Western Sydney Primary Health Network Needs Assessment Report November 2017

Western Sydney Primary Health Network Needs Assessment Report November 2017 Page 1

Contents SECTION 1 NARRATIVE... 4 Needs Assessment process and issues... 4 Additional Data Needs and Gaps... 5 Additional comments or feedback... 7 SECTION 2 OUTCOMES OF THE HEALTH NEEDS ANALYSIS... 8 ABORIGINAL HEALTH... 8 AGED CARE... 11 POPULATION HEALTH... 12 Cancer Screening... 12 Viral Hepatitis... 13 Immunisation... 13 VULNERABLE POPULATIONS... 14 Socio-economic disadvantage... 14 Vulnerable populations Refugee... 14 Vulnerable populations --Homeless... 15 PARTNERSHIP PRIORITIES... 15 Maternal, Child and Family... 15 Chronic disease - lifestyle risk factors... 17 Chronic disease prevalence... 19 Health Literacy... 21 SECTION 3 OUTCOMES OF THE SERVICE NEEDS ANALYSIS... 23 SERVICE INTEGRATION AND COORDINATION... 23 ABORIGINAL AND TORRES STRAIT ISLANDER... 23 AGED CARE... 24 DIGITAL HEALTH... 26 POPULATION HEALTH... 27 HealthPathways... 27 Viral Hepatitis... 27 Page 2

Veterans... 28 PARTNERSHIP PRIORITIES... 29 Maternal, Child and Family... 29 Chronic Disease... 29 Health literacy responsiveness... 31 AFTER HOURS... 32 HEALTH WORKFORCE... 36 SECTION 4 OPPORTUNITIES, PRIORITIES AND OPTIONS... 38 COORDINATION and INTEGRATION OF SERVICES... 38 PRIMARY CARE and DEVELOPMENT and CARE PATHWAYS... 39 DATA DRIVEN IMPROVEMENT and DATA LINKAGE... 41 CHRONIC DISEASE - risk factors... 42 CHRONIC DISEASE- prevalence... 42 CHRONIC - pain... 42 ABORIGINAL and TORRES STRAIT ISLANDER HEALTH... 42 MATERNAL, CHILD and FAMILY... 43 POPULATION HEALTH... 45 VULNERABLE POPULATIONS... 46 AGED CARE... 48 AFTER HOURS... 49 WORKFORCE PLANNING... 50 Page 3

SECTION 1 NARRATIVE Needs Assessment process and issues Introduction This report expands and augments the analysis undertaken for the Baseline Needs Assessment in 2016. It provides more information on emerging trends and a more granular detail of the health and service needs in western Sydney. The November 2017 report should be read as a companion document to the November 2016 Needs Assessment. It complements a range of other reports including our Activity Work Plans for commissioning services across the region. Process A data scan was undertaken for the identified western Sydney Primary Health Network (WSPHN) priority areas. Some data sets have been updated since the November 2016 Needs Assessment. In some instances, while new data is available at a state or national level, it is not yet available at a PHN level. Business intelligence in relation to service needs is also incorporated. Data collection Data for the update was collected from a range of sources, including: Australian Bureau of Statistics (ABS), Public Health Information Development Unit (PHIDU), National Health Performance Authority (NHPA), Australian Early Development Census (AEDC), Australian Institute of Health and Welfare (AIHW), Australian Childhood Immunisation Register (ACIR), Medicare statistics. Interrogation of information from the Western Sydney Local Health District and the Sydney Children s Hospital Network 2016-17 Annual Reports, and the Reporting for Better Cancer Outcomes (RBCO) Report 2016. Findings from WSPHN evaluations and stakeholder consultations are also incorporated. Consultation The WSPHN has consulted with key staff from within the PHN, Clinical and Consumer Advisory Councils, and the WentWest Board in relation to the process for the update and an overview of relevant data updates and trends. Next steps The WSPHN will continue to consult with members of the Clinical and Consumer Advisory Councils and with health professionals, consumers, commissioned agencies and other Page 4

stakeholders from across the region to co-design activities to address the identified priority areas. The nine priority areas will be the focus in development and service design for the WSPHN action and investment through to 2017-18. Specific areas of need have been identified and categorized as follows: - The Australian government s six nominated national health priorities 1. Aboriginal and Torres Strait Islander health 2. Aged Care 3. Digital health 4. Health Workforce 5. Mental health (separate Needs Assessment process) 6. Population health Additional priorities funded by the Australian government 1. After Hours Two additional Partnership Priorities identified at the regional level by Western Sydney Primary Health Network (WSPHN), Western Sydney Local Health District (WSLHD), Sydney Children s Hospital Network (SCHN). 1. Chronic and Complex conditions 2. Child and Family Additional Data Needs and Gaps Limited updates from MBS data broken down into SA3 regions and/or age groups Unclear on the website which data sources have been updated Lack of locally specific information for health areas, differing time periods, age groups, geographical breakdown (LGA, SA3) for data sources making it difficult to compare across sources Limited data available on advanced care for aged care Limited data available from general practice, despite use of PenCAT Data quality from general practice is variable Assessment Synthesis and triangulation A triangulation process was applied simultaneously to data collection and analysis to ensure that issues were consistent across multiple data sources, and that issues identified as priority areas were accurate and feasible. This process included cross-checking data across multiple sources, the application of eight prioritisation criteria, and an internal review process. Page 5

