000 persons) when compared to the ML. 6.0 5.0 4.0 3.0 2.0 1.0 Figure 2.8: Housing and homelessness indicators versus ML and state comparators, 2006 - In improvised dwellings, tents or sleeping out Staying temporarily with other households Living in 'severely' crowded dwellings All homeless persons Living in other crowded dwellings Bega Valley Southern NSW NSW Source: Australian Bureau of Statistics (2006) 10 Bega Valley Shire Council, State of the Shire Report, Accessed 14 February 2013: : http://x.begavalley.nsw.gov.au/your_council/management_plan/bvsc_state_shire_report_feb2011.pdf 11 Public Health Information Development Unit and Australian Bureau of Statistics (2012) Southern NSW Medicare Local Page 6

Population % 3 Health risks of the population Headlines Higher health risk profiles for most factors as compared to the ML and NSW Highest incidences of alcohol related domestic violence compared to sub-regions in the ML Highest participation rate for bowel cancer screening compared to sub-regions in the ML Second lowest participation rate for breast cancer screening compared to sub-regions in the ML Highest percentage of children whose parents have withdrawn consent for vaccinations compared to sub-regions in the ML. 3.1 HEALTH RISK FACTORS Figure 3.1 shows that the health risk profile of Bega Valley is slightly higher for most risk factors than the ML and NSW, with the exception of risky alcohol consumption. Of note, the proportion of physically inactive persons in Bega Valley (41.6%) is higher than the ML overall (36.6%), followed by the proportion of smokers (24.8% to. 22.4%). Figure 3.1: Health risk factors versus ML and state comparators, 2007-08 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Smokers Risky alcohol consumption Overweight persons Obese persons Physically Psychologically inactive persons distressed Bega Valley (A) Southern NSW New South Wales Source: Public Health Information Development Unit and Australian Bureau of Statistics 2007-08 National Health Survey Note: Data represents a mean of age-standardised rates 3.2 ALCOHOL RELATED DOMESTIC VIOLENCE INCIDENCES Figure 3.2 shows the total number of domestic violence incidents and the percentage which are alcohol related in all sub-regions in the ML. In real numbers, Bega Valley has the 4 th highest number of reported domestic violence incidences, but the highest proportion of domestic violence that is reported to be related to alcohol (58%). This rate of alcohol-related domestic violence is higher than both the average across the ML (51%) and across NSW (39%). These figures are surprising, given the lower proportion of risky alcohol consumption as compared to the ML overall as shown in Figure 3.1. Figure 3.2: Comparison of alcohol related domestic violence incidences across the ML, Jan-Dec 2011 Southern NSW Medicare Local Page 7

% screened Total number of domestic violence incidents 160 140 120 100 80 60 40 20 0 55% Upper Lachlan/ Goulburn Mulwaree 43% Yass Valley/ Palerang 46% 47% 58% 53% Queanbeyan Eurobodalla Bega Valley Monaro Alcohol related incidents Non-alcohol related incidents Source: NSW Bureau of Crime Statistics and Research, 2011. 3.3 HEALTH SCREENING RATES This section presents the bowel cancer, breast cancer and cervical screening rates in Bega Valley LGA. 3.3.1 Bowel cancer screening rates Figure 3.3 shows the percentage of people who participated in the National Bowel Cancer Screening Program for each sub-region in the Southern NSW ML. Bega Valley has the highest overall rate among the sub-regions (43.2%), is higher than the NSW average (34.9%) and had a much higher participation of females (47.1%) compared to males (39.4%). Figure 3.3: Comparison of bowel cancer screening rates across the ML, 2010 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Bega Valley Eurobodalla Queanbeyan Upper Lachlan/Goulburn Mulwaree Yass Valley/Palerang Monaro NSW Source: Department of Health and Ageing - Note: 1. Formal publication and reporting of the NBCSP data is undertaken by the Australian Institute of Health and Welfare on behalf of the Department of Health and Ageing. NBCSP data included in this report provided by the Department of Health and Ageing is not part of the formal publication and reporting process for NBCSP data. Note: 2. Cautionary note about small numbers - Due to a larger degree of statistical fluctuation in small numbers, great care should be taken when assessing apparent differences involving small numbers and measures based on small numbers. 3.3.2 Breast cancer screening rates Figure 3.4 shows the biennial participation rate of women aged 50 to 69 who were screened for breast cancer for the period ending 30 June 2012. Bega Valley had the second lowest rate among the ML (39%), and is lower than both Eurobodalla (43.3%) and Queanbeyan (46.2) sub-regions, which have a similar population of females in the 50-69 age group. Bega Valley is also 28.9% lower than the NSW average (50.2%). Southern NSW Medicare Local Page 8

