Population Health Commissioning Atlas

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1 Population Health Commissioning Atlas the PHCAtlas The Northern Territory Medicare Local Health Atlas 2014 NORTHERN TERRITORY ACT

2 Introduction Contents 2 INTRODUCTION 2 3 The PHCAtlas Concept The NTML Region 4 SECTION A Population Health in The Northern Territory 4 Demographic Trends & Socio-Economic Status 6 Social Determinants of Health 10 Population Health & Profiling 16 GP Location & Attendance Data 18 NTML Health Domains & Medicare Local Benchmarking 21 SECTION B Understanding Aboriginal Health and Wellbeing In The Northern Territory 22 Introduction and Determinants of Aboriginal Health 24 Aboriginal Key Performance Indicators Matrix 26 Social Determinants of Aboriginal Health 27 Aboriginal Population Health & Profiling 33 SECTION C Understanding the Health Workforce Challenges in the Northern Territory 38 SECTION D Key Themes Emerging from the NT PHCA and Commissioning Approach 40 SECTION E Data Qualifications and Limitations; Glossary 41 APPENDIX References and Acknowledgements The Northern Territory Medicare Local recognises and acknowledges the traditional owners of this land, their culture, history and vision for the future, particularly in improving the health and wellbeing for all Aboriginal people and their communities. The PHCAtlas Concept The Population Health Commissioning Atlas (PHCA ) brings together information from a range of sources to create a population health profile incorporating the National Health Performance Authority (NHPA) 1 Indicators for Medicare Locals as a starting point. The intent is to provide an information rich and visual document for decision makers who are setting priorities on behalf of the Northern Territory Medicare Local (NTML) and its partners. A focus is to highlight variations in health status and (where appropriate data is available) health service utilisation. Indicators showing recent improvements in population health are highlighted throughout and are identified using a tick symbol. The PHCA TM includes a dedicated chapter examining Aboriginal and Torres Strait Islander health and wellbeing and a chapter on the Northern Territory's (NT) health workforce. It is acknowledged that data gaps exist particularly with a widespread and dispersed population. Limitations and qualifications of the data are described at the end of this document. Determinants of Health Social, environmental and economic factors play a significant role in shaping the health and wellbeing of individuals and populations and are commonly referred to as the Social Determinants of Health (SDH) as shown in Figure 1.1. Evidence documenting the contribution of the SDH to population health outcomes is well established and undisputed, prompting international, national and regional health authorities to act to address these factors. 2 Figure 1.1 Social Determinants of Health Source: Dahlhren, Whitehead 3 For Aboriginal and Torres Strait Islander peoples (hereafter referred to as Aboriginal people) a number of additional determinants have been found to play an important role in population health outcomes. These include connectedness to family, land, culture and identity and opportunities for self determination. These are discussed in the Aboriginal section of this Atlas. 4 The links between SDH and the development of diseases such as chronic conditions are complex, although often associated with access to opportunities and resources such as quality education, adequate and meaningful employment, safe and affordable housing, accessible transport, nutritious food, safe local environments and accessible health services. Income also plays a critical role as it provides flexibility and increased options, enabling people to access the SDH they need. SDH underpin health and influence the movement of individuals and populations across the population health chronic disease continuum, described in figure ,5 Population Health Chronic Disease Continuum Figure 1.2 Population Health Chronic Disease Continuum Well Population At Risk Established Disease Primary Prevention > Promotion of healthy behaviours & environments across the life course > Universal & targeted approaches > Public health > Primary health care > Other sectors Health Promotion Source: NHPH 6 Prevent Movement To The At Risk Group Secondary Prevention/ Early Detection > Screening > Case finding > Periodic health examinations > Early intervention > Control risk factors lifestyle and medication > Primary health care > Public health Health Promotion Controlled Chronic Disease Disease Management and Tertiary Prevention > Treatment & Acute Care > Complications management > Specialist services > Hospital care > Primary health care Health Promotion Prevent Progression To Established Disease & Hospitalisation > Continuing Care > Maintenance > Rehabilitation > Self management > Primary health care > Community care Health Promotion Prevent/Delay Progression To Complications & Prevent Readmissions The above framework has been used to guide the development of the PHCA TM. It describes the population health chronic disease continuum from a well population to the development of risk factors, through to the progression of established chronic disease patterns. It recognises the interconnections between the socio-economic and environmental conditions in which people live and that access to health and other services has a direct impact on health status of a population. Action to improve health status needs to occur at each level of the continuum. It recognises that collaboration and partnerships with multiple stakeholders and sectors including Aboriginal people will be required to achieve improved population health and wellbeing outcomes. Medicare Locals are in a prime position to drive these improvements and fulfil their mandate under the NHPA. 7 2 Population Health Commissioning Atlas

3 The Northern Territory Medicare Local Region Message from the NTML CEO The Northern Territory Medicare Local Health Atlas 2014 provides a visual snapshot of health and social indicators across urban and remote regions of the NT, as well as benchmarking our achievements against the indicators set by the NHPA. The Atlas demonstrates a real opportunity to make further advances in improving health particularly for Aboriginal peoples and those at risk of chronic disease and mental health conditions. This information will allow the NTML, in collaboration with our community, service providers and other stakeholders, to develop and coordinate an equitable and comprehensive primary health care system that meets the health needs of the Northern Territory. NTML CEO Debbie Blumel Map 1.1 The Northern Territory Health Service Districts NTML: At a Glance Boundary: The NTML covers the whole of the jurisdiction of the Northern Territory and is bounded by 5437 kms of coastline in the north from the Timor Sea in the west to the Gulf of Carpentaria in the east. It shares land borders with Western Australia, South Australia and Queensland. Geography: The NT covers one-sixth of Australia's land-mass with a land area of 1,364,000 square kms (the third largest of Australia s states and territories). It is sparsely populated with a multi-cultural population of more than 230,000 people. Darwin, the capital city is closer to Asia than to the major cities of southern Australia. The NT has a diverse geography and climate - to the north is the Tanami Desert and to the south the Simpson Desert. The NT has disconnected ranges scattered across the landscape, and wetlands in Kakadu and Arnhem Land. The Top End weather is tropical with distinct wet and dry seasons. During the wet season (summer) the humidity averages over 70%, with monsoonal rains and tropical cyclones. The large central region is a semi-arid desert environment. Population: Total 231,862 8 Aboriginal Population: 69,625 (30% of total population) 8 SEIFA: Lowest - Victoria-Daly (460) to highest - Bayview-Woolner (1128) 9 General Practitioners: 142 FWE 10 General Practices: 40 (Private) 10 ACCHS: Health Service District Darwin Urban Darwin Rural East Arnhem Katherine Barkly Alice Springs Urban Alice Springs Rural Statistical Local Area (SLA) No. *Darwin North East (1) *Darwin North West (2) *Darwin South West (3) *Palmerston (4) Litchfield - Pt A (5) Litchfield - Pt B (6) Belyuen (7) Coomalie (8) Finniss-Mary (9) Wagait (10) Tiwi Islands (11) Jabiru (12) West Arnhem Bal (13) Alyangula (14) East Arnhem (15) Nhulunbuy (16) Katherine (17) Roper Gulf (18) Wadeye and OS (19) Victoria-Daly (20) Tennant Creek (21) Barkly (22) Alice Springs - Charles (23) Alice Springs - Heavitree (24) Alice Springs - Larapinta (25) Alice Springs - Ross (26) Alice Springs - Stuart (27) Central Desert (28) MacDonnell (29) Yulara (30) * Statistical Local Areas are defined by the Australian Bureau of Statistics to produce areas for the presentation and analysis of data. Most SLAs are based on suburbs: as many of these have very small populations, they have in some cases been grouped to form areas of larger (statistically relevant) populations. In the NT 4 SLA groups have been created to cover 40 SLAs in the Darwin area these are Darwin North West (12 Suburbs), Darwin North East (7), Darwin South West (12), Palmerston (9) Practice Nurses: RACFs: Public Hospitals: 5 10 Private Hospitals: 1 10 Pharmacies: Universities: 2 (Charles Darwin, Flinders) ML Formation: 1st July 2012 Health Service Districts Populations Health Service District Aboriginal Non-Aboriginal Total Population Darwin Urban 14, , ,725 the PHCAtlas Darwin Rural 12,211 4,784 16,995 East Arnhem 10,733 6,223 16,956 Katherine 10,757 9,417 20,174 Barkly 4,315 2,362 6,677 Alice Springs Urban 6,119 22,973 29,092 Alice Springs Rural 11,475 2,768 14,243 Total 69, , ,862 Population Health Commissioning Atlas 3

4 Section A Population Health in the Northern Territory Demographics and Trends The NT has a young population relative to the rest of Australia with 70.9% of the population (146,643 people) under the age of 45 years compared to 60.6% for Australia (Figures 2.1 and 2.2). 11 This difference is projected to increase into the future as the Australian population ages at a faster rate than the NT. There is a higher proportion of young people living in the NT in each of the five year age cohorts up to the ages of 49 for males and up to 44 for females. After this point the NT population drops rapidly, in particular between the ages of 50 and 64. From 65 years onwards the population profile declines more than the Australian curve and the proportion of population in these older age brackets is smaller. The population pyramids suggest that additional people enter the population between the ages of 20 and 40, and this could be related to workers moving to the NT for employment in agriculture, construction, mining, tourism, defence and health/ community services. This increase in the young working population is likely to include families with children, which in part explains the higher proportion of children 0-14 years in the NT. Aboriginal People Figure 2.3 shows the Aboriginal population is young relative to the non-aboriginal population with over a third of the Aboriginal population under the age of 14 (18,840 Aboriginal children) and well over half the Aboriginal population under the age of 30, a pyramid similar to developing countries. Population Migration The NT population is transient, with significant numbers of people moving in and out of the region during a five year period. In the 2011 census, 70,398 people aged 15 years and older stated that they had moved in the previous five years. The NT had the highest population turnover of any state or territory. For the year ended 31 December 2009, the NT recorded 15,700 departures, which was equivalent to a loss of 7% of the total population. The same proportion (7%) also arrived in the NT during the year. This compares to 5% turnover for the Australian Capital Territory while the other states recorded turnover rates between 1% and 3%. 12 The working aged population of the NT includes a proportion of fly-in fly-out workers and defence personnel, whose numbers are not always captured due to the methods of collecting census data. Population Projections The NT Department of Treasury and Finance 13 has predicted that the NT population will grow to 281,404 (currently 231,862) by 2026 with the Aboriginal population to increase to 89,456 (currently 69,625) in the same period (Figure 2.4). The annual average growth rate will be 1.5% up to 2016 and it then moderates beyond this date. The age structure will stay largely static but a declining fertility rate will mean a decrease in the proportion of people under 15. This will include a major reduction in the Aboriginal population, while the NT's non-aboriginal population under 15 years will increase slightly. Figure 2.2 NT vs Australia Source: ABS 15 Life Expectancy Figure 2.1 Population Pyramid NT vs Australia Source: ABS 15 Life expectancy at birth is an estimate of how long a person born today would live (on average) if current mortality rates in every age group remained constant throughout the person s life. 4 Life expectancy for all Northern Territorians has improved significantly over the past forty years with a four year improvement between for both males (71.3 years to 74.7 years) and females (76.7 years to 80.0 years). 14 Source: ABS 15 Figure 2.3 NT Aboriginal Population vs Non-Aboriginal Population Figure 2.4 NT Population Projection Age ,149 1, ,965 3,498 4,575 6, ,221 11,471 13,630 15, ,512 55,179 58,529 61, ,053 81,668 86,987 92, ,530 36,016 37,599 40, ,887 36,492 39,333 41, ,537 19,857 21,152 22,267 Source: NT Dept. of Treasury and Finance 13 4 Population Health Commissioning Atlas

5 Demographics, Trends and Socio-Economic Status Map 2.1 NT Index of Relative Social Disadvantage (IRSD) by SLA (including Darwin and Alice Springs detailed maps) Source: ABS 9 Map 2.2 SEIFA Index of Relative Socio-Economic Advantage & Disadvantage (IRSAD) by LGA Source: ABS 9 Socio-Economic Index for Areas The Socio-Economic Index for Areas (SEIFA)defines the relative social and economic advantage and disadvantage of a region, by measuring a community s access to material and social resources and their ability to participate in society. A variety of census indicators are used to develop the four indexes that summarise different aspects of advantage and disadvantage. The indicators used are based on education, occupation, employment, income, families and housing. 16 Northern Territory SEIFA Analysis IRSD A low Index of Relative Social Disadvantage (IRSD) score indicates a high proportion of relatively disadvantaged people in the area as highlighted by the red colours in Map 2.1. This map shows that with the exception of urban centres, the rest of the Northern Territory is extremely disadvantaged with the average IRSD score for NT being 848 with SLA scores ranging from 460 to The two inset sections of the map provide finer grain detail of the region s main urban centres: Darwin and Alice Springs. The IRSD scores for Darwin SLAs range from Moulden (888) to Bayview-Woolner (1128) with most tending to be higher than for the SLAs within the Alice Springs area, Heavitree (968) to Ross (1032). 9 In part, this difference may reflect the remoteness of Alice Springs, making access to material and social resources more difficult. Four of the NT s SLAs rank in the bottom 10 for all of Australia (Victoria-Daly 460, Belyuen 508, East Arnhem 521 and Barkly Balance 542), and 15 SLAs in total are in the bottom decile. In contrast, 8 SLAs within the greater Darwin area rank in the least disadvantaged decile. 9 IRSAD The Index of Relative Socio-Economic Advantage and Disadvantage (IRSAD) highlights the extreme differences between areas across the NT (Map 2.2). For example the remote Local Government Areas (LGAs) all fall in the bottom decile and so their populations experience disadvantage when compared to Australia. However in contrast the main urban centres across the NT have over half the population (153,217 people) living in LGAs considered to be relatively advantaged (indicated by the blue colours on the map). It should be noted that within all LGAs there is a broad range of IRSAD scores indicating pockets of disadvantage potentially hidden by the overall score for the area. 9 Levels of Remoteness the PHCAtlas The Accessibility Remoteness Index of Australia (ARIA) classifies the NT region as very remote, with the exception of Alice Springs (remote) and Darwin (outer regional). Very remote means locationally disadvantaged with very little access to goods and services such as education, retail, and social services. The NT has 22.4% of the population living in very remote areas and 21.6% in remote areas. 9 Population Health Commissioning Atlas 5