Prioritisation criteria and review After data was collected and analysed, a list of emerging priority areas was created. A prioritisation process was applied to identify a shortlist of priority areas for WSPHN. This process included the application of eight criteria which were based on current literature and evidence. These criteria were: 1. Scale of the issue (a. Number of people affected; b. Prevalence of the issue; c. Incidence of the issue; d. Trends/changes over time) 2. Benchmarking against national/state data and other similar regions 3. Impact of the issue (a. Consequences of the issue; b. Consequences of inaction) 4. Degree of health inequities 5. Linkages with known determinants of health 6. Alignment with priorities, targets and opinion (a. Government; b. Community; c. Stakeholders; d. WSPHN mandate, strategic plan and current commissioning activities) 7. Unmet need 8. Feasibility (a. Resource feasibility; b. Impact feasibility; c. Evidence-base feasibility). A review process was undertaken with key staff from WSPHN as well as members of the consumer advisory council to sense check the identified priority areas, and to ensure that no key areas were missing. Endorsement of the priority areas was sought from WSPHN Senior Program Managers; Director, Partnerships and Stakeholder Engagement; Director, Integrated Care and Commissioning; CEO, Walter Kmet. Priority areas In addition to the priority areas stipulated in the WSPHN schedule further research and consultation with stakeholders and the community has identified twelve specific priority areas for the western Sydney region. They are as follows: Priority target groups Coordination and Integration of Services Primary Care Development and Pathways Chronic Diseases Data Driven Improvement Data Linkage Aboriginal and Torres Strait Islander peoples Maternal, Child and Family Population Health / Vulnerable Populations Aged Care After Hours Workforce Planning Page 6

Additional comments or feedback Due to the Council mergers in 2016, WSPHN region is now comprised of four LGA s. Cumberland is one of only two new councils formed on May 2016 by re-drawing boundaries rather than simply merging existing councils. It includes Holroyd Council, the older parts of Auburn Council south of the M4, plus what was once Woodville Ward in the former Parramatta City Council. There is a small area of Parramatta Local Government Area (LGA) which is now outside the Western Sydney Local Health District boundaries. Page 7

SECTION 2 OUTCOMES OF THE HEALTH NEEDS ANALYSIS Identified Health Need Key Health Issue Description of Evidence ABORIGINAL HEALTH Aboriginal and Torres Strait Islander Health There is a much lower life expectancy for both male and female Aboriginal residents 1. 1. Western Sydney is the home to the largest urban Aboriginal and Torres Strait Islander population in Australia. More than 13,300 people (1.5% of the population) in the WSPHN region are of Aboriginal or Torres Strait Islander descent. Life expectancy for males is 78 years in NSW and for females 84 years. For the Aboriginal and Torres Strait Islander population in western Sydney born in 2010 2012, life expectancy was estimated to be significantly lower than non-aboriginal and Torres Strait Islander people (males 69.1 and females 73.7). This relates to the early onset and poor self- management of long-term health conditions 1. Aboriginal mothers are less likely to have an antenatal visit during their first trimester 2. Higher proportion of low birth weight babies compared to non- Aboriginal babies 3. 2. Rates of antenatal care are low, and a large gap exists compared to non-aboriginal rates. 36.5% of Aboriginal women in WSLHD had their first antenatal visit to a clinician prior to 14 or 20 weeks of pregnancy in 2014 compared to 55.1% for non-aboriginal women. This difference was greater in WSLHD than in NSW. 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. 3.The incidence of low birth weight babies for Aboriginal women in Western Sydney increased from 9.8% in 2001 to 13.9% in 2015. A large gap exists compared to non- Aboriginal women (6.5% in 2001 compared to 6.6% in 2015). Page 8

Identified Health Need Key Health Issue Description of Evidence Higher rates of smoking amongst Aboriginal mothers 4 4.It is reported by the WSLHD rates of smoking for aboriginal mothers is three times higher than for non-aboriginal mothers. Aboriginal and/or Torres Strait Islander mothers are also more likely to smoke during pregnancy (49.5 % in 2014; 6.3% for non-aboriginal mothers) Higher rates of hospitalisations for Aboriginal residents across a range of causes 5. Low levels of health literacy amongst the Aboriginal communities 6. Increasing chronic disease within the Aboriginal Community 7. Aboriginal and Torres Strait Islander peoples are overrepresented in the homeless population 8. There is a need for Social and emotional wellbeing services, particularly in relation to drugs and alcohol 9. 5.In the past two decades, hospitalisations for Aboriginal people increased by 189% in western Sydney, compared to 66% for non-aboriginal people. The most common causes of hospitalisation were for renal dialysis, followed by mental and behavioral disorders, injury and poisoning. 6.Service providers in western Sydney have recognized low levels of health literacy as a major challenge in working towards better health outcomes 7.Chronic disease within the western Sydney community has been highlighted as an area of concern. The Aboriginal population experience far worse health outcomes than non- Indigenous people with earlier onset of chronic disease, such as; Cardiovascular Disease, Diabetes, Chronic Obstructive Pulmonary Disease and higher rates of hospitalisations and mortality. 8. In 2014-15, 23% of people supported by specialist homelessness services identified as Aboriginal or Torres Strait Islander, including more than 1 in 4 children aged 0-10. 9.The need for holistic care was raised during the consultations, given the social and emotional wellbeing issues that exist for Aboriginal people living in Western Sydney. Socio economic indicators reveal unemployment levels across most Local Government Areas (LGAs) in western Sydney is higher for Aboriginal people as compared to non-aboriginal people. There are low levels of privately owned housing and home rental is predominantly from the NSW Government Housing Authority across all LGAs, with Blacktown being the highest. Page 9