% of women screened % of women screened aged 50-69 Figure 3.4: Comparison of biennial breast cancer screening rates for women aged 50-69 across the ML, period ending 30/06/2012 60% 50% 40% 30% 20% 10% 0% Bega Valley Eurobodalla Queanbeyan Upper Lachlan/Goulburn Mulwaree Yass Valley/Palerang Monaro NSW Source: Cancer Institute NSW and HOIST database, Period: 01/07/2010 to 30/06/2012 3.3.3 Cervical cancer screening rates Figure 3.5 shows the biennial participation rate of women in age ranges 20 to 49, 50 to 69 and overall aged 20 to 69 who were screened for cervical cancer for the period ending 30 June 2012. Bega Valley had a relatively higher participation rate compared to the other sub-regions across all age ranges. Bega Valley had the second highest participation rate for age range 20 to 49 (55.4%), ranked third for age range 50 to 69 (61.5%) and was second highest for the overall age range 20 to 69 (58.1%). Bega Valley had similar rates for all age ranges in comparison to the NSW average. Figure 3.5: Comparison of biennial cervical cancer screening rates for women aged 20-69 across the ML, period ending 30/06/2012 70% 60% 50% 40% 30% 20% 10% 0% Bega Valley Eurobodalla Queanbeyan Upper Lachlan/Goulburn Mulwaree Yass Valley/Palerang Monaro NSW 20-49 years 50-69 years 20-69 years Source: NSW Pap Test Register, Cancer Institute NSW, HOIST database and NSW Health Survey 2008, Period: 01/07/2010 to 30/06/2012 3.4 IMMUNISATION Figure 3.6 shows the percentage of children who are fully immunised in Southern NSW ML during October to December 2012. Southern NSW ML has a very high rate of children who are fully immunised, with the age range between 24 to 27 months having the highest percentage (93.1%). Southern NSW Medicare Local Page 9

% of children whose parents have withdrawn consent for vaccination %of children fully immunised Figure 3.6: Percentage of children fully immunised in Southern NSW ML, Oct to Dec 2012 93.5% 93.0% 92.5% 92.0% 91.5% 91.0% 90.5% 90.0% 89.5% 12-<15 Months 24-<27 Months 60-<63 Months Southern NSW Source: Department of Health and Ageing Figure 3.7 shows percentage of children whose parents have withdrawn consent for them to have vaccinations across the ML. Bega Valley has the highest rate across the ML in 2011-12 (4.5%) and the second highest rate in 2012-13 (1.7%). Figure 3.7: Percentage of children whose parents have withdrawn consent for vaccination across the ML, 2011-2012 and 2012-2013 5.0% 4.5% 4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% Upper Lachlan/Goulburn Mulwaree Yass Valley/Palerang Queanbeyan Eurobodalla Bega Valley Monaro 2011-2012 2012-2013 Source: Department of Human Services, 2011-12 & 2012-13 Figure 3.8 shows the vaccine preventable notification rates for Pertussis per 1,000 persons for Southern NSW and NSW from 2008 to 2012. The data highlights a prolonged period of increased epidemic activity from 2009-2011 with the highest rate being in 2011 (2.5 per 1,000 persons). A high concentration of notifications occurred in children aged 5-14 years during the epidemic period. Southern NSW Medicare Local Page 10

Rate per 1,000 persons Rate per 1,000 persons Figure 3.8: Vaccine preventable Pertussis notification rates per 1,000 for Southern NSW and NSW, 2008 to 2012 3.00 2.50 2.00 1.50 1.00 0.50 0.00 2008 2009 2010 2011 2012 SNSW NSW Source: Public Health Unit covering Murrumbidgee and Southern NSW Local Health Districts, 2008-2012 Note: Only those cases that were notified to the Public Health Unit are included in the analysis and as a result, the data might only represent a small proportion of the actual number of cases and the data is not absolute Figure 3.9 shows the vaccine preventable notification rates for Pneumococcal per 1,000 persons for Southern NSW and NSW from 2008 to 2012. The data reflects a divergence in local notification rates from the comparative NSW rate. A low number of reports in young children (aged 1-4 years) could be seen to reflect a high uptake of vaccine in this cohort, while higher number of cases among older people could be indicative of lower immunisation coverage rates. Figure 3.9: Vaccine preventable Pneumococcal notification rates per 1,000 for Southern NSW and NSW, 2008 to 2012 0.12 0.10 0.08 0.06 0.04 0.02 0.00 2008 2009 2010 2011 2012 SNSW NSW Source: Public Health Unit covering Murrumbidgee and Southern NSW Local Health Districts, 2008-2012 Note: Only those cases that were notified to the Public Health Unit are included in the analysis and as a result, the data might only represent a small proportion of the actual number of cases and the data is not absolute During the reporting period, there were no reported cases of measles, rubella, tetanus or diphtheria and a low level activity of mumps and meningococcal disease, which is consistent with the trend seen in NSW over the period 2008-2012. Southern NSW Medicare Local Page 11