6 Social Determinants of Health Social Determinants of Health (SDH) This section highlights key social determinants for the NT, with a focus on the unequal distribution, most evident in the urban-remote divide. The SDH (see page 2) describe the conditions that play a key role in shaping people s health and wellbeing. Importantly, the distribution of these determinants can vary across populations, and thereby either increase or decrease a community s opportunities to be healthy. The unequal distribution of the SDH across populations is considered to be one of the driving factors leading to differences in health status and creating health inequities - the unfair and avoidable differences seen within countries, regions and populations. 4,17 School Participation Higher levels of education are associated with higher levels of employment and earnings for individuals. Participation in schooling and/or training is an important protective factor for young people, reducing the risk of substance misuse, incarceration, social exclusion, homelessness and poverty. Evidence shows that health improves with increasing levels of educational attainment. 18 Map 2.3 demonstrates the variability across the NT for post compulsory school participation rates which is low when compared with other MLs (NTML ranks 59th out of 61). The very remote regions e.g. Barkly, Central Desert and MacDonnell SLAs have extremely poor participation rates (0-32%). In comparison, the two large urban centres of Darwin and Alice Springs have SLAs with participation rates of 60% or higher. Interestingly, within the greater Darwin area participation rates are extremely low. Unemployment Unemployment is a social problem and is associated with poor physical and mental health outcomes. 19 The health effects are linked to psychological consequences, financial problems (debt) and reduced life opportunities, with outcomes worse in regions where unemployment is widespread. Map 2.4 suggests that unemployment across the NT is widespread compared to the Australian average of 4.2. Four SLAs have rates of people claiming unemployment benefits of between 17.7% and 24.6%. Further analysis highlights the differences between urban and remote/very remote regions, as demonstrated by Darwin ( %) and Alice Springs (4-5%) having low levels of people claiming unemployment benefits. Families and Welfare Poverty and social exclusion have a negative impact on the health of populations. 2 Welfare dependant families may have insecure housing, experience higher levels of stress and find it difficult to provide optimal development environments for their children. The NT has a significant number of welfare dependant families and ranks third worst when compared with other ML populations. The remote/very remote and urban divide is evident in Map 2.5, with only the Darwin region keeping pace with the national average of 9.3% of welfare dependant families. Map 2.3 Full Time Secondary School Attendance at Age 16 Source:: PHIDU 8 Map 2.4 People Receiving Unemployment Benefit Map 2.5 Low Income, Welfare Dependant Families (With Children) 6 Population Health Commissioning Atlas

7 Social Determinants of Health Map 2.6 Concession Card Holders Wealth and Income Wealth and income are amongst the most important determinants of health with an individual's health improving with each step up the economic and social ladder. 20 Thus people with a higher income enjoy better health and longer lives than those with lower incomes. Lack of income can be measured in a variety of ways e.g. concession card holders and numbers of welfare dependent families. Total Personal Income (15+ Personal Weekly Income) Northern Territory Australia Negative/Nil income 6.5% 8.2% < $400 per week 21 (Equivalent to the poverty line) 22.9% 27.7% $400 - $999 per week 25.4% 30.3% $ $1999 per week 25.6% 19.8% > $2000 per week 6.1% 6.2% Map 2.7 Households Receiving Rent Assistance Map 2.8 Low Income Households With Rental Stress Not stated 13.5% 7.9% Source: ABS 22 While a third of the population are living below the poverty line, there is over 30% earning more than $1000 per week which is a greater proportion than the Australian average. Concession Card Holders The number of people holding concession cards is a proxy measure for disadvantage. Map 2.6 shows that the remote areas of the NT are significantly above the Australian average (23%) and all urban areas are below the national average, even Litchfield (Pt B) where 16.5% of the population hold concession cards. Housing Housing wellbeing is influenced by a range of dimensions and evidence suggests that the three elements of housing that impact most on health are suitability, affordability and security of tenure. 2 The NT housing market has ongoing supply and affordability concerns in both the private rental and home ownership markets. Rent and house purchase price growth are at historically high rates and represent significant barriers for low and moderate income households. 23 the PHCAtlas Rent Assistance Map 2.7 show affordability issues are more prevalent in the urban areas of the NT (e.g % of households in Alice Springs and up to 14.3% in the Darwin area). Rental Stress The private rental sector leads to further housing stressors associated with security, affordability and quality where tenants have less capacity to change or influence these factors compared with home owners. Map 2.8 shows households in the bottom 40% of income distribution, spending more than 30% of their income on rent. This suggests there is housing stress relating to affordability across the urban areas of the NT. A number of other housing stressors (e.g. chronic and historical housing shortages, homelessness and severe overcrowding) exist across other more remote areas of the NT and is discussed further in the Aboriginal section of this Atlas. Population Health Commissioning Atlas 7

8 Social Determinants Of Health - The Early Years Child Health The importance of the early years and the impact they have on a child s health and development is acknowledged in the Key National Indicators Framework developed by the Australian Institute of Health & Welfare (AIHW). This framework brings together all of the determinants of children s health outcomes and includes safe communities and environments, family circumstances, exposure to risk and protective factors, learning and development, healthy child development and access to health and social services. 24 Child health is an important indicator of the health of a community. In particular the rate of infant mortality within a population is considered a strong predictor for the overall health status of that population. 25 For the NT infant mortality (0-5 years) is ranked in the worst quintile for MLs in the country and the proportion of low weight babies is also in the worst quintile for all MLs (see matrix page 18). Smoking during pregnancy, birth weight and childhood immunisation rates are three key indicators from the AIHW Key National Indicators Framework and Maps 2.9, 2.10 and 2.11 show the variation in these indicators across the NT. Smoking in Pregnancy Smoking during pregnancy is a significant risk factor for the health of the mother and her unborn baby. It increases the risk of low birth weight, preterm birth, placental complications and perinatal mortality. These problems may then affect children through to adulthood including a higher risk of disability, developmental delay, decreased lung function and increased respiratory illness. 24 Map 2.9 shows a variation in the smoking during pregnancy rates across the NT. It is important to note however, the entire NT is above the national rate of 15.0%. Rural Central Australia appears to have lower rates ( %) than their rural northern neighbours ( %). Low Birth Weight Babies Birth weight is a key indicator of infant health and a principal determinant of a baby s chance of survival and good health. The health effects of low birth weight can continue into adulthood including increased risk of Type 2 diabetes, high blood pressure, cardiovascular disease and obesity. 24 Map 2.10 shows that both urban and remote regions of the NT are above the national average (6.5%). The data also indicates differences between very remote and urban centres and Aboriginal and non- Aboriginal births (which will be explored further in the Aboriginal section). There is evidence that smoking during pregnancy is playing a role in the high number of low birth weight babies born in the region and excessive alcohol use may also be a factor. Immunisation Rate Coverage Map 2.11 shows the immunisation rates at 12 months (2008) and indicates that the remote areas of the NT including Alice Springs (with the exception of Stuart) had low rates of immunisations (<90%). However more recent figures reflect an improved picture with 92% of all children immunised at 12 months (2011/12). 26 Map 2.9 Mothers Smoking During Pregnancy Map 2.10 Proportion of Low Birth Weight Babies Map 2.11 Proportion of Children Immunised at 12 Months 8 Population Health Commissioning Atlas

9 Social Determinants Of Health - The Early Years Figure 2.5 Children Vulnerable on One or More AEDI Domains Community Source: AEDI 28 Map 2.12 Children Developmentally Vulnerable on 2 or More AEDI Domains (communities) Source: AEDI 28 Investments In Early Childhood The improvements in the NT AEDI results are likely to be the result of investments in early childhood strategies, programs and services. 132 Significant improvements were made in some regions - in particular within the Top End (Nhulunbuy and Tiwi Islands). A review of programs being provided at state level around children's health and wellbeing indicates both universal programs and programs targeted at specific populations and this supports research on best policy approaches. 29 This is explored further in the Aboriginal health Section. Communities Figure 2.6 Key Indicators of Child Health and Wellbeing NT AUS Infant mortality (IMR) Exclusively breastfed at 4 months (%) 43.3% % 24 Poor dental health at 6yrs Developmentally vulnerable children commencing school (2012) 35.5% 28 22% 28 Teen births (15-19 years) 9.3% % 32 Smoking in pregnancy 26.0% % 32 Alcohol use in pregnancy 63.5% 33 51% 24 Low birth weight 9.6% % 32 Children living in low income families Child abuse and neglect (living in out of home care) 26.4% % per 7.7 per 1, , Children immunised at 12 months 92% 26 92% 26 Source: Multiple - as indicated by superscript in table Childhood Development During early childhood (from the prenatal period to eight years of age), children undergo rapid growth that is highly influenced by their environment. Many challenges faced by adults, such as mental health issues, obesity, heart disease, criminality, and poor literacy and numeracy, can be linked back to early childhood. 27 The socio-economic status (SES) of families has been found to impact on their ability to provide healthy, stimulating and nurturing environments for their children, due to limited access to resources, supports and opportunities. 4 AEDI The Australian Early Development Index (AEDI) is a population based measure of how children have developed by the time they start school. It looks at five domains of early childhood development: physical health and wellbeing; social competence; emotional maturity; language and cognitive skills; and communication skills and general knowledge. The AEDI National Report indicates there is a particular concern around child development in remote areas of the NT. One Domain (or more) Between 2009 and 2012 there was slight improvement in children developmentally vulnerable on one or more domain (from 38.7% to 35.5%). Note - there have been significant improvements in both the Top End and Central Australia from 2009 to 2012 in particular the communities of Tiwi, Elsey, Litchfield, Finnis, South Barkly and Sandover-Plenty. Despite these improvements only Litchfield (20.9%) performed better than the Australian average for children developmentally vulnerable on one or more domain. The only significant decline in children s developmental outcomes in the NT between 2009 and 2012 AEDI surveys was in Barkly North (52.9% to 72.2%). Two Domains Children vulnerable on two or more domains are considered to be at particularly high risk developmentally. Map 2.12 indicates that children do better in communities closer to the urban centres of Alice Springs and Darwin. Only Nhulunbuy (10.8%) and Litchfield (9.2%) record results in line with the national average for children Immunisations Considering the level of remoteness across the NT and the challenge of delivering preventive health services it is a positive sign that in 2011/12 the NT was on track with National childhood immunisation rates, with 91.8% of NT children immunised at 12 months. 26 This is an indication of commitment from providers. the PHCAtlas developmentally vulnerable on two or more domains (10.8%), both these regions making significant i m p r o v e m e n t s between 2009 and The NTML looks forward to further i m p r o v e m e n t s over time building on the culturally sensitive data collection techniques used in the 2012 AEDI survey. Population Health Commissioning Atlas 9

10 Population Health and Profiling [1] National Health Priority Areas - Risk Factors The social determinants of health influence people s exposure to risk and protective factors. This section of the Atlas profiles the prevalence of a range of common diseases, conditions and their risk factors within the NT. Figure 3.1 shows a number of nationally selected diseases and conditions where focussed prevention and management are likely to result in significant improvements in the health of Australia s population. Communities can be supported to reduce the risk factors for these conditions and hence limit the need for use of hospital and ED services. Note There is variability in the available data for chronic disease risk factors across the NT, due to difficulties in the collecting of reliable and sharable data in remote communities. Obesity The prevalence of overweight and obesity in Australia has been steadily increasing over the past 30 years. Recent evidence has found that over 63% of Australian adults and one in four children are overweight or obese. 35 Even modest weight gain in adulthood increases the risk of developing serious illnesses such as type 2 diabetes, cardiovascular disease, high blood pressure and some cancers. Obese people in particular are more likely to suffer a number of chronic conditions, many of which are life limiting. Overweight and obesity is measured at the population level for adults using Body Mass Index (BMI). Studies have found that having a BMI greater than 30, which is the obese category, led to an average of seven years of lost life compared to a person with a healthy weight. Map 3.1 highlights the lack of available data on levels of obesity for people living outside the major urban centres. However where data is available, the level of obesity is significant with every health region's rate above the Australian average (ASR 18.0 per 100). The National Health Survey 36 also shows the obesity rate in the NT (27.9%) to be above the Australian rate (27.2%). Underweight people are a population of concern throughout remote NT which will be discussed in the Aboriginal health section. Type 2 Diabetes Prevalence The rate of type 2 diabetes in the NT is high when compared with other ML populations, ranking fourth out of 61 MLs. Hospitalisations due to diabetes complications increased for both non-aboriginal and Aboriginal people between 1992 and The opportunity is to improve early detection, by targeting populations known to be at risk and focus on optimal treatment and management within the community of those people who already have diabetes. Figure 3.1 National Health Priority Areas - Risk Factors Risk Factor NT Aust Disease or Condition Map 3.1 Rates of Obesity Tobacco Smoking Risky Alcohol consumption Physical Inactivity Poor Diet & Nutrition Excess Body Weight Map 3.2 Type 2 Diabetes Prevalence High Blood Pressure High Blood Cholesterol Age Standardized Ratio (ASR) Per 100 COPD X Asthma X Type 2 diabetes X X X X Kidney disease X X X X X Depression X X X Osteoporosis X X X Deaths ASR Per 100,000 Ischaemic heart disease X X X X X X Stroke X X X X X X X Lung cancer X Colorectal cancer X X X X Source: Risk Factors - AIHW 38, Data (ASR) - PHIDU 8 Hospitalisations Due To Diabetes Complications Separations Per 1000 Population Years Aboriginal Male Non- Aboriginal Aboriginal Female Non- Aboriginal 1992/93 to 1995/ /97 to 1999/ to 2003/ /05 to 2007/ Source: Li et al Population Health Commissioning Atlas

11 Population Health and Profiling [2] Map 3.3 Smoking Map 3.4 Deaths from COPD Map 3.5 Deaths From Lung Cancer Figure 3.2 Cancer Of The Lip Mouth & Pharynx Mortality Health Service District Aboriginal Non- Aboriginal Deaths per 100,000 Darwin Urban 18 7 Darwin Rural 20 6 Katherine East Arnhem 17 0 Barkly Alice Springs Urban 35 3 Alice Springs Rural 4 0 Total - Northern Territory 17 7 Total - Australia 4 Source: 41 Reduce The Impact Preventing the onset of smoking and increasing the numbers of smokers who quit is the single most important strategy to reduce the prevalence of, and deaths from COPD, Lung Cancer and heart disease. Smoking Smoking continues to be Australia s largest preventable cause of death and diseases. It escalates the risk of a number of cancers (especially lung cancer), coronary heart disease, peripheral vascular disease, Chronic Obstructive Pulmonary Disease (COPD) and stroke. There is a strong direct relationship 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 (23.0% compared with 9.9%). Males living in the most disadvantaged group had a particularly high rate of smoking (27.4%). 39 "About half of the smokers who continue to smoke for a prolonged period will die early, half of them in middle age when children and grandchildren depend on them, and while they are in the most productive years of their working lives." 40 The NT had the highest rate of daily smokers (23.7%) followed by Tasmania (20.6%), while the Australian Capital Territory had the lowest rate (12.6%). The Australian national smoking rate has been in steady decline and now sits at 18.2%. 39 Based on 2008 data 8, Map 3.3 highlights the challenges of accessing data for remote NT, however where data is available it indicates smoking rates are higher (average ASR per 100 for NT is 25.3) than the Australian average (20.3 ASR per 100) in all regions. COPD Deaths COPD generally develops later in life and the primary cause is smoking, with the amount smoked and length of time smoking increasing the risk. Map 3.4 shows the deaths from COPD and may indicate smoking is occurring in regions where smoking data is not available as the death rate from COPD is extremely high in parts of the Top End (e.g. East and West Arnhem). Over the past decade hospitalisation rates for COPD have been steadily increasing for the NT Aboriginal population while remaining steady for non-aboriginal Territorians. 37 Smoking and the onset of COPD are a significant concern for the NT given the young age profile of the population. Cancer the PHCAtlas Deaths from lung cancer (Map 3.5) in the NT are significantly higher than for Australia, with the Top End carrying a greater disease burden. Furthermore, trend data indicates higher incidence and mortality rates, particularly for Aboriginal people living in the NT. Cancer of the lip, mouth and pharynx is responsible for a significant number of deaths in the NT. These cancers may be associated with smoking or chewing tobacco. Figure 3.2 highlights the death rates across health service districts and by Aboriginal status. Population Health Commissioning Atlas 11