Identified Health Need Key Health Issue Description of Evidence The western Sydney Aboriginal population had a much smaller proportion in the working stage of life (15 65 years), compared to the non-aboriginal population, and with a much higher proportion of children under 15 and a much smaller proportion of elders aged 65+. Education rates show attainment of primary education amongst Aboriginal and Torres Strait Islander people, declining through Year 12 attainment. There are significantly low levels of technical and further education and, particularly, university attainment. The health profile for Aboriginal people compared to non-aboriginal people reveals: lower life expectancy higher rates of chronic and other disease, low birth rates, preterm babies and high child mortality higher rates of communicable disease higher rates of drug and alcohol use higher rates of mental and behavioral disorders. In addition to the above, the issue of social isolation and its impact on social and emotional wellbeing has been repeatedly raised by consumers, carers and services in consultations. Sources: 1. ABS, Census of Population and Housing Counts Aboriginal and Torres Strait Islander Australians 2016; 2,3,4,5 Epidemiology and Health Analytics, Epidemiogical Profile WSLHD Residents. Sydney: Western Sydney Local Health District 2016; Centre for Epidemiology and Evidence. HealthStats NSW. Sydney: NSW Ministry of Health. Available at: www.healthstats.nsw.gov.au. Accessed March 2016; 6. Community consultation; Close the gap team; Allied health provider focus groups; Engagement with a range of Non-Government organisations and Semi-structured interviews with Aboriginal and Torres Strait Islander health service providers and community organisations; 7. Overweight and obesity rates (ABS National Aboriginal and Torres Strait Islander Health Survey 2005-05); Diabetes prevalence in Aboriginal adults 2014 (Centre for Epidemiology and Evidence NSW Health); Diabetes related death rate Aboriginal population 2013-2014 (Centre for Epidemiology and Evidence NSW Health); Respiratory disease-related deaths 2008-12 (Centre for Epidemiology and Evidence NSW Health), Aboriginal and Torres Strait Islander national age-standardised death rate (ABS 2010); 8. Homelessness Australia. Homelessness and Aboriginal and Torres Strait Islanders Fact Sheet. ACT: Homelessness Australia; 2016; 9. Prepared for the Western Sydney Primary Health Network (WentWest) by 33 Creative Pty Ltd, Aug 2017; Page 10

Identified Health Need Key Health Issue Description of Evidence AGED CARE Ageing population - increasingly chronic and complex health needs Increasing clinical demand on the health system 1. Projected increase in numbers of people living with Dementia 2. 1. As the population ages and life expectancy increases, older people will experience more chronic health conditions and associated disabilities, steadily In western Sydney about 16.4% of older people in the community reported severe to profound disability which is higher than state average of 13.6%. 2. Dementia is set to surpass cardiovascular disease as the main cause of death for older people aged 75+. It is estimated that 12,788 people are living with dementia in western Sydney. This is projected to increase by more than 200% by 2050. The State Electoral Division of Parramatta, Auburn, Granville is estimated to have the highest numbers of people living with Dementia. High rates of Falls in older people and increase in attendances by NSW Ambulance 3. Aged Care facility residents enter aged care with complex medical conditions and end of life care needs 4. 3. Falls continue to be a public health issue which can lead to functional decline. The risk of falls is associated with chronic health issues, polypharmacy, vision & cognitive impairment. About 1 in 3 older people in the community will experience a fall. Consultations with Ambulance and WSLHD highlighted this as a major issue. In 2015/16, 3,449 people aged 65+ were hospitalised in western Sydney for falls. In 2014, approximately 7,951 falls related attendances were received by NSW Ambulance and is reported to be increasing. About 30% of patients are not transported to hospital but re-present with another fall. 4.Of the 5157-residential aged care facility (RACF) places in WS, 59.6% of residents have a diagnosis of dementia, an increase of 7% in the last 7 years. The average length of stay in RACF is 3 years, reflecting that older people are entering RACFs as they approach end of life. Page 11

Identified Health Need Key Health Issue Description of Evidence Sources: 1. ABS, 2012; 2. Alzheimer s Australia NSW & Deloitte Access Economics (2014). Dementia prevalence in NSW by SED (state electoral district). [Data set]. Retrieved from https://nsw.fightdementia.org.au/ ; Australian Institute of Health and Welfare (2016) GEN Aged Care Data; NSW Health (2016) 3. HealthStats - Falls related hosptialisation in 65+ 2015-16; NSW Ambulance (2014) Falls Patients Evaluation of Activity Report; Public Health Information Development Unit (PHIDU). (2015). 4. Social health atlas of Australia: Data by Primary Health Network POPULATION HEALTH Cancer Screening rates for cervical, bowel and breast cancer Participation in all the National cancer screening programs (breast, bowel and cervical) is lower than National and State participation rates 1. 1.Breast Screening rates for women aged 50-69, in 2015-16 was lower in WSPHN (48.4%) compared to NSW (53.8%). The SA3 Mt Druitt had a much lower participation rate at (43.2%) 1.Cervical Screening rates for women aged 20-69 was lower in WSPHN in 2015-16 (49.5%) compared to NSW (55.4%). The recently available cancer screening participation data indicates that residents in SA3s Blacktown (46.5%), Merrylands (46.5%) and Mt Druitt (42.5%) had much lower participation rates compared to both the state and national rates. 1.Bowel Screening rates for ages 50-74 was lower in WSPHN in 2015-16 (34.3%) compared to NSW (38.2%). The recently available cancer screening participation data indicates that residents in SA2s Lethbridge park (25.5%), Bidwill (25.6%) and Mt Druitt (26.6%) had much lower participation rates compared to both the state and national rates. Low participation by Aboriginal people in all the National cancer screening programs (breast, bowel and cervical). 2.Across NSW rates of breast cancer screening are lowest among Aboriginal women at (40.2%), when compared to participation rates for all women (51.6%). WSPHN recorded a significantly lower rate at (27.3%) for Aboriginal women. Breast cancer screening was significantly lower 2. Page 12