% of total population 4 Long term conditions, chronic disease and disability Headlines Slightly higher prevalence rate for most chronic diseases compared to the ML and NSW averages High incidence of all cancers compared to the ML and NSW averages Slightly higher premature mortality resulting from cancer compared to the ML and NSW averages Notably lower rate of mortality from preventable causes compared to the ML and NSW average Lowest suicide rate among other sub-regions in the ML Lowest prevalence rate of chlamydia per 1,000 persons compared to the ML High proportion of persons aged 50 years and less who require assistance with core activities. 4.1 PREVALENCE OF CHRONIC DISEASE Figure 4.1 shows that with the exception of respiratory system diseases, Bega Valley has a slightly higher prevalence rate for most chronic diseases in comparison to the ML and NSW. The higher prevalence rates compared to the ML and NSW may be attributed to the higher risk profile of the population. 35% 30% 25% 20% 15% 10% 5% Figure 4.1: Prevalence of selected chronic conditions versus ML and state comparators, 2007-08 0% Type 2 Diabetes High Cholestorol Mood Disorders Circulatory System Diseases Bega Valley (A) Southern NSW New South Wales Respiratory System Diseases Musculoskeletal Conditions Source: Public Health Information Development Unit and Australian Bureau of Statistics 2007-08 National Health Survey Note: Mood disorders include depression, anxiety, dysthymia and bipolar; Circulatory system conditions include ICD-10-AM codes I00 to I99; Respiratory system diseases include ICD-10-AM codes J00 to J99; Musculoskeletal conditions include ICD- 10-AM codes M00 to M99. Note: Data represents a mean of age-standardised rates Figure 4.2 presents the incidence of selected cancers in Bega Valley, which shows that the incidences of all cancers types are higher than the ML. Melanoma (0.81 cases per 1,000 persons) represents the largest difference from the ML (0.6 cases per 1,000 persons) and may be due to the large number of Southern NSW Medicare Local Page 12

Cases per 1,000 persons Prevalence per 1.,000 persons farmers and residents going to the beach in the community. Bega Valley has been identified as a melanoma red zone in NSW by the Cancer Institute NSW. 12 Figure 4.2: Incidence of selected cancers per 1,000 persons versus ML and state comparators, 2004 to 2008 1.00 0.80 0.60 0.40 0.20 0.00 Breast Colon Lung Melanoma Prostate Stomach Bega Valley Southern NSW NSW Source: Cancer Institute NSW (2010); Note: Incidences reported are crude rates (not age-standardised) 4.2 MORTALITY Figure 4.3 presents mortality rates from chronic conditions in Bega Valley for persons aged between 0 and 74. Data shows that premature mortality from cancer (1.08 deaths per 1,000 persons) is the only chronic disease slightly higher in Bega Valley than across both the ML (1.06 deaths per 1,000) and NSW (1.05 deaths per 1,000). These results could potentially be linked to the higher prevalence rates of all cancers in Bega Valley than the ML and NSW as shown in Figure 4.2. Despite having a higher prevalence rate for circulatory system diseases than the ML and NSW, the premature mortality rate is lower (0.56 cases per 1,000 persons). Figure 4.3: Premature mortality* from chronic disease (ages 0 to 74 years) and external causes per 1,000 persons versus ML and state comparators, 2003 to 2007 1.20 1.00 0.80 0.60 0.40 0.20 - Cancer Circulatory system disease Respiratory system disease Bega Valley (A) Southern NSW New South Wales External causes Source: Public Health Information and Development Unit and Australian Bureau of Statistics (2012). Note: * Premature mortality is defined by PHIDU as mortality occurring prior to 75 years of age; Circulatory system conditions include ICD-10-AM codes I00 to I99; Respiratory system diseases include ICD-10-AM codes J00 to J99; External causes include deaths arising from transport accidents, accidental falls, accidental poisoning, assault and suicide; Death rates reported are crude rates (not age-standardised). 12 Cancer Institute NSW s Melanoma Red Zone, Accessed on 14 February 2013: http://www.cancerinstitute.org.au/media/148332/melanoma-red-zones-nsw.pdf Southern NSW Medicare Local Page 13