12 Population Health and Profiling [3] Cancer For all cancers combined, Aboriginal Australians experience higher incidence and mortality rates than non-aboriginal Australians. Incidence and survival rates are lower for people living in remote areas compared with those in major cities, while mortality rates rise with increasing remoteness. As a person's socio-economic status decreases, incidence and mortality rates rise and survival rates from all cancers fall. Risk factors such as being overweight or obese, being physical inactive, having a poor diet and harmful consumption of alcohol all contribute to increased cancer risk. Figure 3.3 shows incidence and mortality for the most common cancers in the NT. Lung cancer stands out as the most common cancer affecting people in the NT and has the highest death rate, significantly above the Australian average. For men, prostate cancer has the highest incidence rate (106 per 100,000 ASR) and is more likely to occur in non-aboriginal males, but results in a relatively low death rate (30 per 100,000 ASR) compared with the Australian rate (38 per 100,000). 42 Breast cancer accounts for over a quarter of all cancers in women in the NT (88 per 100,000) but this is below the Australian incidence rate (111 per 100,000). 42 Cancer Screening Some types of cancer are preventable, while others can be identified early through population screening programs. Participation in cancer screening programs is influenced by a range of factors. Barriers such as remoteness, different cultural backgrounds and low socio-economic status can impact on participation rates. The NT has lower participation rates for all national screening programs compared to Australia. In particular, the NT has the lowest screening rate of any ML for the national bowel screening program. Cancer Mortality Relative to Australia, the NT has lower cancer incidence rates but a higher cancer mortality rate when combining all cancers. Cancer accounts for the greatest proportion of deaths in the NT. Map 3.6 shows the majority of SLAs in the NT have mortality rates above the Australian rate (102.5 per 100,000). For example the Arnhem Land region has cancer death rates 2-3 Reducing Cervical Cancer Investments to increase screening participation across the NT appear to be paying dividends as cervical cancer incidence has decreased by more than 50% for Aboriginal women and 40% for non-aboriginal women between and Mortality has also decreased by about 75% for both groups. 46 times higher than the Australian average. The Arnhem Land region faces a number of challenges associated with poor cancer outcomes, including remoteness, low screening rates and poor socioeconomic indicators. 8 Reducing cancer incidence and mortality requires proactive planning and investments to reduce exposure to risk, increase screening rates and support improved treatment outcomes for patients. Figure 3.3 Selected Cancer Incidence And Mortality Rates ( ) Cancer primary site Trachea, bronchus, lung Incidence % of all cancers in NT NT ASR Per 100,000 Aust ASR Per 100, Breast Cancer primary site Trachea, bronchus, lung Colon and rectum Mortality % of all cancers in NT NT ASR Per 100,000 Aust ASR Per 100, Melanoma Unspecified Colon and rectum Lip, oral, pharynx Breast Unspecified Source: Zhang et al 42 Lip, oral, pharynx Figure 3.4 Cancer Screening Rates Cancer Screening Program Oesophagus and stomach Map 3.6 Deaths From All Cancers (0-74 Years Old) National Health Performance Authority - Peer Group (Rural 2) NT Kimberly Pilbara ML 8 Goldfields- Midwest ML 8 Far North Queensland ML 8 Central & North West QLD ML 8 Australia Bowel 24.0% % 34.8% 34.3% 26.7% 38.4% 43 Breast 40.4% % 53.5% 60.3% 57.2% 54.9% 44 Cervical 54.5% % 52.1% 60.6% 51.8% 57.4% 45 Source: as indicated by superscript in table 12 Population Health Commissioning Atlas

13 Population Health and Profiling [4] Map 3.7 Psychological Distress Map 3.8 Deaths From Suicide/Self Inflicted Injury (0-74 Years) Figure 3.5 GP Mental Health Plans 2012 Source : Medicare Australia 49 Figure 3.6 Mental Health Related Hospitalisations Without Specialised Psychiatric Care State/Territory New South Wales Hospitalisations per 1,000 population Patient days per 1,000 population Victoria Queensland Western Australia South Australia Tasmania ACT Northern Territory Australia Source : AIHW 48 Mental Health Psychological distress is an indicator of the mental health of a community, and is considered the best population-wide measure currently available. 47 Map 3.7 shows that within the urban centres, levels of psychological distress are generally below or equivalent to the Australian average (11.7 per 100). Treatment rates for mental illness is another indicator of the mental health of a community. Data from AIHW indicates that the NT has the highest rate of people receiving clinical mental health services (2.7 per 100 population) compared to Australia (1.8 per 100). The rates for remote (2.8 per 100) and very remote (3.3 per 100) are also high and only surpassed by NSW rates (3.3 and 5.2 respectively). 47 Other data such as hospitalisations for depression amongst other mental disorders 37 and the suicide rate clearly suggest that mental health is an area of concern across the whole NT. Suicide & Self Inflicted Injury Map 3.8 shows variations in the rates of deaths from suicide or self inflicted injury across the NT, with some remote regions having very high rates Tiwi Islands (68.9 per 100,000), Victoria- Daly (48.9), Tennant Creek (36.8) and MacDonnell (35.7) compared with the Australian average (12.3 per 100,000). The completed suicide rate in the NT, which is 60% above the national average highlights great social and health needs in the region. The impact across the NT of isolation, remoteness, seasonal conditions and transient populations may result in reduced social networks and social support, which are known to be protective factors for maintaining positive mental health. Importantly, governments and agencies across the NT well recognise the problems associated with mental health and recently increased investments in services and programs to improve outcomes. GP Mental Health Care Plans GP Mental Health Plans are a requirement for patient referrals to short-term psychological interventions (e.g. CBT) under the Medicare funded ATAPS Programs. Figure 3.5 indicates that the preparation of GP Mental Health Plans in the NT is significantly below the Australian average of 150 per 10,000 people. The NT is recognised for having a strong network of AMS (including both Aboriginal Community Controlled Heath Services (ACCHS) and NT Health Primary Health Centres (PHC)) which provide a range of health services, including mental health services to Aboriginal people living in both urban and remote areas. Medicare item numbers are not routinely claimed within AMS, this along with the use of occupational health services by some of the population may explain the low numbers of GP Mental Health Plans. Figure 3.6 details mental health related hospitalisation rates where specialised psychiatric care was not provided, comparing the NT with other states. 48 There is extremely limited inpatient facilities across the NT with less than 50 mental health beds available, with no facilities available in remote areas. 49 the PHCAtlas Population Health Commissioning Atlas 13

14 Population Health and Profiling [5] Risk Taking Behaviours Adolescence and young adulthood are well recognised as a time when people are more likely to begin and engage in risk taking and unhealthy behaviours (e.g. smoking, consuming alcohol at unsafe levels, practicing unsafe sex and unsafe driving), and many of these behaviours will persist through later life. Social patterning of individual health behaviours are intimately linked with poverty and social disadvantage. Engaging in unhealthy behaviours is also thought to occur in response to social circumstances rather than individual poor decision making. 5,50 Harmful Alcohol Use Harmful alcohol use in the NT is a major concern. Approximately 34.5% of people drink at levels that put them at risk of long term harm (NHMRC 2009 guidelines) compared to the Australian average of 29.1%. 36 The NT levels are likely to be understated due to the difficulty in gathering survey data from remote areas. Interestingly, Map 3.9 (2008 data) shows a significant difference in the level of harmful alcohol consumption between Darwin and Alice Springs. The population of Darwin had a harmful alcohol consumption rate higher than the Australian average (5.4 per 100) whereas Alice Springs consumption rates were below the Australian average. Only Stuart (5.8 per 100) recorded higher rates than the Australian average. This may be associated with different alcohol licensing regulations operating between the two cities at that time (2008). From , Tennant Creek was regarded as having the highest alcohol consumption in Australia (15.8L per person of pure alcohol a year compared to 9.8L for Australia) which has led to the introduction of an Alcohol Management Plan in the region. 51 Sexually Transmitted Infections The number of notifications in the NT for sexually transmitted infections (including Chlamydia, Gonorrhoea and Syphilis) is of concern. This high rate points to unsafe sexual behaviour which places the individual and local populations at risk of increasing rates of STI infections. Figure 3.7 indicates STI rates in the NT are well above the Australian average, for both the Aboriginal and non-aboriginal populations. Note also, research suggests there is a relationship between alcohol consumption and sexual activity which leads to increased STI rates. 52 Road Accident Fatalities The NT consistently has higher death rates as a result of road traffic accidents compared to Australia. Map 3.10 shows rates in central Australia are ten times the Australian average. Data suggests most of the deaths occur in single vehicle accidents; and death rates have recently increased in the NT. 55 Alcohol consumption is considered a risk factor in motor vehicle accidents and the proportion of serious crashes involving alcohol has also been found to increase with an increasing level of remoteness. 56 In 2010 the greatest proportion of fatal crashes (47%) occurred on roads where the posted speed limit was 100km/h and above. 55 Declining Rates Until 2006 the notifications for syphilis were trending upwards and were higher than in other states and territories (71 per 100,000 in NT, 4.3 per 100,000 for Australia). The rate of syphilis notifications has improved significantly since 2006, decreasing by 80% to 13.9 per 100,000 in A major achievement. Map 3.9 Harmful Alcohol Consumption Figure 3.7 STI Notification Rate By State And Territory Per 100,000 population NSW Vic Qld SA WA Tas ACT NT Aust Chlamydia Gonorrhoea Syphilis HIV (note: 2010 data) Source: NNDSS Map 3.10 Deaths From Road Accidents 14 Population Health Commissioning Atlas

15 Population Health and Profiling [6] Map 3.11 Volunteering Figure 3.8 Households Who Could Raise $2000 Within A Week Persons aged 18 years and over whose household could raise $2,000 within a week ASR Per 100 Map 3.12 Dwellings With Internet Access Persons aged 18 years and over whose household could raise $2,000 within a week ASR Per 100 Litchfield (M) - Pt A 97.1 Darwin North West 84.5 Alice Springs (T) - Ross 94.0 Palmerston 83.7 West Arnhem (S) - Jabiru 89.6 Alice Springs (T) - Heavitree 82.9 Darwin South West 89.0 Alice Springs (T) - Charles 82.6 Litchfield (M) - Pt B 87.9 Katherine (T) 81.7 Darwin North East 86.9 Alice Springs (T) - Stuart 77.5 Alice Springs (T) - Larapinta 85.2 Coomalie (S) 74.8 Australia 83.3 Social Capital The quantity and quality of social relationships (e.g. informal and formal connections and norms of reciprocity and trust that exist in a place or community) can provide protection against adverse social and environmental conditions. These relationships and networks are often captured under the concept of social capital which is defined by Robert Putman as the features of social organisations such as networks, norms and trust that facilitates action and cooperation for mutual benefit. 57 This page describes a number of factors that are considered to contribute to the social capital of a community. Volunteering Forms of social participation such as volunteering can benefit individuals and communities in a range of areas including social inclusion, reduced crime, better education outcomes and improved health and wellbeing. 58 The level of volunteering across the NT (16.6%) while below the national average (17.8%) is encouraging given the remoteness, level of opportunity and disadvantage across the region. Interestingly a number of communities have volunteering rates substantially above the national average and these include Nhulunbuy (27.8%), Alyangula (23.0) and most of the SLAs in Alice Springs (see Map 3.11). Community Support Indicators of financial stress, such as being able to raise $2000 within a week in a time of emergency give an insight in to the economic wellbeing of a community and demonstrates access to a strong well resourced network that can act as a support in difficult times. The reporting of financial stress does not necessarily imply that a household has low income. In the NT the ability to raise $2000 quickly varies across the region (Figure 3.8). For example people living in Litchfield (Part A) find it easier to access funds (97.1 ASR per 100) than the general Australian rate (83.3). In contrast to this people living in other areas such as Coomalie (74.8) find it more difficult. There is limited data available for very remote areas (where the figures are likely to be very different) with a majority of the population unable to raise $2000 quickly. Internet Access the PHCAtlas Having internet access available in the home enables access to a range of Feeling Safe resources which can connect people The NT has the and their community. It is a means of highest rate communicating with friends and family, when compared and access to information, resources and to all other MLs government, public and private services. for people feeling unsafe Map 3.12 shows there is an urban/remote to walk alone around divide in the NT for internet access, and a their neighbourhood at number of urban areas have access at a night. This is a problem for all areas where data is level higher than the Australian average available. (76.8%). 8 In most of the very remote areas, internet access rates are between 30-50% which is encouraging given the distance and sparsity of the population. Smart phones and mobile coverage have had a large impact on rural populations' ability to access the internet. Due to lack of facilities and high costs, land based and satellite connections are challenging in remote areas. Population Health Commissioning Atlas 15

16 GP Practice Location and Attendance Data GP Practices Primary health care services across the NT are provided in a variety of settings including private GP practices, Aboriginal Medical Services/Community Health Services, Workplace Health Services and in hospital outpatient clinics. GPs are likely to work across all of these service settings. Map 4.1 shows the availability of private GPs across the NT. Workplace GP Services have a focus on occupational health by providing medical checks for workers. ACCHS and PHCs, while staffed to address the needs of the local resident population can be required to respond to mobile travelling populations in the region seeking medical care. Many doctors work in isolated communities where the social and environmental contributors to ill health are frequently challenging. The responsibilities of health practitioners often broaden from individual patients and families to entire communities. All these factors make medical practice in the NT unique and challenging, combining individual and community care. A key concern for the NTML is building an integrated and comprehensive primary health care network when the health workforce is transient. This can result in 1) reduced professional support networks, 2) practitioners who are unfamiliar with the region's complex health needs and 3) reduced utilisation of available chronic disease prevention and management systems. This is further explored in the workforce section. GP Attendance Data GP Attendance Data (Figure 4.1) from Medicare for the NT shows that the percentage of Level C and D consults are higher than the Australian averages indicating that GPs are seeing more people with complex or chronic health problems or are being opportunistic when they do consult. 59 Though consults are on average longer, there are fewer consultations per person per year (Figure 4.2). There is a proportion of the population who only access GPs in an ACCHS or PHC; MBS items may not always be routinely claimed in these settings. Note: These consultations are not represented in this data. It is also likely that some people in the NT are not accessing primary health care services when needed (e.g. to prevent or detect chronic disease early). GPs and RACFs ehealth There are 15 Residential Aged Care Facilities (RACF) in the NT which may reflect the young age profile of the population and the low numbers of people aged 65 plus. The low level of GP consults per RACF bed per year in the NT (Figure 4.3) raises the question of who provides the clinical care (i.e. is it delegated to nurses?). Six of the RACF sites are in very remote locations which is likely to make it difficult for GPs to provide regular consults. 59 Telehealth may provide better access to GPs (and specialists) through RACFs, provided it is adequately funded. Map 4.1 Private GP Locations (by postcode) Source: NTML 60 The NT has one of the most advanced electronic healthcare record programs in Australia, extending coverage to a highly mobile, widely dispersed and largely indigenous population. The Territory s My ehealth Record (MeHR) in many ways has pioneered the concept of a shared electronic healthcare record in Australia, allowing clinicians to access a patient s record regardless of where they live, where they have travelled to, or where they last sought treatment. The MeHR is in the process of being transitioned towards the national Personally Controlled Electronic Health Record (PCEHR) rollout in the NT. 61 Figure 4.1 GP Consultations In Consulting Rooms (2012) Figure 4.2 GP Consults Per Person Per Year In Rooms Source: Medicare Australia 59. Note: Numbers may not add up to 100% due to rounding Figure 4.3 GP Consults Per RACF Bed Per Year Source: Medicare Australia 59 Source: Medicare Australia Population Health Commissioning Atlas