Identified Health Need Key Health Issue Description of Evidence Source: 1. AIHW Cancer Screening in Australia by small geographical areas 2015-2016; 2. Cancer Institute NSW, 2016. Reporting for Better Cancer Outcomes Performance Report 2016. High rates of Chronic Hepatitis B Viral Hepatitis which leads to complications such as liver cirrhosis and liver cancer 1. Low screening rates of people at risk of Hepatitis B & C due to lack of community awareness by consumers and health professionals 1 Higher concentration of Hepatitis B in suburbs where people were born from endemic countries 1 1.The Australasian Sexual Health Medicine Society (ASHM) Third National Hepatitis B Mapping Project Report 2014-15 indicated that: - Western Sydney had the 3 rd highest number of people living with Chronic Hepatitis B in NSW. (14,122 in 2014 approximately 1.4% of the population). - At an SA3 level, Auburn, Parramatta, Merrylands-Guilford, Blacktown and Mt Druitt had higher numbers of people living with Hepatitis B. - It is estimated that about 38% of people living with Hepatitis B are undiagnosed. - About half of people affected by Hepatitis B were born from endemic countries which include Vietnam, China, Fiji, Philippines. This poses additional challenges in increasing health literacy and addressing stigma. Sources: 1.HIV, viral hepatitis and sexually transmissible infection in Australia https://kirby.unsw.edu.au/sites/default/files/kirby/report/serp_annual-surveillance-report-2016_upd170627.pdf; Immunisation Percentage of children fully immunized at 5 years Lower immunisation rates than the NSW average 1. 1. 93.2% of children in western Sydney are fully immunised at 5 years of age. The NSW average was 93.71% and the proposed target is 95%. Specific data is as follows: One-year old s 92.2% in western Sydney compared with 93.90% nationally Two-year old s - 89.4 % in western Sydney compared with 90.69% nationally Five-year old s 93.2% in western Sydney compared with 93.71% nationally. Lower immunisation rates in Aboriginal children than the NSW average 2. 2. 93.4% of Aboriginal children in western Sydney are fully immunised at 5 years of age. The NSW average for Aboriginal children was 96.5%. Source: 1,2 HealthStats NSW, 2016 Based on data from the Australian Immunisation Register. Health Protection NSW. Centre for Epidemiology and Evidence, NSW Ministry of Health. Page 13

Identified Health Need Key Health Issue Description of Evidence VULNERABLE POPULATIONS Socio-economic disadvantage Complex health needs amongst the Socio-economic disadvantaged population of western Sydney The poor health outcomes of the most disadvantaged members of our communities consistently emerge as a theme and the need to act on the social determinants of health is apparent. The WSPHN region is disadvantaged relative to the state and the nation, with areas and pockets within the region having very high levels of socio-economic disadvantage. SEIFA index by LGA in the WSPHN region ranges from the most disadvantaged at 917(Auburn LGA) to the least disadvantaged at 1011 (The Hills LGA) Source: PHIDU Social Health Atlas Published 2017: September 2017 Vulnerable populations Refugee Complex health needs of vulnerable refugee population settling in western Sydney 1 1.Western Sydney settles the 2 nd highest number of humanitarian entrants in NSW. Consultations with stakeholders of the WS Refugee Health Coalition identified Syrian and Iraqi refugees are moving into the western Sydney to settle for reasons such as reuniting with family or housing availability. They have observed that this cohort of arrivals experience more chronic and complex health issues. Older people are arriving with preexisting chronic conditions such as diabetes, heart disease which have been poorly managed prior to arrival. Younger children arrive with physical disabilities, some with developmental disability which are often undiagnosed. This poses challenges for new arrivals to navigate a very unfamiliar health and disability service system. Page 14

Identified Health Need Key Health Issue Description of Evidence Vulnerable populations --Homeless Homelessness is an increasing issue amongst vulnerable populations 2 2. Homelessness in NSW Rate per 10,000 population at 40.8 per 10,000. Blacktown LGA has a higher homeless rate than NSW at 45.17 per 10,000. Research consistently finds that high numbers of people who experience homelessness also experience mental illness. This group experience the dual stigma of homelessness and mental illness, and face lack of access to health services (both community and clinical), as they are both economically and socially excluded. Please note: The ABS will not release new data on homelessness from the 2016 census until 2018 Sources: 1.NSW Refugee Health Services (2016) https://www.swslhd.health.nsw.gov.au/refugee/faq-statistics.html. 2.2011 Census of Population and Housing: Estimating homelessness, 2011.2012 3. Australian Diabetes Council, 2012 PARTNERSHIP PRIORITIES Maternal, Child and Family High percentage of low birthweight babies 1. 1. The proportion of low birth weight babies is higher in western Sydney (6.5%) compared to NSW (6.2%). Blacktown South-West and South-East have the highest percentages of low birthweight babies compared to the national rates for all women. These two SLA s also have high proportion of mothers smoking during pregnancy (12.4%) and the highest proportion of mothers smoking during pregnancy. Risk factors include maternal smoking, socio-economic disadvantage, weight and age of the mother, poor antenatal care and illness during pregnancy. Low birth weight is a risk factor for neurological and physical disabilities and low birth weight babies may be more vulnerable to illness throughout childhood and adulthood. Page 15