Cases per 1,000 persons Deaths per 1,000 persons The per-capita rate of avoidable mortality in Bega Valley (0.94 deaths per 1,000 persons) is 10% lower than the Southern NSW ML (1.05 deaths per 1,000 persons) and is 4% lower than the NSW rate (0.98 deaths per 1,000 persons), as illustrated in Figure 4.4. Figure 4.4: Avoidable mortality* per 1,000 persons versus ML and state comparators 1.06 1.04 1.02 1.00 0.98 0.96 0.94 0.92 0.90 0.88 Bega Valley (A) Southern NSW New South Wales Avoidable mortality Source: Public Health Information and Development Unit and Australian Bureau of Statistics (2012). Note: * Data relates to persons aged from 0 to 74 years where mortality is caused by a number of conditions specified by the Public Health Information Development Unit. A list of ICD codes used as the basis for the calculation of avoidable mortality is available here; Mortality rates reported are crude rates (not age-standardised). Bega Valley has the lowest suicide rate in the region (0.06 cases per 1,000 persons) compared to the average across the ML (0.10 cases per 1,000 persons) and NSW (0.09 cases per 1,000 persons) despite the higher prevalence rates of mood disorders and higher proportion of psychologically distressed residents as shown in Figure 3.1 and 4.1 respectively. Figure 4.5: Premature mortality* from suicide^ and self-inflicted injuring (ages 0 to 74 years) per 1,000 persons across the ML and state comparators, 2003 to 2007 0.16 0.14 0.12 0.10 0.08 0.06 0.04 0.02 0.00 Upper Lachlan/ Goulburn Mulwaree Yass Valley/ Palerang Queanbeyan Eurobodalla Bega Valley Monaro Southern NSW NSW Source: Public Health Information and Development Unit and Australian Bureau of Statistics (2012). Note: * Premature mortality is defined by PHIDU as mortality occurring prior to 75 years of age; Death rates reported are crude rates (not agestandardised). Note^: Suicide rates were not available for Yass Valley, Upper Lachlan, Snowy River or Bombala LGAs. 4.3 INFECTIOUS DISEASE In Southern NSW, sexually transmitted chlamydia infections are the most frequently notified condition. Figure 4.6 shows the rate per 1,000 persons for sexually transmitted chlamydia infections across the ML. Bega Valley has the lowest prevalence rate among the sub-regions (7.3 per 1,000 persons) and is lower than Queanbeyan, Eurobodalla and Upper Lachlan/Goulburn Mulwaree sub-regions which have a similar population size. Bega Valley has seen a steady increase in the rate of chlamydia from 2008 to 2012. In Southern NSW, chlamydia has a higher prevalence rate among age range 15 to 24 and is higher for females than males. Southern NSW Medicare Local Page 14

% of all persons in age group Rate per 1,000 persons Figure 4.6 Prevalence rates of sexually transmitted chlamydia infections per 1,000 persons across the ML, 2008-2012 18.0 16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 Upper Lachlan/Goulburn Mulwaree Yass Valley/Palerang Queanbeyan Eurobodalla Bega Valley Monaro Source: Public Health Unit covering Murrumbidgee and Southern NSW Local Health Districts Note: Population data used to calculate notification rates has been sourced from the Australian Bureau of Statistics. From 2008 to 2012, there have been a total of 60 notifications of gonorrhoea in Southern NSW. Notified cases of syphilis, newly acquired hepatitis B and C are also infrequently reported in Southern NSW. For privacy reasons, the total number of cases has not been included in this report. 4.4 DISABILITY Figure 4.7 shows that Bega Valley residents aged less than 50 (2.7%) and in age range 50 to 59 (4.8%) have a much greater need for assistance with core activities than the average over both the broader ML (4.2%), and NSW (4.3%). There has been an increase of 98 persons in age range 20 to 59 from 2006 who require assistance with core activities. 13 These findings, coupled with the fact that residents aged 50 years and above account for almost half of the population (47.5%) of the Bega Valley LGA, will have direct implications for health service requirements in Bega Valley both now and into the future. Figure 4.7: Proportion of persons requiring assistance with core activities* versus ML and state comparators, 2011 40% 35% 30% 25% 20% 15% 10% 5% 0% Less than 50 50 to 59 60 to 69 70 to 79 80+ Age Bega Valley Southern NSW NSW Source: Australian Bureau of Statistics (2011) Note: * Core activities are defined by the ABS as needing help in one or more of three activity areas of self-care, mobility and communication 13 Profile Id: Bega Valley, (2012), accessed from http://profile.id.com.au/bega Valley/ Southern NSW Medicare Local Page 15