17 Preventable Hospital Admissons and Premature Death Figure 4.4 Potentially Preventable Hospital Admissions By Condition Acute Conditions Chronic Conditions Cellulitis 818 Diabetes complications 1,277 Convulsions and epilepsy 797 COPD 1,169 Dental conditons 763 Congestive cardiac failure 540 Pyelonephiritis 760 Asthma 448 Ear, nose and throat infection 728 Angina 372 Dehydration and gastroenteritis 675 Rheumatic heart disease 208 Total per 1,000 People 23.0 Total per 1,000 People 23.4 Australian Comparison 14.9 Australian Comparison 13.0 Source: 62 Map 4.2 Ischaemic Heart Disease Deaths Source:: PHIDU 8 Map 4.3 Premature Mortality Potentially Preventable Hospitalisations Potentially Preventable Hospitalisations (PPH) have been defined as those hospitalisations which could have been avoided with access to quality primary care and prevention strategies. Acute conditions still pose a significant risk in the NT with the top 3 PPH for acute conditions being cellulitis, epilepsy and dental conditions. Interestingly vaccine preventable conditions (3.1 per 1,000) are more than 3 times higher than the Australian average (0.8 per 1000) and may reflect limited access to services, low vaccination rates in the past and adverse seasonal and environmental conditions. 62 The top two chronic PPH admissions identified (Figure 4.4) for the NT are diabetes complications and COPD. The risk factors for diabetes are physical inactivity, poor nutrition and excess body weight while for COPD the key (but not only) risk factor is smoking. IHD Deaths Ischaemic heart disease (IHD) is a disease characterised by reduced blood supply to heart muscle tissue, usually due to coronary artery disease. IHD risk increases with age, smoking, high cholesterol levels, diabetes and hypertension. Patients with IHD need close monitoring by primary care teams, risk factor management and exercise programs. The NT ranks third worst in the country for deaths from IHD deaths with rates of 55.7 per 100,000 people, twice the Australian rate of 27.9 per 100, Map 4.2 shows almost all of the remote/very remote SLAs in the NT having rates of IHD deaths well above the Australian average, likely to be due to limited access to hospitals for timely treatment. Premature Mortality Premature mortality refers to deaths which occur at a younger age than expected and can be measured by potential years of life lost (PYLL). PYLL highlights deaths that occur at younger ages as it counts the number of years of life lost for each death before the age of 75. It can be used as an indicator of the social and economic impact of premature mortality and therefore used in setting public health priorities. 63 Map 4.3 shows variation across the NT for premature mortality, and suggests that urban centres have better outcomes when compared with remote regions. Importantly and despite this variation, the entire region is above the Australian average (244.5 per 100,000) reflecting the negative impact of social and economic factors on population health outcomes. the PHCAtlas Population Health Commissioning Atlas 17

18 NTML Health Domains and Medicare Local Data Benchmarking DOMAIN (A) - Aboriginal, (NA) - non-aboriginal INDICATOR ML KPI ML Median ML Range NTML Result NTML Rank (1-61) Highest Need ML Quintile Range Med-Hi Medium Need Med- Low Lowest Need SLA Range GP MBS Utilisation (Consults Per Year Person) No Data GP Services Waiting Times (Between 4-24Hrs) % 8-28% 18% 37 No Data ACCESS UTILISATION LIFESTYLE 1 PREVENTION GP After Hours Service Utilisation No Data Specialist Service Utilisation % 22-42% 25% 58 No Data Primary Care Type ED Attendances (Category 4 & 5) CAT4=54.2% CAT5=9.1% Selected Potentially Avoidable Hospitalisations No Data 38% Allied Health Utilisation (Services / Person) No data No data Community Health Services Waiting Times No data No data Smoking Prevalence (18 Years And Over) (ASR per 100) Overweight Prevalence - Males (ASR per 100) Overweight Prevalence - Females (ASR per 100) Obesity Prevalence - Males (ASR per 100) Obesity Prevalence - Females (ASR per 100) Alcohol Use / Abuse (ASR per 100) Nil Physical Inactivity (ASR per 100) Nil Prevalence Diabetes (ASR per 100) Prevalence COPD (ASR per 100) Nil CDM 2 PREVENTION Death Rate COPD (ASR per 100,000) Nil Death Rate IHD (ASR per 100,000) Nil Incidence IHD (per 1000 people) No data Incidence End Stage Kidney Disease (Per 1000) No data Males 14.1(A) 5.7(NA) GP MBS Diabetic Annual Care Plan (SIP Services) No data 1460 GP MBS Asthma Care Plan (SIP Services) No data 122 Females 9.1(A) 3.3(NA) Males Females 1.5(A) 0.4(NA) 1.2(A) 0.2(NA) Screening Participation Breast Cancer (%) % % 40.4% N/A No Data SCREENING CHILD HEALTH MENTAL HEALTH Incidence of Breast Cancer (rate/100,000) N/A 5 Year Survival Breast Cancer (%) No data 75.3 (A) 85.9(NA) Death Rate Breast Cancer (Rate/100,000) Nil No data 17.6 Screening Participation Bowel Cancer (%) NBCSP Positive test result (ASR per 100) Year Survival Bowel Cancer (%) No data Death Rate Bowel Cancer (ASR/100,000) Nil (A) 55 (NA) Screening Participation Cervical Cancer (%) N/A Incidence of Cervical Cancer (rate/100,000) No Data 5 Year Survival Cervical Cancer (%) No data 39.4(A) 86.3(NA) Death Rate Cervical Cancer ( Rate/100,000) Nil No data 3.4 overall Estimated Life Expectancy At Birth No data Males = 74.7 Females = 80.0 Infant / Young Child Mortality (Rate/100,000) Proportion Babies Low Birth Weight (%) % 49** Vaccination rates for Children (%) No. Women With One Antenatal appt 1st Trimester No data 69.9% 4 Yr Old Development Check (Claims) No data 598 Completed Suicide Rate (rate/100,000) Nil Prevalence of Depression (ASR per 100) Nil Population receiving MH Care (%) No data Child/Young use Primary MH care No data 463 No Data No Data Proportion aged 85+(%) Nil RACF AGED Aged care beds/pop. 70+ years (total care places/1,000) RACF GP services utilisation (services/1000 residents) Prevalence of Dementia (per 10,000) Nil No data Population Health Commissioning Atlas

19 NTML Health Domains and Medicare Local Data Benchmarking COMMENTS GP Attendances per person Self reported: percentage of adults who felt they waited longer than acceptable for a GP appointment Average number of after-hours GP attendances per person, Percentage of adults who saw a medical specialist in the preceding 12 months, by Medicare Local catchments, Cat 4 and 5 attendances 65 Potentially Avoidable Hospitalisations 65 NO DATA NO DATA Current smokers (synthetic prediction), persons 18 years and over ( ) 8 Overweight (not obese) males (synthetic prediction), 18 years and over ( ) 8 Overweight (not obese) women (synthetic prediction), 18 years and over ( ) 8 Obese males (synthetic prediction), 18 years and over ( ) 8 Obese females (synthetic prediction), 18 years and over ( ) 8 Alcohol levels considered high risk to health (synthetic prediction), persons aged 18 years and over ( ) 8 Physical inactivity (synthetic prediction), persons aged 15 years and over ( ) 8 Type 2 diabetes (synthetic prediction) ( ) 8 Chronic Obstructive Pulmonary Disease (synthetic prediction)( ) 8 Deaths from COPD, 45 to 74 years ( ) ave annual ASR/100,000 8 Deaths from IHD, 0 to 74 years ( ) ave annual ASR/100,000 8 Ischaemic heart disease separations per 1000 population (ICD , ICD-10 I20-I25) 37 Renal failure separations per 1000 population (ICD , ICD-10 N17-N19) 37 A18 GP attendance associated with PIP incentive payments 2) Completion of an annual cycle of care for patients with diabetes mellitus 49 A18 GP attendance associated with PIP incentive payments 3) Completion of the asthma cycle of care 49 AIHW, BreastScreen Australia monitoring report and Equivalent ranking shown (Quintile of Highest Need) Table 4 Cancer of the breast, incidence and mortality, by Indigenous status and period, NT Equivalent ranking shown (Quintile of Highest Need) Table 8 Cancer of the breast, survival rate, by Indigenous status and period, NT Table 4 Cancer of the breast, incidence and mortality, by Indigenous status and period, NT (A), 15.6 (NA) 2010 National Bowel Cancer Screening Program participation percentage National Bowel Cancer Screening Program: positive test result per 100 (2010) 8 Table 8 Incidence and mortality for cancer of colon and rectum, by sex and Indigenous status, per100,000 (57NA, 19A Overall 47) 41 Table 3 Cancer of colon and rectum, Avoidable Mortality as a result of colorectal cancer, 0-74 years ( ) 8 Table 8 Incidence and mortality for cancer of colon and rectum, by sex and Indigenous status, per100,000 (57NA, 19A Overall 47) 41 AIHW Cervical screening in Australia Equivalent ranking shown (Quintile of Highest Need) Table 10 Cancer of the cervix, incidence and mortality by Indigenous status and period,nt (A) 9.6(NA) Table 14 Cancer of the cervix, survival rate, by Indigenous status and period, NT Table 10 Cancer of the cervix, incidence and mortality by Indigenous status and period, ABS 14 Note: Increase of 4 years over the past decade for both males and females from 2001 Child mortality(<5yrs) ( ) Rate average annual rate per 100,000 8 Percentage low birth weight babies ( ) 8 ** out of 50 MLs with data (QLD not included) Immunisation status of children 2008 (12-15 months 8 NHPA 2011/ % Table 16. Gestation at first antenatal visit, by Indigenous status, NT mothers with at least one visit, (A) 81.0(NA) 67 NT Medicare claims against 701 for 0-4 year olds 45 MBS Item # 701 (104), 703 (354), 705 (122), 707 (18) Premature mortality by cause - Deaths from suicide and self-inflicted injuries, 0 to 74 years ( ) Average annual rate per 100,000 8 High/very high psychological distress levels (syn. prediction), >18 years and over ( ) 8 Note: Kessler Psychological Distress Scale-10 - two highest levels Better Access Program: Preparation of Mental Health Care Plan by GPs 8 10,247 claims under A20 GP Mental Health Treatment (1 GP Mental Health Care plans) 45 Medicare claims 2012 against MBS items for ages MBS Item # 2700 (82), 2701 (25), 2712 (28), 2713 (129), 2715 (134), 2717 (64) and 2719 (1) Persons 85 yrs and over (2010) 8 Residential aged care places - Total residential care places per 1,000 8 Average number of GP attendances in residential aged-care facilities per patient who received at least one GP attendance in a facility, by Medicare Local catchments, Access Economics - Dementia Across Australia: Note report is likely to significantly underestimate the true prevalence of dementia in the NT. Absolute number 838 (Deloitte Access Economics) the PHCAtlas Population Health Commissioning Atlas 19

20 Indicator Analysis DOMAIN Highlights and Observations ACCESS UTILISATION Available data indicates challenges with service access and utilisation for the NT population when rated against other Medicare Locals. The National Health Performance Authority s - Healthy Communities Report , found that 1) GP attendance rates, 2) GP after-hours attendance rates and 3) Utilisation of specialist service rank the NT in the lowest quintile for service utilisation despite being a population of high need. Analysis of MBS and PBS data 69,70, indicates PHC service utilisation rates are significantly lower than the rest of Australia. This does not align with the high levels of chronic disease 71 and disadvantage in the NT. However, the more extensive use of longer consults, given the complex chronic disease burden may address this. In addition, issues of access are exacerbated by remoteness, seasonal factors, transient populations and challenges associated with navigating the health system. Challenges in assessing access and utilisation include: 1) Multiple providers deliver primary care services 2) Available data sets, e.g. ACCHS, NT Government Primary Health Centres, CHS, ED, NGOs, industry medical services and private GP clinics. To fully determine the scope and extent of access, one utilisation dedicated modelling and predictive analysis would be required based on purpose built data sets. LIFESTYLE 1 PREVENTION CDM 2 PREVENTION The presence of risk factors for chronic disease indicates a need for individuals and communities to be supported to improve this situation through universal and targeted prevention and management. Good nutrition and an adequate daily intake of fruit and vegetables are important protective factors in the prevention of chronic disease. 38,72 However access to affordable fresh fruit and vegetables is an issue for a number of communities in particular those living in remote areas. Freight costs to these remote areas are thought to be a key factor. 73 The National Health Survey ( ) 36 supports the findings in the PHIDU data and shows that shows 23.8% of the NT population smokes compared to the Australian population (18.2%). Smoking rates, including smoking during pregnancy, are higher within the Aboriginal population and the causes and implications of this are discussed in further detail in the Aboriginal Health section of this Atlas. The rates of obesity in the Northern Territory like the rest of Australia are increasing. Currently 27.9% of the NT population is considered to be obese which is close to the Australia average (27.2%). 39 Harmful alcohol use in the Northern Territory is of major concern with 23.5% of people drinking at levels that put them at risk of long term harm (NHMRC 2009 guidelines), which compares poorly against the Australia average of 18.6%. 39 These levels are likely to be understated due to the challenges gathering survey data from remote areas. The high rate of chronic disease in the NT links to the high exposure to risk factors, as described above, demonstrating a need to improve detection and optimise treatment and management in primary care. There is a high prevalence of type 2 diabetes and the NT is ranked in the highest quintile for all Medicare Locals with hospitalisations associated with the complications of diabetes increasing for both non-aboriginal and Aboriginal populations. While the prevalence rate for COPD is in the second lowest quintile for all Medicare Locals, the death rate from COPD is the worst in the country. It is likely that COPD is under diagnosed in the NT and programs to improve detection and management to limit disease progression are required. The death rate from IHD is also in the highest quintile when compared to other Medicare Locals with the NT ranking third worst in the country for deaths from IHD with rates of 55.7 per 100,000 people, which is twice the Australian rate of 27.8 per 100,000. The NT has the highest incidence and prevalence of End Stage Kidney Disease (ESKD) in Australia. 74 SCREENING The NT has low participation rates for all screening programs with participation in the national bowel cancer screening program being at the lowest in Australia. The low rate (24%) of bowel cancer screening participation is of major concern as the NT has one of the worst death rates from bowel cancer. There is a much higher prevalence of bowel cancer in the non-aboriginal population with incidence rates of 60 per 100,000 for non-aboriginal people while only 16 per 100,000 Aboriginal people. 42 The death rate from bowel cancer is also weighted towards non-aboriginal population with rates of 27 per 100,000 compared to 8 for the Aboriginal population. Cervical screening participation is lower for NT women than for Australian women generally, 55% in the NT compared with 61.2% nationally in Despite the apparent poor participation rate, screening rates have been increasing, and as a result cervical cancer incidence has decreased by more than 50% for Aboriginal women and 40% for non-aboriginal women between and Incidence rates may have also reduced due to the HPV immunisation programs for girls and now boys across Australia. Mortality has also decreased by about 75% for both groups. 45 Cervical cancer incidence and mortality rates remain much higher for Aboriginal than non-aboriginal women; screening participation needs to increase for Aboriginal women to further reduce incidence and mortality. 45 The incidence of breast cancer is almost twice as high for non-aboriginal women (98.9 per 100,000) compared to Aboriginal women (53.1 per 100,000), while the Australian average was per 100,000 in CHILD HEALTH The Healthy Communities report by the National Health Performance Authority on immunisation rates for 2011/ indicates that the NT is performing at the national average for children immunised (91.8%). When looking at the Aboriginal population the NT ranks as 7th overall in Australia with 90.3% of Aboriginal children immunised at 1 year. The NT has the worst rate of child mortality in Australia and has twice as many deaths as the Australian average. There has however been a 35% drop in the Aboriginal infant mortality rate between 1997 and 2005 which has helped to lift the life expectancy at birth for Territorians. 74 The NT has the second highest rate of low birth weight babies in Australia which can be linked to the high rates of smoking during pregnancy and lack of access to the healthy food options, particularly in the remote areas. There is a large disparity between Aboriginal (13.8 per 100) and non-aboriginal (5.5 per 100) babies with low birth weight in the region. 75 MENTAL HEALTH RACF AGED Mental health is a very difficult area in which to perform quantitative analysis, as one of the few reliable indicators is completed suicide. The NT ranks third highest for completed suicide when compared with other MLs with a suicide rate 60% above national average. The NT is the second lowest ranked ML in terms of accessing mental health plans by a GP, 60% below the average for Australia. Hospitalisation for mental health issues for non-aboriginal people has remained steady over the past 20 years, but has been increasing for Aboriginal people. This may be related to better identification of mental health issues in the Aboriginal communities. 37 The NT only has three percent of its population aged 85 and over, placing it as the second lowest in Australia. Over time the proportion of the population over 85 is projected to increase modestly, but absolute numbers will remain fairly low. NT ranks as having one of the highest proportion of aged care beds per 70+ population. The average number of attendances of a GP in a RACF ranks as the lowest in Australia and is an area that could be improved by the NTML (e.g. via the use of telehealth services). Increasing primary care services to the over 65 population may reduce the burden on more expensive tertiary admissions. 20 Population Health Commissioning Atlas