Identified Health Need Key Health Issue Description of Evidence High rates of adolescent pregnancies 2. 2a. Blacktown has the largest number of mothers in the WSPHN region under the age of 19 years. The younger the mother, the greater risk to the baby. Newborns born to adolescent mothers are also more likely to have low birth weight, with a risk of long term effects. 2b. In 2015, there were 14,640 births in the region. Blacktown had the highest number of births in the region (at 5,590) and the largest number of mothers under the age of 19 (70% of all mothers under 19 years across the region) High percentage of children developmentally vulnerable on one or more domains 3. 3. Rates of children developmentally vulnerable on one or more domain and two or more domains is slightly higher in western Sydney than the NSW average, particularly in the Auburn and Parramatta LGAs. Rates also appear to be increasing, particularly in Holroyd and Parramatta LGAs. 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: Holroyd 28.8%, Auburn 27.3%, Parramatta 24%, Doonside 23.7%, Blacktown 22.8%, and The Hills Shire slightly lower at 17.6%. The same LGAs are higher than national (11.1%) and NSW (11.8%) averages for two or more domains with Holroyd 13.2%, Auburn 11.8%, Blacktown 11.6%, Parramatta 11.6% and Doonside 11.5% (suburb of Blacktown LGA) and The Hills Shire is lower than the NSW average at 8.4%. High proportion of children do not consume the recommended amount of vegetables 4. 4. A significant percentage of populations in the WSLHD are food insecure, with Aboriginal Australians over-represented. 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. In WSLHD it is reported that 9.4% of children aged 2-15 years consume the recommended vegetable intake (2014) Page 16

Identified Health Need Key Health Issue Description of Evidence High rates of overweight and obesity in children aged 12-17 years 5 5. 24.8% of secondary school students aged 12-17 years in WSLHD are overweight and obese. Less than 20% of children aged 5-15 years in WSLHD engage in adequate physical activity. Being overweight or obese can have a profound and enduring impact on these children s lives and they are often marginalised. High child and infant mortality rates 6 High rates of domestic assault 7 6.The Child Mortality rate is very high in Blacktown and Auburn LGA s. Deaths occurring before 5 years of age in Blacktown and Auburn LGA s (4.7 and 4.5 deaths per 1,000 live births) compared to the national rate of 4.4 deaths per 1,000 live births. 7. Rates of domestic assaults in the western Sydney region are higher than NSW rates for the period 2015-16 (414.89 per 100,000 and 385.38 per 100,000 respectively). The issue of social isolation impact on social and emotional wellbeing has been repeatedly raised by consumers, carers and services in consultations. Source: 1. PHIDU Social Health Atlas of Australia. Published 2017: September 2017 2a. WHO Adolescent pregnancy http://www.who.int/mediacentre/factsheets/fs364/en/, 2b. Centre for Epidemiology and Evidence. Health Statistics New South Wales. Sydney: NSW Ministry of Health. Mothers giving birth: by Local Government Area, NSW 2015. Available at: www.healthstats.nsw.gov.au Accessed October 2017; 3. Public Health Information Development Unit. Social Health Atlas of Australia: Data by Primary Health Network. December 2016. Accessed March 2017; 4. The Mapping food Environments Australian Localities (MEAL) Project (2014), Epidemiological Profile WSLHD Residents Feb 2016; 5. http://www.healthstats.nsw.gov.au/indicator/beh_bmi_secstud/beh_bmi_secstud_lhn_snap, NSW 2014; 6. PHIDU Social health atlas of Australia September 2017. 7. NSW Bureau of Crime and Statistics, 2014. Accessed via the Family and Community Services (FACS) website at: https://www.facs.nsw.gov.au/facs-statistics/facs-districts/western-sydney Accessed November 2017. Chronic disease - lifestyle risk factors Higher rates of obesity contributing to poor health outcomes. 1. Half the WSLHD residents aged 16 years and over are overweight or obese (50.8% in 2016) WSLHD residents aged 16 years and over have the following risk factors: 31.3 % of adults overweight (not obese) 19.4% of adults obese High incidence of chronic disease risk factors 2. 2.WSLHD residents have the following risk factors: 4.3% adults consume recommended veg intake (2016), this is lower than the NSW rate of 6.7% Page 17

Identified Health Need Key Health Issue Description of Evidence 42.7% adults consume recommended fruit intake (2016) 9.4% children 2-15 years old consume recommended veg intake (2014) 62.7%children 2 15 years old consume recommended fruit intake 50.4% adequate physical activity in adults (2016) 19.3% children aged 5-15 adequate physical activity (2016) 48.0% children 5-15 sedentary behaviors (2016) compared to 43% nationally. Food deserts exist in three western Sydney LGAs; these are Mt Druitt, Blacktown and south Granville 3. Rates of hospitalisation attributable to smoking are high across the region and above the NSW PHN average 4. Rates of hospitalisation attributable to alcohol in western Sydney (2014-2015) were significantly higher overall than other PHN areas 5 3.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. 4. 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 least disadvantage (23% to 10% nationally). Smoking attributable hospitalisation rates for all persons in WSPHN are 543.5 rate per 100,000 people. All PHN s rates are 542.1 per 100,000 people. 5. 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 hospitalisation rates for all persons in WSPHN are 680.4 rate per 100,000 people. All PHN s rates are 671.6 per 100,000 people Page 18