5 Health service availability Headlines Two public hospitals located in Pambula (Pambula District Hospital) and Bega (Bega District Hospital) One private hospital (Bega Valley Private Hospital) performs acute surgical procedures; Highest per capita rate of GPs of any sub-regions in the ML Greater high and community care aged care places per 1,000 persons aged 70+ than across the ML overall. 5.1 INPATIENT SERVICES Bega Valley has two public hospitals located in Pambula (Pambula District Hospital, D1a Community Acute with Surgery) and Bega (Bega District Hospital, District C1). Pambula District Hospital offers emergency department, surgery and medical services, while Bega District Hospital offers a range of services including emergency, ICU, oncology and maternity. Bega Valley Private Hospital is an acute surgical hospital and is the only private hospital in the Bega region providing acute surgical services. A new South East Regional Hospital is due to come on line in 2016 which will have 152 overnight beds and provide an increased level of service for the south east region. 14 Table 5.1: Inpatient facilities in Bega Valley Health Service Name Service Type Location Public sector health services Pambula District Hospital Public Hospitals Pambula Bega District Hospital Public Hospitals Bega Private sector health services Bega Valley Private Hospital Private Hospital Bega Source: NSW Health Establishment Registration Online (HERO) database 5.2 GENERAL PRACTITIONERS Figure 5.1 shows the number of full-time equivalent General Practitioners per 1,000 persons across the sub-regions in Southern NSW ML. Bega Valley has the highest rate of GP-related FTEs per 1,000 persons across the ML (1.06) and is higher than other sub-regions in the ML with a similar population (Yass Valley/Palerang, Upper Lachlan/Goulburn Mulwaree). When using 1 GP per 1,133 residents as a benchmark, the availability of GPs appears adequate to service residents within this region. 15,16,17 14 http://www.serh.org.au/ 15 May J, Jones PD, Cooper RJ, Morrissey M, Kershaw G. (2007) GP perceptions of workforce shortage in a rural setting. The International Electronic Journal of Rural and Remote Health Research, Education, Practice and Policy. http://www.rrh.org.au/articles/subviewaust.asp?articleid=720 16 Wilkinson D. Inequitable distribution of general practitioners in Australia: analysis by state and territory using census dat a. Australian Journal of Rural Health 2000; 8: 87-93. 17 May J, Morrissey M, Cooper R, Kershaw G. Supporting the rural GP workforce: impact of a managed care practice. In, Proceedings, General Practice & Primary Health Care Conference; 5-7July 2006; Perth, WA; 2006. Southern NSW Medicare Local Page 16

FTE per 1,000 persons GP FTE per 1,000 persons Figure 5.1: Comparison of General Practitioners per 1,000 persons across the ML 1.20 1.00 0.80 0.60 0.40 0.20 0.00 Upper Lachlan/Goulburn Mulwaree Palerang/Yass Valley Queanbeyan Eurobodalla Bega Valley Monaro Source: Provided by Southern NSW Medicare Local, Data received on 27 Feb 2013 5.3 ALLIED HEALTH Figure 5.2 shows the availability of private and NGO allied health practitioners per 1,000 persons in Bega Valley LGA compared to the ML. Bega Valley LGA appears to be better serviced for audiology, dentistry, pharmacy, occupational therapy, and physiotherapy services, however is under serviced for chiropractic, diabetes educator, optometry and podiatry services when compared to the ML. Figure 5.2: Private and NGO allied health practitioners per 1,000 persons in Bega Valley LGA versus the ML 0.60 0.50 0.40 0.30 0.20 0.10 0.00 Bega Valley Southern NSW Source: Provided by Southern NSW Medicare Local, Data received on 22 March 2013 Figure 5.3 shows the total Private and Public Mental Health practitioners per 1,000 persons across the sub-regions in Southern NSW ML. Bega Valley has the second highest rate of Psychologists (0.66 per 1,000 persons) and the third highest rate of social workers (0.30 per 1,000 persons) in comparison to the other sub-regions. Southern NSW Medicare Local Page 17

FTE per 1,000 persons Figure 5.3: Comparison of Private and Public Mental Health Practitioners per 1,000 persons across the ML 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 Upper Lachlan/Goulburn Mulwaree Yass Valley/Palerang Queanbeyan Eurobodalla Bega Valley Monaro Clinical Psychology Nurse* Psychology Social Worker Source: Provided by Southern NSW Medicare Local and Southern NSW LHD, Data received on 22 March 2013 Note* Nurse = Mental Health Nurse, Registered Nurse and Enrolled Nurse 5.4 COMMUNITY HEALTH SERVICES This section presents an analysis of the community services available within the Bega Valley sub region, including mental health community services. 5.4.1 Community health facilities, services and providers Bega Valley has three community health centres in Bega (Bega Community Health Centre), Pambula (Pambula Community Health Centre) and Eden (Eden Community Health Centre) as shown below in Table 5.2. Table 5.2: Community health facilities in Bega Valley Health Facility Name Facility/Service Type Location Public sector health services Bega Community Health Centre Community Health Centre Bega Pambula Community Health Centre Community Health Centre Pambula Eden Community Health Centre Community Health Centre Eden Source: Provided by Southern NSW LHD, Received on 5 July 2013 In addition, according to the Southern NSW Local Health District, a number of community health sites deliver a range of public programs and services which are determined by: 1. Ministry of Health Community Based Service Streams and 2. General funded community nursing and allied health services. As shown in Table 5.3, there is a full range of child, youth and family services, chronic care, rehabilitation and aged health services, oral health services and priority population health services provided under the Ministry of Health Community Based Service Streams. Southern NSW Medicare Local Page 18