21 Population Health Commissioning Atlas Aboriginal Health Section B: Understanding Aboriginal health and wellbeing in the Northern Territory "In Aboriginal culture, health is defined as the social, emotional and cultural wellbeing of the whole community and the concept is therefore linked to the sense of being Indigenous" 76 the PHCAtlas Population Health Commissioning Atlas 21

22 Section B Contents 22 Introduction and Determinants of Aboriginal Health 24 Aboriginal Key Performance Indicators (KPI) Matrix 26 Social Determinants of Aboriginal Health Aboriginal Population Health & Profiling 27 Maternal and Child Health 28 The Early Years 29 Chronic Disease 30 Infectious Disease 31 Alcohol and Injury Aboriginal Health Introduction Section A of this Atlas provides a comprehensive picture of the health and wellbeing of those living in the Northern Territory, service utilisation and the determinants impacting on outcomes. It includes some information on Aboriginal residents. Section B goes into more detail, focusing on specific indicators widely used to measure Aboriginal health and highlighting particular needs. Determinants of Aboriginal Health The poorer health status of Aboriginal people in the NT is influence by a number of additional social determinants. Diminished self determination, connectedness to family, land, culture and identity all present additional challenges for individuals, communities and governments in achieving better health outcomes and closing the gap between Aboriginal and non-aboriginal health and wellbeing outcomes. The 2011 census showed 29.8% of the people living in the Northern Territory identify as Aboriginal, a much higher proportion of the overall population than in other jurisdictions. The social and economic disadvantage that Aboriginal people experience significantly impacts on poorer health outcomes for adults and children including a higher burden of disease and lower life expectancy when compared with non-aboriginal people. 4 Figure 5.1 highlights the range of determinants and the central role that families, communities and Aboriginal culture play in creating an individual's health and wellbeing. Factors including poverty, dispossession and discrimination have a significant impact and racism and prejudice exacerbate the disadvantage experienced by Aboriginal people marginalising many from social and community life, contributing to loss of identity and low self esteem particularly for young Aboriginal people. For some, this disadvantage is further compounded by geography, climate and the impacts of living in remote regions. Due to their history of colonisation and ongoing racism, if a health service is not culturally safe Aboriginal people are likely to avoid that service. The health disadvantage experienced by Aboriginal people can be considered historical in origin but perpetuation of the disadvantages owes much to contemporary structural and social factors embodied in what have been termed the Social Determinants of Health 76 It is important to understand how Aboriginal people conceptualise and value health. Health encompasses everything important in a person s life, including land, environment, physical body, spirituality, community, relationships and law. These factors need to be recognised and taken into account when agencies are developing policies and strategies aimed to improve the health and social circumstances of Aboriginal communities. Health systems need to systematically move beyond a disease focussed approach towards a whole of person, whole of community approach. Figure 5.1 Social Determinants of Aboriginal Health Adapted from Dahlgren & Whithead 4 by Healthfirst Network 22 Population Health Commissioning Atlas

23 Indicators of Aboriginal Health Status Figure 5.2 Health Service District Aboriginal vs non-aboriginal Populations Populations There are 641 distinct Aboriginal communities in the Northern Territory, 570 of which have populations of less than 200 people and 50 communities with populations ranging between 200 and 1,000 people. 77 Data on the Aboriginal population is difficult to obtain at SLA level. This section of the Atlas contains data and maps showing the 7 NT Health Service District levels. Figure 5.2 and the table below show the populations of the Heath Service Districts and the proportion of the population that is Aboriginal. Health Service Districts Populations Health Service District Aboriginal non-aboriginal Total Population Darwin Urban 14, , ,725 Darwin Rural 12,211 4,784 16,995 NT Aboriginal Health Performance Indicators Domain 1 - Health Services 1. Episodes of health care 7. Chronic disease management plans 2. Timing of first antenatal visit 8. Type II Diabetics - HbA1c in last 6 months 3. Number of low, normal and high birth weight babies 9. Diabetic with albuminuria on ACE or ARB 4. Number of children fully immunised 10. Number of adult health checks East Arnhem 10,733 6,223 16,956 Katherine 10,757 9,417 20,174 Barkly 4,315 2,362 6,677 Alice Springs Urban 6,119 22,973 29,092 Alice Springs Rural 11,475 2,768 14, Number of underweight children < Number of 55+ adult health checks 6. Number of anaemic children Source: NT Aboriginal Health Forum 78 Aboriginal Health Performance Framework Tier 1 - Health Status and Outcomes Health Conditions 1.13 Community functioning 1.01 Low birth weight 1.14 Disability 1.02 Top reasons for hospitalisations 1.03 Injury and poisoning 1.04 Respiratory disease 1.05 Circulatory disease 1.06 Acute rheumatic fever and rheumatic heart disease 1.07 High blood pressure 1.15 Ear health 1.16 Eye health 1.08 Cancer Deaths 1.09 Diabetes Life Expectancy and wellbeing 1.17 Perceived health status 1.18 Social and emotional wellbeing 1.19 Life expectancy at birth 1.20 Infant and child mortality 1.10 Kidney disease 1.21 Perinatal mortality 1.11 Oral health 1.12 HIV/AIDS, hepatitis and sexually transmissible infections Human Function.Source: AHMAC All causes agestandardised death rates 1.23 Leading causes of mortality 1.24 Avoidable and preventable deaths 12. Number of women with at least 1 pap smear Aboriginal Health Performance Framework Tier 2 - Determinants of Health Environmental Factors 2.12 Child protection 2.01 Housing 2.13 Transport 2.02 Access to functional housing with 2.14 Access to utilities traditional lands 2.03 Environmental tobacco smoke Socio-Economic Factors 2.04 Literacy and numeracy 2.05 Education outcomes for young people 2.06 Educational participation and attainment of adults Health Behaviours 2.15 Tobacco use 2.16 Risky alcohol consumption 2.17 Drug and other substance use 2.18 Physical inactivity 2.07 Employment 2.19 Dietary behaviour 2.08 Income 2.09 Index of disadvantage Community Capacity 2.10 Community safety 2.11 Contact with criminal justice system 2.20 Breast feeding practices 2.21 Health behaviours during pregnancy Person-related Factors 2.22 Overweight and obesity Indicators of Aboriginal Health Status The matrix on the following pages is used to display data relevant to the key performance indicators of Aboriginal health status and includes indicators from the Aboriginal and Torres Strait Islander Health Performance Framework (2012) 4 and the NT Aboriginal Health Key Performance Indicators 78. the PHCAtlas These indicators are shown on this page and have been developed to monitor progress in Aboriginal and Torres Strait Islander health outcomes, health system performance and broader determinants of health and to provide information to support health services in planning activities and in contributing to evidence based reporting requirements. There is a level of alignment between the two sets of indicators in particular for maternal and child health outcomes. The Commonwealth Department of Health s framework provides a broad whole of system set of performance measures, while the NT has developed 12 locally relevant and targeted measures. Population Health Commissioning Atlas 23

24 Aboriginal KPIs - Northern Territory and National Performance Framework INDICATOR KPI NT RESULT Episodes of Health Care and Client Contacts NTAHKPI Episodes of care per population 10 First Antenatal Visit NTAHKPI 1.2/ AHMAC % Birth Weight NTAHKPI 1.3/ AHMAC % Fully Immunised Children NTAHKPI 1.4/ AHMAC % Underweight Children NTAHKPI % Anaemic Children NTAHKPI % Chronic Disease Management Plan NTAHKPI 1.7/ AHMAC 3.18 HbA1c Tests NTAHKPI % NTML Needs Assessment ACE Inhibitor and/or ARB NTAHKPI % NTML Needs Assessment Adult aged Health Check NTAHKPI Medicare Item (ages 15-54) Adult aged 55 and over Health Check NTAHKPI Medicare Item (ages 55+) Pap Smear Tests NTAHKPI % NTML Needs Assessment Top reasons for hospitalisations AHMAC 1.02 Injury and Poisoning AHMAC Respiratory Disease AHMAC M, 59F Circulatory Disease AHMAC Acute rheumatic fever and rheumatic heart disease AHMAC COMMENTS 45.1% first trimester in 2007, 96.5% attended in % of indigenous women attended at least one antenatal visit 4 Low Birth Weight In LBW = 14.0%, NBW = 79.0% and HBW = 7.1% 67 1 year, 2 years, 5 years in 2011/ , 96.3 and 90.7 in Proportion (%) of Indigenous children aged less than 5 years with growth impairment, by growth measure and region, rural and remote Northern Territory, 2007 underweight and wasted % in % in MBS item for the provision of monitoring and support to people with a chronic disease by a practice nurse or registered Aboriginal Health Worker on behalf of a GP (July 2012-June 2013) 59 Renal dialysis followed by for Males - Respiratory (17.2%), Injury (16.0%), Females Pregnancy related (23.8%), Respiratory (11.1%) and Injury (10.7%) per (68.0 M, 61.8 F) injury and poisoning An increase from 2008 where M 57.4 F 52.1 (per 1,000) making up 17.0% of all hospitalisations for males, and 11.8% for females 37 (per 1,000) July June In to was 60.0 per 1000 males, 56.7 per 1000 females 37 (per 1,000) July June 2010 ASR per M, 29.4F 4 In to was 31.9 per 1000 males, 25.9 per 1000 females 37 (per 1,000) rheumatic heart disease prevalence (as at 21 Dec 2010) 4 In to hospitalisations were 1.0 per 1000 males, 1.8 females 37 High blood pressure AHMAC M, 0.8F (per 1,000) Hospital Separations for hypertension to Cancer AHMAC 1.08 Bowel/Lung incidence rate 24/72 per 100,000, Breast/Cervical 54/22 per 100,000 4 Hospital Separations for All cancers per 1,000 males, 11.3 per 1,000 females 37 Diabetes AHMAC M 16.4F Hospital Separations for diabetes per 1,000 population to Kidney disease AHMAC per 100,000 people ASR (132 per 100,000 males, 166 per 100,000 females) Incidence of end stage kidney disease Was 71.8 per 100,000 (64.7M, 81.1F) from Oral health AHMAC % Oral health problems identified during Child Health Check (between 1 July 2007 and 3 June 2009) 4 STI AHMAC 1.12 Jul-Dec, 2012 totals rates per 100,000 Gonorrhoea , Chlamydia , Syphilis 40.5, Tricomoniasis , Hepatitis C Disability AHMAC % Proportion of ATSI peoples with core activity need for assistance Perceived Health Status AHMAC % The proportion of ATSI peoples reporting fair or poor health in NT Social and emotional wellbeing AHMAC M 11F per 1,000 population, hospitalisations for mental health-related conditions (July 2006-June 2008) 87 Life expectancy at birth AHMAC M 69.2F Life expectancy at birth ( ) 4 Infant and child mortality AHMAC Infant mortaility rate per 1,000 live births Perinatal mortality AHMAC Perinatal mortality rate per 1,000 births All causes ASDR AHMAC ,541 Leading causes of mortality AHMAC 1.23 Age-standardised all-causes mortality rate Note: difference from non-aboriginal Circulatory diseases ASR per 100,000 Aboriginal Non-Aboriginal Endocrine, metabolic & nutritional disorders ASR per 100, non-aboriginal Respiratory compared to Avoidable and Preventable deaths AHMAC per 100,000 - NT has the highest avoidable mortality rates in Australia 4 Housing AHMAC % Literacy (R) and Numeracy (N) AHMAC Reading 0.6 Numeracy Education outcomes AHMAC Apparent retention rates 2011 (year 7/8 to 12) 4 Educational participation and attainment of adults AHMAC Employment AHMAC % Income AHMAC % Index of disadvantage (SEIFA) AHMAC % Community Safety AHMAC % Contact with criminal justice system AHMAC Child Protection AHMAC % home ownership in % overcrowding Census of Population and Housing 22 Proportion of Advantaged and Disadvantaged Year 9 Students in the Top Band of Results, Australia 2011 (Aboriginal) 83 Number of adults with Cert III or above Post school qualifications 22 Equates to 13.2% of Aboriginal population (37,915) compared with 52% of non-aboriginal population 19% Unemployment (Selected labour force, education and migration characteristics by Aboriginal status) 22 Proportion of ATSI peoples aged 18 years or over who were in the lowest quintile of equivalised gross weekly household income quintiles 2008 (NATSISS 2008) 4 58% in Quintile 1 (most disadvantaged) 2006 SEIFA. Population distribution by SEIFA IRSAD (only 6% in most advantaged) 4 Aboriginal persons aged 15 years and over, by formal contact with police, % feel unsafe to walk after dark, 10.9% feel unsafe at home after dark People in prison custody - Rate per 100,000 people. 4 Compared to 182 per 100,000 non-aboriginal Rate per 1,000 Children aged 0-16 who where the subject of a substantiation Out-of-home care 18.2 per 1,000 chldren 4 Access to traditional lands AHMAC % Percentage of Aboriginal population who lives on traditional lands 84 Tobacco use AHMAC % Risky alcohol consumption AHMAC % Drug and other substance use AHMAC % Physical activity AHMAC % Dietary behaviour AHMAC % and 18.6% Current Smokers - Aboriginal persons aged 15 years and over, % Low, medium and high risk drinking ATSI adults who drank at short-term risky/high risk levels at least once a week 04/05 16% 4 NATSIHS 2004/ % 85 Table 10 Neighbourhood or community problems, Aboriginal persons aged 15 years and over, by remoteness, sex, NATSIHS 2004/ % 85 Sedentary - Level of physical activity, Aboriginal persons aged 15 years and over, non-remote areas, (note - 34% low level of physical activity) 86 Vegetable and Fruit intakes - does not consume daily % Proportion of persons aged 15 years and over who ran out of food and couldn t afford to buy more at some time over the previous 12 months and of this 7% went without food 87 Breast feeding practices AHMAC % Children aged 0-3 years best in the country Health behaviours during pregnancy AHMAC % Overweight and Obesity AHMAC % NATSIHS result 2004/5 85 Proportion of mothers who smoked during pregnancy % used illicit drugs or substances during pregnancy Population Health Commissioning Atlas