Identified Health Need Key Health Issue Description of Evidence Sources: 1,2 HealthStats NSW data 2016. http://www.healthstats.nsw.gov.au/indicator/beh_bmi_age/beh_bmi_phn ; 3. The Mapping Food Environments in Australian Locations (MEAL) project final report; 4. Healthstats.nsw.gov.au/Indicator/beh_smoafhos/beh_smoafhos_phn_snap Smoking attributable hospitalisations by Primary Health Network and sex, NSW 2014-15; 5. http://www.healthstats.nsw.gov.au/indicator/beh_alcafhos/beh_alcafhos_phn_snap Chronic disease prevalence Significantly higher rates of mortality for coronary heart disease and heart failure compared with NSW 1. 1. Cardiovascular disease and its associated risk factor are 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. Circulatory disease hospitalisations are higher in Blacktown (2057.1 per 100,000) and Cumberland (1774.3 per 100,000) than the national average (1706.7 per 100,000). The rate of chronic heart disease hospitalisations is higher in western Sydney (533.3 per 100,000 in 2015-16) compared to nationally (525.7 per 100,000) Demographic issues cloud the burden of data regarding chronic disease as a major cause of death across western Sydney. 2 2. 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 affluent Hills region may be a contributing factor to reduced figures. Additionally, chronic diseases are major causes of death across western Sydney. Deaths from endocrine diseases are 26.2 per 100,000 in western Sydney compared of 22.6 nationally. CALD communities apportion for a significant component of the western Sydney population, with 55.63% of the Cumberland LGA, 52.61% of the Parramatta LGA and 42.80% of the Blacktown population born overseas. Those at high risk for Type 2 diabetes, include those of Melanesian, Polynesian, and Mediterranean, Middle Eastern and Asian (especially Indian subcontinent) background. Many of these ethnic groups develop diabetes at levels of obesity at a younger age than people of European descent. Page 19

Identified Health Need Key Health Issue Description of Evidence Diabetes remains one of the most significant health challenges. The region is defined as a diabetes hotspot 3. 3. The prevalence of diabetes is increasing in both western Sydney and NSW residents. More than 60% of the western Sydney population is overweight and at risk of developing type 2 diabetes. It is estimated that 15% of residents have diabetes and 35% are at high risk of type 2 diabetes with pre-diabetes or high blood glucose. The high rates of undiagnosed diabetes are a major concern. The incidence of type 2 diabetes is 95.5 per 100,000 in western Sydney compared to 87.4 nationally (2015-16) Hospitalisation due to diabetes is significantly higher than the state average. NSW 2015-16 data for Diabetes Type 2 was 95.5 Rate per 100,000 compared to NSW 87.4 Rate per 100,000 population. 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. Asthma and COPD hospitalisation rates increasing 4. 4. Asthma is a growing issue 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. Asthma hospitalisations are increasing. In 2015-16, 1,011 persons were hospitalized in western Sydney compared to 885 in 2014-15. COPD hospitalisations are increasing particularly in females. In 2015-16, 862 females were hospitalized in western Sydney compared to 776 in 2014-15. Page 20

Identified Health Need Key Health Issue Description of Evidence Increasing rates of chronic disease 1 and High rates of potentially preventable hospitalisations 2. 1,2. High rates of chronic disease are placing a burden on the health of our community and on the health system, resulting in an increase in hospitalisations which could have been prevented if the chronic disease had been treated and managed well within primary health care setting. Hospital activity in western Sydney is rising significantly faster than population growth with a projected 2% compound annual growth rate in population and an accompanying 4.7% increase in hospital activity. Key drivers of this growth are chronic disease, with close to an estimated 1000 avoidable hospitalisations in 2013-14. In 2015-16, WSPHN has the highest rate in NSW of Potentially preventable hospitalisations for Asthma 177.5 Rate per 100,000. The All PHN rate was 123.9 Rate per 100,000 population. In 2015-16, WSPHN has the highest rate in NSW of Potentially preventable hospitalisations for Pneumonia and Influenza 99.5 Rate per 100,000. The All PHN rate was 63.8 Rate per 100,000 population. Source: 1. http://www.healthstats.nsw.gov.au/indicator/bod_dth_cat/bod_dth_cat_phn_snap; 2. HealthStats NSW, 2016; Taking the heat of our diabetes hotspot, 2016. HealthStats NSW, 2017; 3. http://www.healthstats.nsw.gov.au/indicator/dia_typehos/dia_typehos_phn_snap; 4. http://www.healthstats.nsw.gov.au/indicator/res_asthos/res_asthos_phn_trend; 5. http://www.healthstats.nsw.gov.au/indicator/res_copdhos/res_copdhos_lgamap Health Literacy Low levels of health literacy are a major challenge in working towards better health outcomes 1,2. 1.Low levels of health literacy experienced across WSPHN region, particularly in vulnerable and disadvantaged populations. 2.Preliminary analysis of the results from over 140 respondents suggest that there are three main groups of people within the region, with differing levels of health literacy and demographic characteristics. The first group (comprising 19% of the total sample) had relatively higher levels of health literacy across the nine domains, particularly in relation to their ability to actively manage their health, and find and understand health information. On average, people in this group were currently experiencing 1.4 chronic health conditions. Page 21