Table 5.4: Ministry of Health Community Based Service Streams Child, Youth and Family Services Chronic Care, Rehabilitation and Aged Health Services Oral Health Services Priority Population Services Antenatal and postnatal care Child and Family Health (including Early Childhood Health Services and HealthOne NSW) Immunisation (including infant, adolescent & adult services) Sustaining NSW Families Programs Building Strong Foundations for Aboriginal Children, Families and Communities Out of Home Care Assessments and Coordination Statewide Eyesight for Preschoolers Screening Statewide Infant Screening Hearing Child Protection (including Physical Abuse and Neglect of Children services) Domestic and Family Violence Services Sexual Assault Services Victims of Crime Services Youth Health Services Aged Health (geriatric medicine aged care assessment and transitional aged care) Chronic Care (Connecting Care, other Chronic Care Services, and HealthOne NSW services) Dementia Services Home and Community Care Palliative Care Rehabilitation Services Pain Management Services Oral health promotion Early Childhood Oral Health Program services Specialist and special needs dental services Dental services for Aboriginal communities and older people Clinical training placements of dental and oral health students Dental services delivered through Justice health services Aboriginal Health Breast Cancer & Cervical Screening Carer Support Services Disability Services Multicultural Health Refugee Health Source: Provided by Southern NSW LHD, Received on 5 July 2013 In total, there are 36.84 FTE providing Ministry of Health Prescribed Service Streams services (in community and hospital) in Bega Valley LGA: Southern NSW Medicare Local Page 19

Table 5.4: FTE providing Ministry of Health Prescribed Service Streams Health Service s Home and Commu nity Care Palliativ e Care Chronic Care Aged Service s Emerge ncy Team/A ged to Acute Rehab Care Aged Care Assess ment Team Transiti onal Aged Care progra m Hospita l in the Home Oral Health Women Health Statewide-de eyesigh t preschool screeni ng Statewide Infant hearing screeni ng Sexual Assault Service s Child Protecti on Counse lling Service s Aborigi nal Health Breast Cancer Oncolo gy Cancer Care Total Bega Valley 4.42 1.09 2.12 2.0 2.47 8.0 * 4.42 0.63 0.1 0.53 1.84 1.12 2 0.42 4.42 1.26 36.84 Source: Provided by Southern NSW LHD, Received on 26 March 2013 Note*: Hospital based Southern NSW Medicare Local Page 20 Population Health Sub-Regional Profile v3.2

In addition, Table 5.5 outlines services that are provided under the General funded community nursing and allied health services. Table 5.5 General funded community nursing and allied health services Community Nursing Services Provided both in patients homes and in community health clinic settings Models of service delivery include a mix of generalist, specialist and program funded services Services include chronic disease management, wound care, cardiac and pulmonary rehabilitation, palliative care, diabetes education, tuberculosis, cancer care, palliative care, women s health (cervical screening, breast care and violence prevention), child and family nursing, immunisation, infant hearing and preschool sight tests. A significant number of community-based nursing services are also funded through the Community Health and Home and Community Care (HACC) programs requiring separate reporting on client outputs. Allied Health Services Provided by clinicians employed under identified programs and generalist and specialist services. Provide a mix of hospital in-reach and community based services Services include audiology, allied health assistants, dietetics, occupational therapy, physiotherapy, psychology, social work and speech pathology Source: Provided by Southern NSW LHD, Received on 26 March 2013 The following FTE provide the General funded community nursing and allied health services provided to both inpatient units and the community in Bega Valley LGA: Health Services Table 5.6: FTE providing General funded community nursing and allied health services Nursing Audio Dietician Occupational Therapy Physiotherapy Speech Pathology Social Work Psychology Bega Valley 10.84 0.71 1.79 2.84 8.20 2.24 1.59 Source: Provided by Southern NSW LHD, Received on 26 March 2013 5.4.2 Community mental health services and providers Bega Valley has one mental health team located in Pambula and a mental health inpatient unit at the Bega District Hospital. Full-time equivalents (FTE) associated with providing community mental health services in Bega Valley have been included in Figure 5.3. 5.5 AGED CARE 5.5.1 Residential aged care facilities Bega Valley has ten residential aged care homes providing a total of 322 high care places and 282 low care places. Southern NSW Medicare Local Population Health Sub-Regional Profile v3.2