25 Indicator Analysis NT Aboriginal Health Key Performance Indicators Aboriginal Health Performance Framework Tier 1 - Health status and outcomes In 1999 the Northern Territory Aboriginal Health Forum (NT AHF) identified the need for a common set of key performance indicators (KPIs) in Aboriginal primary care in order to establish this baseline. The NT AHF undertook a project to further develop KPIs measuring Aboriginal health outcomes in such areas as chronic disease, antenatal care, babies, child health and adult health. This project identified 44 Aboriginal health KPIs and agreed to initially implement 19 of these. The domain analysis for the NT's Aboriginal population reports current results against the first 12 NTAHKPIs. The available data paints a mixed picture for the NT with a number of indicators demonstrating improvements in health but at levels still well below National and non-aboriginal populations. For example there has been a significant decrease in anaemia rates for Aboriginal children from 29% in 2004 to 20.9% in ,74, however this is still an unacceptable rate. There appears to be improving number of diabetic patients having HbA1c tests across the NT with the level increasing from below 60% to almost 70% of the Aboriginal people living with diabetes. An increase has also been observed in the number of patients living with diabetes who have albuminuria and are on ACE inhibitor and/or ARB with 85% of the patients in 2012 compared to 55% in There appears to be improved management of diabetes throughout the NT and hopefully this will result in reduced diabetic complications and hospitalisations. Other areas of concern for the NT include the number of children who are considered underweight and this issue is discussed in more detail in following pages. The NATSIHS 2004/05 85 found that 69.7% of eligible Aboriginal women had a pap smear in the previous two years. In contrast data from the NTMLs Needs Assessment indicates that only 40% of eligible Aboriginal women had a pap smear in the previous two years 10. This may indicate differences in data collection techniques or may represent a worrying decrease in the number of pap smears occurring across the NT. The national Aboriginal Torres Strait Islander Health Performance Framework monitors progress in Aboriginal Health outcomes and has developed key performance indicators across three tiers. These tiers are Health status and outcomes, Determinants of health and Health system performance. In the NTML PHCAtlas we have chosen to focus on Tier 1 and Tier 2 indicators as these relate more closely to population health outcomes. In looking at these two tiers it is clear that Aboriginal health is improving on a number of fronts but there is still much to do to close the gap in health Aboriginal Hospitalisations Due to Circulatory Disease status between Aboriginal and non-aboriginal people. The limited trend data available for the NT, indicates that the average life expectancy is increasing for Aboriginal people, but slowly. 4 A 2010 study of mortality trends in the NT indicates life expectancy for Aboriginal males and females has increased considerably between 1967 and 2006: For males there has been an increase of 7.7 years (52.5 years to 60.2 years) and For females a more significant increase of 15.9 years (53.9 years to 69.8 years). 88 It is widely viewed that the improvement in life expectancy has been largely due to a drop in infant mortality over this period with NT infant mortality improving significantly for both Aboriginal and non-aboriginal populations over the 40 year period from 1967 to Cardiovascular disease is the leading cause of death in the NT for the Aboriginal population. Mortality from all circulatory causes is double the national rate for , with mortality highest in NT s remote regions. 8 Hospitalisation rates for ischaemic heart disease were substantially higher for Aboriginal than non-aboriginal Territorians. 37 The table to the right demonstrates that the NT's Aboriginal population has twice the number of hospitalisations due to circulatory disease than the non-aborignal population, the highest differential in the nation. 4 State/Territory Number Rate per 1,000 people Ratio compared to non- Aboriginal population New South Wales 4, Victoria Queensland 5, Western Australia 2, South Australia 1, Northern Territory 2, Tasmania Australian Capital Territory Total 17, Aboriginal Health Performance Framework Tier 2 - Determinants of Health A number of studies have found that between one-third and one-half of the health gap between Aboriginal and non-aboriginal Australians is associated with differences in socio-economic status in areas such as education, employment and income. These key determinants have been included in the Aboriginal Health Performance Framework as they underpin health outcomes and shape how patients interact with the health system. The 2011 Australian census shows an large disparity in the median personal weekly income with Aboriginal people living in the NT having a median personal income of just $269 which is well below the poverty line ($400) while for non-aboriginal people the median is $ One third (33.1%) of the NT's Aboriginal population is living in overcrowded housing, making this a key determinant and a risk factor for many chronic and acute conditions. 22 Aboriginal people experience much higher rates of arrest and incarceration than non-aboriginal people. It is of concern that 36% of the Aboriginal population of the NT has had formal contact with police which is a much higher proportion than the non-aboriginal population. There is a large disparity in the number of Aboriginal Territorians incarcerated in the NT with 82% of the prisoners identifying as Aboriginal in 2011; 1041 prisoners in the NT were Aboriginal compared to 231 non-aboriginals. 4 There is increasing evidence that many people in prison are there as a direct consequence of the shortfall in appropriate community-based health and social services, most notably in the areas of housing, mental health and wellbeing, substance use, disability and family violence. 89 Imprisonment impacts on children, family and community and increases stress, affects relationships and has adverse employment and financial outcomes. A person s access to a healthy diet can be influenced by a range of socio-economic, geographical and environmental factors. Food security, food access and food supply are issues for people living in rural and remote areas. Remote food stores often have limited supplies of fresh fruit and vegetables which are often more expensive than purchasing less healthy food. The results of the Northern Territory Market Basket survey 2012 found the cost of the food basket in remote stores was 49% higher than Darwin supermarkets. Low income combined with high food costs result in many Aboriginal people spending a large proportion of their income on food. 90 the PHCAtlas Population Health Commissioning Atlas 25

26 Social Determinants of Aboriginal Health Income Income is considered one of the most important determinants of health as described on page 7 and disparity in income is a key mechanism through which disadvantage leads to poorer health outcomes for Aboriginal people. Additional factors which may exacerbate the situation faced by low income households include resource commitments to extended families and visitors. Figure 5.3 highlights the income disparity between Aboriginal and non-aboriginal households, and demonstrates that Aboriginal households support greater numbers of people with less money. As stated on page 7, people earning less than $400 per week are considered to be living in poverty; 21 the median total personal income for Aboriginal people in the NT is $269 per week. 22 Both Figure 5.3 and Map 5.1 indicate that significant proportions of Aboriginal people are able to access public housing reducing the economic burden of unsustainable housing costs. Map 5.1 includes both Aboriginal and non-aboriginal households, and data from the 2011 census states that two thirds of these dwellings are rented by Aboriginal people. Furthermore 41% of all Aboriginal households report as renting from NT housing authorities. 22 Overcrowding Factors related to housing, such as overcrowding in housing, housing tenure type and homelessness, have potential impacts on health. The effects of overcrowding occur in combination with other environmental health factors such as poor water quality and sanitation. Together these are associated with increased risk of infectious diseases such as meningitis, acute rheumatic fever, tuberculosis, and skin and respiratory infections. 91 Overcrowding may also increase psychological distress and adversely affect educational opportunities for students. However, the presence of more people in a household may decrease social isolation, which could have a positive impact on health. 92 Figures 5.3 and 5.4 show that 33.9% of Indigenous households are overcrowded in the NT and 58% of the Aboriginal population aged 15 years or over is living in overcrowded households, this is more than twice the proportion of any other state. Homelessness Aboriginal people are more likely than non- Aboriginal people to experience homelessness. Many factors contribute to homelessness, including lack of access to affordable and secure housing, escape from domestic or family violence, overcrowded conditions and relocation. On census night 2006, 1652 Aboriginal people in the NT were categorized as homeless with 1,004 people listed as primary homeless; (i.e. people without conventional accommodation). 93 While public housing is a protective factor, currently there is a 100% occupancy rate which is likely to contribute to homelessness for those who can't access it. As at 30 April 2012 there were 2,797 applicants on the public housing waiting list in urban areas of the NT. 23 Figure Census of Population and Housing - Selected Medians and Averages 2011 Census of Population and Housing Aboriginal persons households Map 5.1 Houses Rented From Housing Authority non-aboriginal persons households Median age of persons Median total personal income ($/weekly) Median total household income ($/weekly) Median mortgage repayment ($/monthly) ,098 1,811 1,963 2,080 Median rent ($/weekly) Average number of persons per bedroom Average household size Proportion of dwellings that need 1 or more extra bedrooms (%) Source: ABS % 4.6% Figure 5.4 Proportion of People 15+ Living In Overcrowded Households (2006) Source: ABS 22 Percentage 26 Population Health Commissioning Atlas

27 Maternal and Child Health Map 5.2 Aboriginal Mothers Who Smoked At 36 Weeks Source: Thompson 67 Map 5.3 Aboriginal Low Birth Weight Babies Source: Thompson 67 Figure 5.5 Aboriginal Teenage Mothers District Figure 5.6 Aboriginal First Antenatal Visit District Teenage Mothers 2010 Darwin Urban 18.6% Darwin Rural 23.1% Katherine 23.5% East Arnhem 21.5% Barkly 32.1% Alice Springs Urban 20.0% Alice Springs Rural 28.9% Source: Thompson 67 First Trimester (%) Darwin Urban 52.4 Darwin Rural 51.6 Katherine 48.9 East Arnhem 43.9 Barkly 41.8 Alice Springs Urban 69.0 Alice Springs Rural 42.4 Total Aboriginal 50.0 Total non- Aboriginal 81.0 Source: Thompson 67 Figure 5.7 Infant Mortality Jurisdiction Rate per 1,000 Aboriginal Rate per 1,000 non- Aboriginal NSW Qld WA SA NT Total 5 Jurisdictions Source: AHMAC Figure 5.8 Perinatal Mortality Rate (per 1,000 births) ( ) Source: AHMAC 4 Reducing The Gap In Infant Mortality Infant mortality rates for Aboriginal people are declining. While mortality for other Australian children is also declining, the gaps in mortality between Aboriginal and other Australian infants in the NT are reducing in both absolute & relative terms. First Antenatal Visit Antenatal care has been found to have a positive effect on the healthy outcomes for both mother and baby. Antenatal care may be especially important for Aboriginal women, as they are at higher risk of giving birth to low birth weight babies and have greater exposure to other risk factors such as anaemia, poor nutritional status, hypertension, diabetes, genital and urinary tract infections and smoking. 94 Most guidelines recommend that antenatal care should commence during the first trimester, as it is at this early stage that risk factors can best be assessed and addressed and birthing outcomes improved. 4 In the NT in 2010, 98.6% of all Aboriginal mothers had at least one antenatal visit compared to 99.7% of non-aboriginal mothers, with no major difference observed between those Aboriginal mothers living in rural/remote versus urban areas. 67 Of these, 50% of Aboriginal mothers attended their first antenatal visit during the first trimester, compared to 81% of non-aboriginal mothers (Figure 5.6). 67 There are numerous barriers for Aboriginal mothers including transport, education, cultural accessibility and appropriateness of services. Low Birth Weight Babies Low birth weight is a risk factor for neurological and physical disabilities, and low birth weight babies may also be more vulnerable to illness throughout childhood and adulthood. 4 Risk factors include maternal smoking, socio-economic disadvantage, the weight and age of the mother, the mother s nutritional status, excessive alcohol consumption, poor antenatal care and illness during pregnancy. In the NT Aboriginal mothers (11.8%) were three times as likely to be consuming alcohol at the time of the first antenatal visit as non-aboriginal mothers (3.8%), this difference increased at 36 weeks (7.5% compared to 1.7%). 67 Maternal smoking status is also of great concern with 52.3% of all Aboriginal mothers being current smokers at the first antenatal visit, and 49% still being current smokers at 36 weeks. 67 Low birth weight babies are nearly three times more likely to be born to Aboriginal mothers (14%) when compared to non-aboriginal mothers (5.8%). The Barkly area is of particular concern with almost a quarter (24.7%) of the babies having a low birth weight. 67 Figure 5.5 shows that Barkly has the highest proportion of babies born to teenage mothers, a risk factor for low birth weight. Infant and Perinatal Mortality the PHCAtlas Infant mortality is the death of a child less than one year of age and is a long established measure of child health, as well as the overall health of the population. In the NT the infant mortality rate is still higher than the rest of Australia, and while achievements have been made since 2000 (21.5 per 1,000), it was still high at 13.7 per 1,000 in Figure 5.7 shows the disparity between the Aboriginal and non-aboriginal population. 4 Perinatal mortality rates include both stillbirths and deaths of babies in the first 28 days after birth and therefore this rate reflects the health status and health care of the general population, antenatal and obstetric services and health care in the neonatal period and also other broader SDH. The NT has the highest perinatal mortality rate at 21.1 per 1,000 for Aboriginal children, compared with the national rate of 12.5 per 1,000 Aboriginal children ( ) (Figure 5.8). 4 Population Health Commissioning Atlas 27

28 The Early Years Breast Feeding Breast feeding provides the best nutritional start for infants and promotes healthy growth and development. 95 Breast feeding offers protection against many conditions, including Sudden Infant Death Syndrome, diarrhoea, respiratory infections, middle ear infections and the development of diabetes later in life. 96 The NT has the highest percentage of Aboriginal children breast fed between the ages of 0-3 years, 88% (Figure 5.9). 4 Breast feeding is one of the simplest ways to improve the health of Aboriginal children and also benefits mothers and communities. 97 Healthy Childhood Development Normal growth in infancy and childhood is vitally important for good health in adulthood, and achieving satisfactory growth for many Aboriginal children is a challenge. The factors contributing to the persisting growth deficiencies are complex with the most important being persistently negative environment factors living in overcrowded, unhygienic conditions and poor nutrition. 98 Map 5.4 shows that the Top End is of particular concern with 21% of children under five years in the Darwin rural area considered underweight. From six months of age the protective factor associated with breast feeding declines which may be linked to poorer growth patterns for Aboriginal children from this age onwards. 98 Ear and Hearing Health Hearing loss among Aboriginal people is widespread and much more common than for non-aboriginal Australians. Hearing loss especially in childhood, can lead to linguistic, social and learning difficulties and behavioural problems in school. Such differences may reduce educational achievements and have life-long consequences for employment, income, social success and contact with the criminal justice system. 99 In the NT the level of hearing problems experienced within the Aboriginal population is of concern with Otitis Media being the most prevalent cause. Map 5.5 shows that 13.5% of Aboriginal children living in Central Australia have either moderate, severe or profound hearing loss which the WHO classifies as a disability. 100 The proportion of children with hearing loss in Arnhem land (6.9%) and the Darwin rural area (8.8%) is lower than central Australia but is still at a level of concern. Oral Health Aboriginal people are more likely than other Australians to have lost all their teeth, have gum disease and receive less caries (teeth with decay) treatment. Aboriginal children living in remote areas have the poorest level of oral health compared to those living in major cities in the NT. Higher levels of socioeconomic disadvantage are associated with poorer oral health in children. Between 2007 and 2011, 8317 Aboriginal children received dental services in the NT, of this number 56% were treated for at least one oral health problem. 101 More than 80% of Indigenous people living in remote locations are not connected to town-water and have no access to fluoridated water supplies. Drinking fluoridated water helps to protect teeth against decay. 102 Breast Feeding The NATSISS 2008 survey found that the median age at which Aboriginal children stopped being completely breast fed was 39 weeks in the NT compared to 17 weeks across Australia. 84 Immunisation Immunisation is highly effective in reducing morbidity and mortality caused by vaccine preventable diseases. In 2011/12 the NT rate of immunisation for Aboriginal children at two years of age was 97% the best coverage in Australia for this age group. With rates of immunisation at ages one (90%) and five years (92%) being above the national averages. 26 Figure 5.9 Aboriginal Breast Feeding Source: AHMAC 4 Map 5.4 Underweight Aboriginal Children Source: Burns et al 98 Source: AIHW 100 Map 5.5 Aboriginal Children with Moderate/Severe/Profound Hearing Loss Figure 5.10 Aboriginal Children Dental Problems Problem Treated Number Percentage Untreated caries 3, Mouth infection or mouth sore Dental abscess Gum disease Broken or chipped teeth due to trauma Abnormal teeth growth Missing teeth Other Number of children treated for at least 1 problem 3, Total number of children who received dental service 6,480* Source: AIHW 101 *8317 children received services, only 6,480 consented to details being shared with AIHW 28 Population Health Commissioning Atlas