Identified Health Need Key Health Issue Description of Evidence The second group of respondents (comprising 42% of the total sample) had lower levels of health literacy across all nine domains. In particular, this group were less likely to be able to navigate the healthcare system, actively engage with healthcare providers, or find and understand good health information. This group reported experiencing an average of 1.6 chronic health conditions. The third group of respondents (comprising 30% of total sample) had higher levels of health literacy in some areas (e.g. their ability to actively engage with healthcare providers, feeling understood and supported by healthcare providers, and the ability to understand health information well enough to know what to do) and lower levels of health literacy in other areas. This group reported the highest number of chronic health conditions, with an average of 2 conditions per person. Source: The Science of Knowing, 2017 Preliminary results Page 22

SECTION 3 OUTCOMES OF THE SERVICE NEEDS ANALYSIS Identified Service Need Key Service Issue Description of Evidence SERVICE INTEGRATION AND COORDINATION Service Integration and coordination Lack of collaboration occurring between services and individual providers. Patients, carers, health professionals and other stakeholders highlighted the lack of collaboration occurring between services and individual providers across the region, particularly between hospitals and primary care services. It was identified as a need to improve the patient journey, enhance communication, information management and information sharing, and increase service integration and coordination. It is recognised that a lack of integration and coordination of services and information exchange in the health system is making the system difficult for patients to navigate and affecting continuity of care. Sources: WentWest GP Survey 2015; Consultation with service providers; Engagement with NGOs and LHD professionals; Allied health provider focus groups; Engagement with refugee and multicultural service agencies; Stakeholder Consultations ABORIGINAL AND TORRES STRAIT ISLANDER Aboriginal Health and Torres Strait islander Barriers accessing and benefiting from mainstream health services 1,2 Several barriers in accessing health services were identified by community members. These included, cost, transport (particularly early morning and late afternoon clinic appointments) and lack of culturally sensitive services. Page 23

Identified Service Need Key Service Issue Description of Evidence More culturally appropriate initiatives, better transition services in child and youth; services for prisoners on release; access for Aboriginal Elders requiring support; more early intervention and prevention programs for Aboriginal youth and more outreach services were identified. It has been reported at a national level that Aboriginal people are not benefiting from mainstream health services as much as other Australians due to barriers accessing services or issues of cultural acceptability. Source: Discussions with Aboriginal and Torres Strait Islander health service workers, stakeholder engagement through local health committees; Engagement with Aboriginal and Torres Strait Islander community organisations; Aboriginal and Torres Strait Islander Health Performance Framework 2014, AIHW AGED CARE Aged care - Difficulties in accessing quality and integrated health services Lack of screening and care planning for older people in primary setting to identify health needs early 1. 1. Stakeholders report that care provided by GPs can be variable. PENCAT data indicate about 20% of people over 75 years have received an over 75 s Health Assessment. Need for integration and coordination of services to build pathways instead of silos. Anecdotal reports from NSW Ambulance and LHD indicate that older people who have had a fall are not receiving appropriate follow up care in the community and re-present with falls. There is a lack of care pathways and services are fragmented due to long waiting lists and unclear entry criteria. Page 24

Identified Service Need Key Service Issue Description of Evidence Long waiting lists for community health services, especially for older people who experience sudden deterioration requiring rapid access to intervention. Stakeholders also indicate that long waiting lists for both health and community services. They have indicated that there is a 2 to 6 month wait to access assessment services through MyAged Care. This is needed before commencement of services such as Occupational Therapy, physiotherapy. This has been observed to attribute to unnecessary presentations to hospital and premature entry into residential aged care. The issue of social isolation and its impact on social and emotional wellbeing has been repeatedly raised by consumers, carers and services in consultations. Transfer of health information between acute care, NSW Ambulance and primary care setting is poor 2. This can be a significant barrier to appropriate care for older people with cognitive impairment, communication difficulties 3. 2. GPs surveyed in 2017 indicate the quality of hospital discharge summaries is declining and are less timely. RACF staff also report this is an issue affecting care such as poor coordination of medication prescription. 3. There are currently less than 20% of older people with a MyHealth Record and utilization is minimal. Difficulty attracting and retaining skilled Aged Care Workforce. Workforce not well equipped to care for increasingly complex residents entering RACF 4. Access to GPs in RACF setting 5 4. Surveys and feedback from managers of aged care facilities indicate difficulties in retaining staff skilled to care for increasingly complex residents. There is a high turnover of staff and the use of agency staff with variable skills and English proficiency is common. This issue remains relevant based on current PHN s interactions with facility staff. 5. RACF staff report difficulty accessing quality GPs for residents. The WSPHN database indicates there are 227 GPs who visit RACFs and 102 of GPs who are accepting new patients. Anecdotal reports via Page 25