Health Facility/Service Name Table 5.7: Residential aged care facilities in Bega Valley Post code Care Type* High care places Low care places Bimbimbie Retirement Village 2548 Residential 0 52 Casuarina Hostel 2550 Residential 0 31 Eden Community Aged Care 2551 Residential 65 20 Hillgrove House 2550 Residential 64 0 Imlay House 2549 Residential 73 0 IRT - Eurobodalla Shire Residential Care Facility 2546 Residential 55 0 IRT - Lakeview Lodge 2546 Residential 0 36 Mariner Park 2548 Residential 0 66 Nullica Lodge 2551 Residential 0 27 Sir James at Dalmeny 2546 Residential 65 50 5.5.2 Community aged care services Source: Department of Health and Ageing, 30 June 2012 Note*: Residential = Residential Aged Care Bega Valley provides the following aged care services to the community: two extended aged care at home dementia services with a total of 21 places, four community aged care packages with a total of 101 places, one extended aged care at home service with a total of 26 places and one transition care service with a total of 14 places. Table 5.8: Community aged care services in Bega Valley Health Facility/Service Name Postcode Care Type* Community care places Transition care places Bega & District Nursing Home EACHD 2550 EACH Dementia 2 0 Bega Valley Transitional and Restorative Aged Care Program 2550 Transition Care 0 14 Bimbimbie Village CACP 2548 Community 25 0 Merimbula Home Nursing Service 2548 Extended Aged Care at Home 26 0 Merimbula Home Nursing Service - CACP 2548 Community 27 0 Merimbula Home Nursing Service - Dementia EACH 2548 EACH Dementia 19 0 Sapphire Coast Home Services 2550 Community 39 0 Twofold Aboriginal Corporation 2551 Community 10 0 Source: Department of Health and Ageing, 30 June 2012 Note*:CACP = CACP Aged Care Package, EACH = EACH, MPS = MPSs, ATSI = ATSI, CDC = Consumer Directed Care, Innovative Care 5.5.3 Residential and community aged care places Community and residential aged care places available within the Bega Valley LGA are illustrated in Figure 5.6. Bega Valley provides a higher number of high care and community care places per 1,000 persons aged 70+ compared to the ML, however is lower for low-care places. Southern NSW Medicare Local Population Health Sub-Regional Profile v3.2

Places per 1,000 persons aged 70+ Figure 5.6 Aged care places per 1,000 persons versus ML and state comparators, 2011 60.00 50.00 40.00 30.00 20.00 10.00 - High-care Low-care Community aged care Bega Valley (A) Southern NSW New South Wales Source: Public Health Information Development Unit and Department of Health and Ageing (2012) Note: Data represents a mean of age-standardised rates Southern NSW Medicare Local Population Health Sub-Regional Profile v3.2

Number per 1,000 persons 6 Health service utilisation Headlines Higher number of primary care services billed to the MBS per-capita than the ML average for practice nurse services, GP health assessments for persons aged 75+ and GP mental health care plans Higher rates of preventable hospitalisation for ambulatory-sensitive conditions than the ML and NSW and top ten avoidable hospital admissions only accounting for 3.9% of all admissions Higher rates of allied health services, case management transport and domestic assistance HACC services than the ML. 6.1 PRIMARY CARE UTILISATION Medicare data shows that primary care services billed to the Medicare Benefits Schedule (MBS) in Bega Valley during 2009/10 was higher for most selected services. Of note, the rate of practice nurse services (413.8 per 1,000persons) was 13% higher than the average rate of services across the ML (365.0 per 1,000 persons). Figure 6.1: Selected primary care services per 1,000 persons, versus ML and state comparators, 2010 450 400 350 300 250 200 150 100 50 0 45 year old health checks GP health assessments for persons aged 75+ GP Enhanced Primary Care services Practice Nurse services GP Mental Health Care Plans Bega Valley (A) Southern NSW New South Wales Source: Public Health Information Development Unit and Department of Health and Ageing (2012) Note: Data represents a mean of age-standardised rates 6.2 EMERGENCY During FY2011-12, there were a total of 11,621 presentations to Bega District Hospital and 6,790 presentations to Pambula District Hospital. Data from Bega District Hospital is the only data that can be further analysed due to the information systems used. For Bega District Hospital, of the 11,621 presentations, 9,642 presentations (83%) were residents from Bega Valley LGA. Triage 4 (semi-urgent) and 5 (non-urgent) emergency presentations are those that are classified as not urgent and could be seen in a GP clinic. At Bega District Hospital, 70.8% of the presentations were classified as triage 4 and 5. Southern NSW Medicare Local Population Health Sub-Regional Profile v3.2