29 Chronic Disease Figure 5.11 Children's body weight (2011) Age Source: Burns et al 98 Age Urban non- Aboriginal Urban Aboriginal Remote Aboriginal Underweight 3.8% 6.7% 7.9% Stunted 2.0% 4.2% 13.3% Wasted 6.0% 5.6% 5.2% Overweight 8.3% 12.3% 3.9% Obese 3.9% 2.2% 0.9% Figure 5.12 Proportion of Aboriginal People with Excess Body Weight by Age (%) (%) (%) 45+ (%) Total (%) Males Overweight Obese Females Overweight Obese Total Overweight Obese Source: ABS 85 Figure 5.13 Proportion of Persons Aged 15 Yrs & over who ran out of Food in the Previous 12 Months, Australia NT QLD TAS/ACT SA WA VIC NSW Source: Browne et al 104 Aboriginal non- Aboriginal Figure 5.15 Estimated Prevalence of Diabetes, Aboriginal People Estimated prevalence of diabetes, 2005 Male 9.1% Sex Female 14% Region Source: Zhao et al 131 Central Australia % Top End 7.7% Malnutrition Malnutrition incorporates the three conditions: 1. Undernutrition (protein-energy malnutrition) due to insufficient intake of energy and other nutrients 2. Overnutrition (overweight and obesity) due to excessive consumption of energy and other nutrients and 3. Deficiency diseases due to insufficient intake of one or more specific nutrients such as vitamins or minerals. Figure 5.14 Incidence of End Stage Kidney Disease - Rate per 100,000 Aboriginal Population Source: AIHW 81 Map 5.6 Aboriginal Bowel Cancer Incidence Source: Condon et al 41 Nutrition and Food Security Nutritious food is fundamental to good health and disease prevention. There are significant health risks associated with poor nutrition, including the increased risk of chronic diseases such as heart disease, type 2 diabetes and some cancers (including bowel cancer). Poor nutrition also contributes to a variety of other risk factors such as high blood pressure, high cholesterol and obesity. The pattern of food access and nutrition status of the NT Aboriginal population is complex. It includes insufficient, low quality or unreliable food intake, which leads to some people being malnourished and others obese. Figures 5.11 and 5.12 examine the different impacts of poor diets on body weight. While Australia is considered food secure compared to other countries, this is increasingly not the case among disadvantaged and low income groups. Food insecurity can refer to the following: 1) not having sufficient food; experiencing hunger as a result of running out of food and being unable to afford more; 2) eating a poor quality diet as a result of limited food options; anxiety about acquiring food; or 3) having to rely on food relief. 103 Within the Aboriginal population, particularly for Aboriginal people living in remote regions, there are issues with reliable access to nutritious food, resulting in significant levels of malnutrition. Figure 5.13 shows that within the NT 45% of Aboriginal people aged 15 years and over ran out of food in the last year, compared with 3% for the non-aboriginal population. Food access is an issue of concern. 104 Diabetes Diabetes is a chronic condition which can result in permanent disability, mental health problems, reduced quality of life and shortened life expectancy. Diabetes increases links to comorbidities such as IHD, stroke, kidney disease and eye health. Diabetes is responsible for 12% of the health gap between Aboriginal and non-aboriginal Australians. 106 Maintaining a healthy balanced diet and exercise are fundamental to effective prevention, management and control of type 2 diabetes. Figure 5.15 shows a high prevalence of diabetes with a higher proportion in Central Australia. 131 the PHCAtlas Kidney Disease Chronic kidney disease describes kidney damage or reduced kidney function that persists for more than 3 months. Risk factors include diabetes, hypertension, smoking and low birth weight. End Stage Kidney Disease (ESKD) occurs when a person's kidneys have deteriorated to a point that treatment is needed to sustain life, such as dialysis or a transplant. Aboriginal people experience high levels of ESKD. There is a strong relationship between incidence of ESKD, identifying as Aboriginal and living remotely. Figure 5.14 identifies that the incidence of ESKD is higher for Aboriginal people living in the NT than for other Aboriginal people throughout Australia. 81 Bowel Cancer Cancers associated with diet are most commonly found in the digestive tract, including the oesophagus, stomach and bowel. 107 Excess body weight & high energy intake have been associated with increased incidence of bowel cancer and risk increases with age. Map 5.6 highlights higher rates of bowel cancer incidence for Aboriginal people living in the least remote areas of the NT (Darwin, Katherine & Alice Springs Health Service Districts). 41 Population Health Commissioning Atlas 29

30 Infectious Disease Infectious Diseases For much of the developed world including Australia, the burden of disease caused by infectious disease related to climate, environmental and social conditions has been well controlled resulting in significant improvements in population health. This is not the case for a number of developing countries nor for Aboriginal people living in remote parts of Australia. Rheumatic Heart Disease Rheumatic heart disease is caused by damage done to heart muscle or heart valves from acute rheumatic fever. Acute rheumatic fever is a delayed complication of an untreated throat infection from Streptococcus bacteria and it may also be caused by streptococcal skin sores. 108 Scabies provides an ideal niche for the development of streptococcal skin infections. Scabies infections are endemic in the remote Aboriginal communities throughout the NT and its spread is associated with socioeconomic disadvantage and overcrowding within households. 109 The remote Australian Aboriginal population has the highest prevalence rates of rheumatic fever and rheumatic heart disease in the world. 110 The prevalence of rheumatic heart disease in the NT Aboriginal population during 2010 was higher in the Top End (29 per 1,000 people) compared with central Australia (18 per 1,000). Figure 5.16 shows declining trends between 2006 and Tuberculosis (TB) TB is an infectious bacterial disease usually spread by respiratory droplets and caused by the bacteria Mycobacterium Tuberculosis and is inhaled by contact with active pulmonary TB patients. Australia has one of the lowest rates of TB in the world however Aboriginal Australians have much higher rates compared to the non-aboriginal population and this is particularly the case in the NT. Figure 5.17 shows that 50% of the cases of TB diagnosed in Australian Aboriginal people between occurred in the NT. 111 The three most common risk factors for the disease are being in contact with an active TB patient, over-using alcohol and being malnourished. Sexually Transmitted Infections Sexually transmissible infections (STIs) are spread by sexual contact. As most STIs are asymptomatic (or produce only mild symptoms) many people affected may only find out they have an infection through screening and contact tracing. A number of STIs are classified as notifiable diseases due to their potential impact on public health, and these include Chlamydia, Gonorrhoea, Syphilis and Trichomoniasis. The NT has disproportionately high notification rates of all STIs. The burden of disease is greatest among Aboriginal people, with the highest rates occurring in the year age group. 108 Trichomoniasis is a parasite transmitted exclusively by sexual contact and is particularly common amongst Aboriginal communities living in the Top End. Map 5.7 identifies the Health Service Districts of East Arnhem and Katherine having high rates and 97% of these cases are people identifying as Aboriginal. Map 5.8 shows Gonorrhoea notifications with Katherine and Alice Springs regions having concerning rates. 82 Importantly, all STIs are preventable and access to and use of condoms is fundamental in preventing STI transmission. Figure 5.16 New Rheumatic Heart Disease Registrations for Aboriginal People ( ) (Rate Per 100,000 People) Source: AHMAC 4 Figure 5.17 Tuberculosis Cases in Australia (Rate per 100,000 People) Map 5.7 Overall Trichomoniasis Notification Rates (Jul-Dec 2012) Source: Dept of Health 82 Source: Health Infonet 111 Map 5.8 Overall Gonorrhoea Notification Rates (Jul-Dec 2012) Source: Dept of Health Population Health Commissioning Atlas

31 Alcohol and Injury Age Percentage Figure 5.18 Prevalence of Alcohol Consumption Among NT Aboriginal Adults Source: NT Government 113 Figure 5.19 Proportion of NT Aboriginal Adults who Consume Alcohol at Risky/High Risk Levels Source: NT Government 113 Figure 5.20 Top Hospitalisations for Aboriginal People in NT (2000/01 to 07/08) (Rate per 100,000 People) Aboriginal Males Aboriginal Females ICD Chapter Percent Rate ICD Chapter Percent Rate Injury Pregnancy related Respiratory Injury Digestive Respiratory Infectious Digestive Circulatory Infectious Source: Li et al 37 Figure 5.22 Road Traffic Fatalities in the NT Total Total fatalities Aboriginal fatalities Alcohol Related Accidents Aboriginal fatalities Aboriginal - seriously injured Seat belts Not Worn Aboriginal fatalities Source: NT Government 114 Percentage Age Alcohol Abstainers In , 24% of Aboriginal Australians aged 18 years and over had abstained from alcohol consumption in the last 12 months, this was twice the rate for non-aboriginal people. 80 Map 5.9 All Hospitalisation per 1000 Population Source: Li et al 37 Figure 5.21 All Causes of Hospitalisations (Rate per 1000 Population) District Darwin urban Darwin Rural Katherine East Arnhem Barkly AS Urban AS Rural Aboriginal male Aboriginal female Source: Li et al 37 Alcohol Excessive alcohol consumption is associated with a range of health and social problems for many Australian communities, and for both Aboriginal and non-aboriginal people. Alcohol consumption is a major contributor to motor vehicle accidents, assaults, falls and suicide and is thought to contribute 5.4% of the disease burden for Aboriginal Australians. For Aboriginal males aged years alcohol was responsible for the greatest burden of disease and injury and is considered a serious public health issue. 4 Figure 5.18 highlights that more Aboriginal people in the NT are consuming alcohol when compared to their non-aboriginal counterparts. Figure 5.19 shows that across all age groups between 20% and 40% of all Aboriginal people in the NT are drinking at risky or high risk levels. 113 Injury Injury is a major cause of death and hospitalisations for Aboriginal people and contributes to the gap in life expectancy between Aboriginal Australians and non-aboriginal Australians. Injury generally refers to physical harm to a person s body either intentional (self-inflicted harm, assault) or unintentional (road traffic accidents, drowning, poisonings, falls etc). However, for Aboriginal communities, injury may also refer to non physical harm such as loss, suffering and other effects of stressful or hurtful events and circumstances. This reflects the holistic view of health and safety understood by Aboriginal people. 112 The causes of injury to Aboriginal and Torres Strait Islander peoples are diverse, and the relationships complex. Many factors related to injury and safety are also relevant to environmental management, transport, crime, family breakdown, and property damage, and require collaborative approaches to these issues across governments and sectors. 112 Hospitalisations While not all injuries result in hospitalisation, it is the best available measure to determine the prevalence of injury within a community. Figure 5.20 shows that injury was the leading cause of hospitalisation in the NT for Aboriginal males and the second leading cause for Aboriginal females (behind pregnancy). This table does not include hospitalisations related to renal dialysis which for the same period doubles the number of hospitalisations for Aboriginal people. Map 5.9 outlines hospitalisation rates for NT Health Service Districts and shows that Alice Springs Urban and Barkly have the highest rates. 37 In 2011/12 the overall hospitalisation rate for Aboriginal people living in the NT was 1,779 per 1,000 people, 5.7 times the rate for non-aboriginal people. 62 the PHCAtlas Aboriginal people have higher rates of hospitalisation associated with renal dialysis; in 2011/12 same day hospitalisations for NT Aboriginal people was 1,405 per 1,000 but only per 1,000 when excluding care involving dialysis. Road Fatalities Nationally in 2010, injury ranked third in the causes of death for Aboriginal people behind CVD and cancer. 87 In 2012 there were 49 deaths from road traffic accidents in the NT; Aboriginal people were over represented with 25 deaths (51%) and this has been a consistent pattern for the past 10 years. Figure 5.22 highlights the impact of alcohol on road deaths, with two thirds of all Aboriginal road deaths between 2000 and 2005 related to alcohol consumption. 114 Population Health Commissioning Atlas 31

32 Suicide Suicide More people die from suicide each year in Australia than from road traffic accidents and some groups are particularly vulnerable including people with a mental illness, males aged and 65 years and over, young men in remote communities and Aboriginal people. Suicide is linked with mental illness including depression, schizophrenia, bipolar and personality disorders. Social factors including unemployment, economic hardship, family conflict and social isolation are thought to contribute to growing rates of depression in the community; these factors are often prevalent within Aboriginal communities. Studies have found higher rates of suicide amongst those with problematic alcohol and drug use. 115 Suicide is a leading cause of death for Aboriginal and Torres Strait Islander peoples, with rates twice that of the general Australian population. Low self-esteem, feelings of grief and loss, cultural identity issues and involvement in the criminal justice system are additional significant contributing factors. Map 5.10 shows deaths from suicide in the NT by Health Service District and highlights the Darwin Rural, Barkly and East Arnhem regions as having higher levels compared to other Districts. Figure 5.23 confirms the disparity between Aboriginal and non-aboriginal populations in the NT with regard to the levels of suicide within the two population groups. 77 Youth Suicide The incidence of Aboriginal suicide in the NT has been increasing since the 1980s and now has exceeded the rates of suicide for non-aboriginal people. Of particular concern is the increasing rate of youth suicide in the Aboriginal population years old, with rates increasing from 18.8 per 100,000 in to 30.1 per 100,000 in For example 19 Aboriginal people aged years died from suicide during , while the total number of suicide deaths in this period for this age group was Mental Health Hospitalisations As with road traffic accidents, risky levels of alcohol consumption are associated with poorer mental health, increased hospitalisations and intentional injuries including self harm and assault. There is growing evidence that alcohol increases the risk of some mental health conditions, and the risk of having a mental illness is around four times higher for people who drink alcohol heavily than for people who don t. Aboriginal people show consistently higher rates of psychological distress; their rates of anxiety and depression symptoms are between two and three times higher than for non- Aboriginal Australians. The steady increase in the rates of hospitalisations for alcohol related mental disorders in Aboriginal people in the NT is shown in Figure 5.25 confirming the interplay between risky levels of alcohol consumption and mental illness. In 2007/08 the rate of hospital separations in the NT for Aboriginal males was 5.7 per 1000 people, but only 0.8 for non-aboriginal males and 2.1 compared to 0.3 for females. 37 Suicide Prevention The recently released inquiry into youth suicide in the NT 77 found that whilst the NT has in place a number of measures to support suicide prevention, there is a lack of physical infrastructure which limits the range of youth specific and culturally appropriate programs and services. Such a complex problem requires multilayered solutions, to reduce the risk factors for suicide, assist those in need, and respond to completed suicides. Figure 5.23 Suicide Deaths per 100,000 Population Source: Select Committee 77 Figure 5.24 Suicide Risk and Protective Factors Individual Social Contexual Risk Factors For Suicide gender (male) mental illness or disorder chronic pain or illness immobility alcohol and other drug problems low self-esteem abuse and violence family dispute, conflict and dysfunction separation and loss peer rejection neighbourhood violence and crime poverty unemployment, economic insecurity homelessness Source: Select Committee 77 little sense of control over life circumstances lack of meaning and purpose in life poor coping skills hopelessness guilt and shame social isolation imprisonment poor communication skills family history of suicide or mental illness school failure social or cultural discrimination exposure to environmental stressors lack of support services Map 5.10 Suicide deaths by Health Service District Source: Select Committee 77 Protective Factors For Suicide gender (female) mental health and wellbeing good physical health physical ability to move about freely no alcohol or other drug problems positive sense of self physical and emotional security family history supportive and caring parents/ family supportive social relationships sense of social relationships safe and secure living environment financial security employment safe and affordable housing sense of control over life s circumstances sense of meaning and purpose in life good coping skills positive outlook and attitude to life absence of guilt and shame sense of social connection sense of selfdetermination good communication skills no family history of suicide or mental illness positive educational experience fair and tolerant community little exposure to environmental stressors access to support services Figure 5.25 Alcohol Related Mental Disorders Hospitalisations per 1000 Population Source: Li et al Population Health Commissioning Atlas