Identified Service Need Key Service Issue Description of Evidence the RACF network and geriatric outreach service indicate the quality of care from GPs is variable. Sources: 1. PENCAT data - Health Intelligence Unit 2. Wentwest GP survey 2017 3. Department of Health. My Health Record statistics by Primary Health Network (PHN) Oct 2017 4. Outcome Services Needs Assessment 2013 5. Chilld DB DIGITAL HEALTH Digital Health Low uptake of MyHealth Record by consumers 1. 1. Although WSPHN has the fourth highest MyHealth Record Registration in NSW, a large proportion of the population do not have one. As of the 29 Oct 2017, there were 212,046 consumer registrations for MY HealthRecord from residents living in the WSPHN region, of these 98,515 were from males and 113,891 were from females. There is an increasing need for patients and carers to access relevant health information in one place to better self-manage their health care. General lack of education, understanding and uptake of ehealth and low rate of uploading patient health summaries 2. Low uptake by WSPHN GP s of electronic Shared Care (LinkedEHR) planning 2. 67% of general practices in WSPHN region are registered for MyHealth. GPs using the system to upload prescription records. To date, only 383 Shared Health summaries have been uploaded. 3.LinkedEHR is a key enabler in ensuring integrated and timely health care. Use of the LinkedEHR tool is still limited, however, with approximately 240 (of a possible 1,203) WSPHN GP s registered for electronic shared care planning. Page 26

Identified Service Need Key Service Issue Description of Evidence POPULATION HEALTH HealthPathways Health practitioners are not aware of all referral options and referral pathways can be unclear and often result in variations of care 1. 1.Clinical variations, or variations in care, are a key contributor to both the effectiveness of treatment and patient outcomes, and efficiency in service delivery. Variations in care are differences in the level of healthcare that are unrelated to the type or severity of illness, and that are unexplained by patient factors. These variations in care typically include overuse, underuse, misuse, duplication, system failures, unnecessary repetition, poor communication, and inefficiency. Source: Improved referral quality: https://www.ncbi.nlm.nih.gov/pubmed/28449017; Improved coordination of care between specialists and GP (Skin Cancer): https://www.healthpathwayscommunity.org/portals/11/documents/skin%20excision%20paper_jphc_2015.pdf ; Improved community based management of conditions (postmenopausal bleeding): https://www.healthpathwayscommunity.org/linkclick.aspx?fileticket=asu6effx1le%3d&portalid=11 Viral Hepatitis Poor access to specialist services 1 Lack of skilled workforce to initiate treatment and monitor patients in the primary care setting 2 Low uptake of Hepatitis B and Hepatitis C treatment in parts of the western Sydney catchment 3,4 1. Although Hepatitis B treatment is getting simpler, GPs still prefer having specialist input which poses a barrier to patients receiving timely treatment. WSLHD stakeholders report there is a significant waiting list to access hospital gastroenterology clinics. 2. Whilst the number of primary care prescribers has increased, there are only 18 GPs who can prescribe the antiviral treatment in Western Sydney and most are concentrated in the Auburn area. 3. In 2014, Hepatitis B treatment uptake was lowest in Mt Druitt (4.3%), Parramatta (5.9%) and Blacktown (6.4%), well under the national target of 15%. Auburn had the highest at 15%. Page 27

Identified Service Need Key Service Issue Description of Evidence 4.It should be noted that injecting drug use is only one source of potential Hep C infections. Hepatitis C infections have been slowly decreasing in Western Sydney PHN region between 2012 and 2015, from 304 notifications down to 279 notifications per year. Veterans Veteran health and wellbeing has been identified as an emerging health and service need 5. 5.The transition of care of defense workers from the Australian Defense Force to the Department of Veteran Affairs have been identified as a barrier to service access and delivery. Several Veterans experience problems accessing a regular GP due to regular relocation and deployment The veteran population have a high prevalence of mental health conditions including PTSD and anxiety disorders and in some cases, are found to experience homelessness. Veteran health has been identified as an emerging need in the WSPHN region by stakeholders including health professionals and service organisations. The total number of veterans reported by the Department of Veterans Affairs residing in the WSPHN region is 5,215 with almost a third of these residing in the Blacktown LGA. Sources: 1. Najjar, N et al (2016) A survey of Sydney General Practitioners management of Chronic Hepatitis B, Medical Journal of Australia. 2016;204(2):74e1-e4.; 2. Australasian Sexual Health Medicine Society (ASHM) 2017; 3,4. Third National Hepatitis B Mapping Project Report 2014-15- Australasian Sexual Health Medicine Society (ASHM); 5 Health Stats NSW 2017 Source: Department of Veteran Affairs, 2015, Social Health Strategy for the Veteran and Ex-Service Community. Available at: http://www.dva.gov.au/sites/default/files/files/publications/ health/social_health_strategy.pdf (Accessed 09 November 2016) A. C. McFarlane, S. Page 28

Identified Service Need Key Service Issue Description of Evidence PARTNERSHIP PRIORITIES Maternal, Child and Family Significant gap for affordable and timely services for children aged three to eight years 1 1.There is a lack of understanding by consumers about availability of health services in the region and no central point for accessing information for consumers. There is a significant gap in the region for affordable and timely services for children aged three to eight, particularly related to speech pathology, mental health, dental services and family based therapies. Barriers include cost, waiting periods, transport and a lack of suitable services. Source: 1 Community consultations and consultation with service providers including NGOs, 2017 Chronic Disease Appropriate care received 50% of the time 1. 1. An analysis of care provision by CareTrack 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. Need for Chronic disease GP Management plans to be reviewed 2. 2. Analysis of Pen Clinical Audit Data for 35 WSPHN practices in 2014-15 shows some encouraging trends but in 2014 only 30% of GPMP s had been reviewed and 34.5 % in 2015. Increase in numbers of total care plans is the result of data cleansing work and increased focus on Page 29