% of total admissions % of all admissions 6.3 HOSPITAL ADMISSION In 2010/11 SNSW ML residents had about 62,000 admissions to a hospital. (This excludes admissions for renal dialysis, chemotherapy and unqualified neonates). Please note that data on admissions to private facilities in the ACT was not available at the time of this analysis. Bega Valley residents had 12,131 admissions to a hospital in 2010/11 and 1,309 visits for renal dialysis. The top ten reasons for admission are presented in Figure 6.2 and account for 29% of the total number of admissions for Bega Valley residents. Figure 6.2: Top ten causes for hospital admissions by DRG from residents in Bega Valley sub-region, 2010/11 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% 161 Other Colonoscopy 503 Glaucoma and Lens Procedures 159 Other Gastroenterology 495 Other Orthopaedics - Surgical 512 Skin, Subcutaneous Tissue and Breast Procedures 829 Other Psychiatry 219 Other Neurology 491 Injuries to Limbs - Medical 162 Other Gastroscopy 529 Other Urological Procedures Source: Ministry of Health Flow info vs. 11.2, provided by Southern NSW Local Health District, Data received on 27 March 2013 Note: Data excludes Renal Dialysis, Chemotherapy and Unqualified neonates and private hospital data in the ACT Of the total admissions, 66% were in hospitals within the SNSW ML, with a further 19% in Private NSW facilities and 10% to ACT public hospitals as shown in Figure 6.3. Figure 6.3: Flow of Bega Valley residents hospital admissions across NSW, ACT and other states/territories, 2010/11 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% SNSW LHD Hospitals Private NSW A.C.T. Sydney LHDs Other States and Territories Other LHDs NSW Source: Ministry of Health Flow info vs 11.2, provided by Southern NSW Local Health District, Data received on 27 March 2013 Note: Data excludes Renal Dialysis, Chemotherapy and Unqualified neonates and private hospital data in the ACT 6.4 AMBULATORY-CARE SENSITIVE ADMISSIONS Figure 6.4 shows the potentially preventable hospitalisations resulting from Ambulatory-Care Sensitive Conditions (ACSCs). ACSCs are those conditions for which hospitalisation is thought to be avoidable with the application of public health interventions and early disease management, usually delivered in Southern NSW Medicare Local Population Health Sub-Regional Profile v3.2

% of all admissions of residents in Bega Valley sub-region Cases per 1,000 persons ambulatory setting such as primary care. High rates of hospital admissions for ACSCs may provide indirect evidence of problems with patient access to primary healthcare, inadequate skills and resources, or disconnection with specialist services. 18 ACSC s include vaccine-preventable conditions, selected acute conditions and selected chronic conditions that are modifiable through behaviour modification and lifestyle change. Rates of preventable hospitalisation for ambulatory-sensitive conditions in Bega Valley (31.5 per 1,000 persons) is higher than both the ML overall (25.3 per 1,000 persons) and NSW (23.8 per 1,000 persons). Figure 6.4: Preventable hospitalisations for ambulatory-care sensitive conditions per 1,000 population versus ML and state comparators, 2009-10 to 2011-12 35 30 25 20 15 10 5 0 Bega Valley Southern NSW NSW Preventable hospitalisations per 1,000 persons Source: NSW Health Centre for Epidemiology and Evidence (2011); Note: Rates reported are indirectly standardised by age and gender Note: Data represents a mean of age-standardised rates Figure 6.5 shows the top ten avoidable hospital admissions resulting from ACSCs from residents in the Bega Valley sub-region. Chronic obstructive pulmonary disease (116 episodes, 1.0%) is ranked number one, followed by congestive heart failure (105 episodes, 0.9%) and diabetes complications (64 episodes, 0.6%). The top ten avoidable hospital admissions account for 3.9% of all admissions. Figure 6.5: Top ten avoidable hospital admissions resulting from ambulatory-care sensitive conditions from residents in Bega Valley sub-region, FY2011-2012 1.2% 1.0% 0.8% 0.6% 0.4% 0.2% 0.0% Chronic obstructive pulmonary disease Congestive heart failure Diabetes Iron deficiency complications anaemia Angina Dehydration Pyelonephritis Influenza and Hypertension and pneumonia gastroenteritis Dental Conditions Source: Provided by Southern NSW Local Health District, Data received on 6 Feb 2013 18 Victorian Department of Health, http://www.health.vic.gov.au/healthstatus/admin/acsc/index.htm Southern NSW Medicare Local Population Health Sub-Regional Profile v3.2