33 Population Health Commissioning Atlas Health Workforce Section C: Understanding the health workforce challenges in the Northern Territory "The NTML is committed to achieving an equitable, comprehensive primary health care system driven by community needs. This will be informed by needs based planning, evidence based research and an understanding of our current and future workforce needs." 116 the PHCAtlas Population Health Commissioning Atlas 33

34 Section C Contents 34 NT Workforce Challenge 35 Health Workforce Overview 36 Workforce Across The NT 37 Aboriginal Primary Health Care Services and Workforce At a Glance Population: Total 231,862 8 Aboriginal Population: 69,625 (30.0% of total population) 8 NT Workforce Northern Territory Workforce Challenge The NT has a high burden of disease with complex aetiology and reducing this burden will require a highly skilled and experienced workforce, that understands the unique health issues of the population. This workforce needs to be well resourced and well connected to professional networks and integrated with communities. This means employing the right people, in the right place, to create the right balance. Creating the right balance of services (health and community) to improve health outcomes, will require training, access to appropriate technology and communications, innovation and the right delivery models. The challenge is to address the imbalance between a community with a high disease burden and a dynamic and insecure workforce. This leads to pressure points within the system related to attraction and retention of suitable skilled personnel. In a population where health and wellbeing is driven by a complex set of determinants, it is important to consider whole of community approaches and this will require a workforce with a population health focus and culturally aware practices. Determining the size and shape of the health workforce is a complex matter. It requires an understanding of the nature and level of health needs within a population, as well as its socio-demographic profile. This picture of health demand must then be balanced by the availability, diversity and skills of health professionals - the supply side. The first two sections of the Atlas have described the NT population and their health needs - the demand for health services. This chapter focuses on the supply side of the equation and discusses the supply of health services, in particular the challenges associated with building a sustained supply of qualified health personnel across the NT. 117 The NT health workforce includes a variety of professions working across different health agencies in various settings across the NT. The mobility of the NT population is relatively high and this is also true for significant proportions of the health workforce. 118 Attracting and retaining a skilled and stable health workforce has been a challenge for Australian health systems generally, however this experience has been compounded in the NT. This may be due to the location of many health services in remote and very remote regions and the challenges associated with providing health services in highly disadvantaged communities. These factors can place significant pressure on some personnel and result in high turnover rates and long term vacancies. Attraction and retention of staff becomes a primary driver for health systems' planning and human resource management. General Practitioners: 142 FWE 10 Figure 6.1 Health Workforce Framework General Practices: 40 (Private) 10 ACCHS: Practice Nurses: Allied Health workers: 1, RACFs: Source: HCA 117 Public Hospitals: 5 10 Royal Darwin Hospital: 363 Beds Alice Springs Hospital: 189 Beds Katherine Hospital: 60 Beds Tennant Creek Hospital: 20 Beds Gove Hospital (Nhulunbuy): 30 Beds Figure 6.1 shows the linkages between population health needs, the demand for health services and the availability and supply of a suitable health workforce. This framework can be helpful when considering issues associated with building a sustainable health workforce. Private Hospitals: 1 10 Darwin Private Hospital: 100 Beds Pharmacies: Population Health Commissioning Atlas

35 Health Workforce Overview Figure 6.3 Medical Practitioners NT 2011 Clinician Number General Practitioner 308 Hospital non-specialist 188 Specialist 192 Specialist-in-training 163 Other 44 Total 895 No. per 100,000 (Australian Average) 420 (353) FWE GP NT 142 Source: HWA 120 Figure 6.4 NT General Practitioner Principal Setting Source: HWA 121 General Practitioners Table 6.3 shows the number of clinicians working in the NT in A third of clinicians work in General Practice (308), while the other two thirds work in acute services. At first glance the proportion of medical practitioners, 420 per 100,000 population, appears positive when compared with the Australian average (353 per 100,000 population). However when the full-time workload equivalent (FWE) of general practitioners is considered the number of GPs (142) declines to less than half. The table below further substantiates this finding with the NT having the lowest rate in the nation of FWE GPs per 100,000 population (2011/12). 120 State FWE GPs per 100,000 population 2011/12 State FWE GPs per 100,000 population 2011/12 NSW SA 98.3 VIC 93.6 TAS 87.6 QLD 95.1 ACT 66.7 WA 69.8 NT 60.4 Figure 6.5 NT Nurses' Principal Setting 2012 Source: HWA 121 Location Dentist Psychologist Pharmacist Physiotherapist Type Number Registered nurse only 2,822 Midwife and registered nurse 714 Midwife only 13 Enrolled nurse only 401 Midwife and enrolled nurse Total 3949 No. per 100,000 population (Australian Average) Source: HWA 120 Occupational therapist (1055) Chiropractor Podiatrist Optometrist Private practice Aboriginal Health Service Community health care service Hospital Defence Education Other Total per 100, Australian Average per 100,000 Source: HWA 120 Figure 6.6 Professional Standing of Registered and Enrolled Nurses 2011 Figure 6.7 NT Allied Health Professional Principal Setting (2012) Australia 93.0 Source: HWA 120 GPs work in a range of different settings across the NT, and it can be usual practice for one GP to work part time in multiple settings. Figure 6.4 indicates that the majority of GPs work either in private practice or in Aboriginal Medical Services, with the next single largest category being GPs working in the defence industry. 121 Evidence from the Aboriginal Health Performance Framework 4 highlights that GPs working in remote/ very remote locations tend to have short stays and as they gain local experience and expertise they then move outside of the NT. This results in both a high turnover of staff and remote communities consistently being cared for by practitioners with limited local experience. Nurses Figure 6.6 shows the nursing full time equivalent per capita is high for the NT (1,406 per 100,000) compared to the Australian average (1,056 per 100,000), which is likely to reflect the remote practice model of nursing and to partly compensate for the low number of GPs. As the NT has to provide health services to small populations scattered across vast areas, nurses operate health clinics in remote communities and are supported by medical practitioners who visit to provide services on a regular but casual basis as seen in Figure 6.5 with 25% of nurses in Aboriginal Health or community services. Allied Health the PHCAtlas It is well known that there is a national shortage of allied health professionals and the problem is worse in rural areas. 122 Additionally the limited ability to train in allied health professions in the NT means that the issues around numbers of professionals are further compounded. 123 Figure 6.7 details where allied health professionals are working across the NT, with rates per 100,000 people well below the Australian average for all professions. Of particular interest is the lack of podiatrists in the NT (a third of the national average), an important professional group required to work with patients with diabetes. Population Health Commissioning Atlas 35

36 Workforce Across The Northern Territory Health Workforce Across the NT Map 6.1 indicates the spread of primary health care services across the NT. There is a large difference in the numbers of doctors, AHW and nurses available in the different Health Service Districts across the NT. The remote/very remote districts rely heavily on nurses to provide primary health care, while most of the doctors in the NT work in either Darwin or Alice Springs. Recruitment and Retention As discussed in the paper by Malyon, Zhao and Guthridge (2010) 118 transience in the NT health workforce is an issue. Strategies designed to increase recruitment and retention are key elements in establishing and maintaining a functioning workforce. Labour market literature outlines a number of factors that influences the attraction and retention of staff across all sectors including health. 125,126 Recruitment Personal factors, particularly associated with choice of place to live; Figure 6.8 Health Service District Populations and Health Workforce 2011 Health Service District Darwin Urban Darwin Rural East Arnhem Katherine Barkly Alice Springs Rural Map 6.1 Health Service District Populations and Numbers of Nurses and GPs Alice Springs Urban Nurses GPs Aboriginal population non-aboriginal population 14,015 12,211 10,733 10,757 4,315 11,475 6, ,713 4,784 6,223 9,417 2,362 2,768 22,973 Total population 127,725 16,995 16,956 20,174 6,677 14,243 29,092 Sources: Population: PHIDU 8, Nurses & GPs: HWA 121 Job satisfaction / interesting and challenging work; Career prospects, especially the potential to fast track progression; Income earning capacity, including salary, benefits, security; Balance between work / life (style) / family. Retention Relationship with work colleagues; Job satisfaction / interesting and challenging work; Personal factors, particularly associated with choice of place to live; Work environment, including a supportive culture; Balance between work / life (style) / family. Flexible work arrangements Age, higher mobility in young workers Sources: HWA Population Health Commissioning Atlas

37 Aboriginal Primary Health Care Services and Workforce Map 6.2 AMSANT Member Services (Aboriginal Community Controlled Health Services) Source: NTML 10 Figure 6.9 Percentage of FTE Positions in Aboriginal Primary Health-Care Organisations, at 30 June 2012 Aboriginal Primary Health Care Services Primary health care services are an essential component of a health system and contribute to improved health outcomes for both Aboriginal and non-aboriginal people. Aboriginal Medical Services (AMS) which incorporates both Aboriginal Community Controlled Health Services (ACCHS) and NT Government Primary Health Centres deliver primary health care services across the NT in a manner that is tailored to meet the cultural requirements of Aboriginal communities. They are an important component of the NT health system. There are significant numbers of AMS in the NT; in 2012 there were 52 Aboriginal PHC services in the NT compared to NSW which has 53 Aboriginal PHC services but a much larger population. 127 Map 6.2 shows the distribution of Aboriginal Medical Services within the NT. The bulk of the NT Aboriginal population receives their primary health care services from an AMS (90.6%). 127 While a large proportion (76,645) of the population rely on AMS for their PHC needs, these services face numerous challenges including long term vacancies in both administration and more importantly health positions. (Figure 6.10) 127 Figure 6.9 compares the make up of the workforce within the AMS. It shows that within the NT nurses make up a larger proportion of the AMS workforce than other states. Aboriginal Health Workforce From the 2006 Census of Population and Housing there were 425 Aboriginal people employed in the health workforce. 128 This means the NT had the highest proportion of the health workforce being staffed by Aboriginal people (8.7%). However the NT has the lowest proportion of Aboriginal people working in health, relative to the size of the Aboriginal population (1.2%). Source: AIHW 127 Figure 6.10 Vacancies in Aboriginal Primary Health Care Organisations Source: Boxall et al 126 State Aboriginal persons employed in health workforce Aboriginal health workforce as a proportion of total health workforce (%) Aboriginal health workforce as a proportion of the Aboriginal population NSW 1, VIC QLD 1, SA WA TAS ACT NT AUST 5, Source: 126 the PHCAtlas Data that is available from Health Workforce Australia 121 estimates the AMS health workforce. From this data, the AMS sector appears to employ a substantial proportion of the NT s medical and nursing workforce; 13.5% of the medical, and 9.9% of the nursing/midwifery NT workforce. Population Health Commissioning Atlas 37

38 Section D Key Themes Emerging from the NT PHCA INTRODUCTION 1 Living Remotely 2 Housing Issues 3 Environmental Conditions POPULATIONS OF INTEREST Aboriginal Children People Living in Remote Communities Prison Populations ISSUES OF INTEREST Alcohol Mental Health & Suicide Diabetes The health issues presented in this Atlas are interconnected and arise from complex social, economic, environmental and cultural factors, which lead to health risks and adverse health outcomes. The Atlas draws attention to three recurring themes; environmental conditions, housing stress and overcrowding and the challenges of living remotely. Evidence consistently justifies that addressing these fundamental needs is critical to closing the gap and improving health outcomes for Aboriginal and other disadvantaged populations. The key challenge for people living remotely is being able to access timely, appropriate and affordable services. This includes basic requirements for daily living such as food and clean water and social opportunities including education and employment. The health impacts of these factors are further compounded by poor access to health services and lack of a stable workforce. Housing issues affect a range of populations across the NT. Different housing problems create different health impacts. Overcrowded housing is a major concern for Aboriginal communities, with the impact felt most severely in remote communities. Overcrowding plays a significant role in the transmission of infectious diseases, mental health issues and can contributes to family violence and injury. Financial housing stress on the other hand, is a significant problem for urban populations in particular people living in Darwin, where housing costs place undue financial pressure on families and individuals, contributing to psychological stress and mental health issues. Historically public health action has sought to address poor environmental conditions (e.g. sanitation and water quality) as a primary strategy to improve population health. The strategies employed have resulted in positive health outcomes. Unfortunately in parts of the Northern Territory poor environmental conditions persist. These conditions create the opportunity for a number of infectious diseases to thrive such as rheumatic fever, tuberculosis and a range of skin diseases. The early childhood period is critical for human development and predicting future health outcomes. A number of health indicators (e.g. those reported by AIHW), demonstrate many areas of improvement in the health status of Aboriginal children over recent years. This includes a 40.9% reduction in mortality rates for Aboriginal infants from 2000 to Despite these positive gains there are a number of areas of ongoing concern highlighted in available research and well known to frontline service providers. These concerns include: (a) high percentage of teenage mothers (b) lower rates of accessing antenatal care, especially in the first trimester (c) high rates of smoking during pregnancy (d) low birth weight (e) ear health and oral health remaining widespread problems for Aboriginal children living in remote areas, contributing to disadvantage associated with learning and development. Over 40% of the Northern Territory population lives in areas classified as remote or very remote, and the data presented in this Atlas indicates that there is a health gap for the people living in these remote areas compared to urban counterparts. The challenge is largely associated with access to services and resources. While living remotely can be a challenge for health and wellbeing, the impacts are not uniformly felt across the NT. This may be associated with different environmental and cultural factors having different impacts in Central Australia than the Top End. A significant proportion of this remote population is Aboriginal. The significant health needs of prisoners as a population group are well known, with prisoners having a disproportionately high prevalence of both chronic and acute health conditions. Prisoners also report regularly engaging in risky behaviour, particularly those related to the spread of blood borne and other infectious diseases, for example, intravenous drug use. The Northern Territory has the highest incarceration rates in Australia and of those in prison over 80% identify as Aboriginal. Given the level of health issues within the prison population, prisons offer an opportunity to address some of these health issues through targeted preventive and treatment programs and services. There are risky levels of alcohol consumption widespread across the Northern Territory population and this includes both urban and remote communities as well as Aboriginal and non-aboriginal communities. Harmful levels of alcohol consumption, in particular intoxication is linked with increased risk taking behaviours and violence, which leads to increased rates or injury and accidents. Long term harmful use of alcohol has been associated with adverse mental health outcomes and other chronic conditions. The numbers of deaths from suicide are increasing in the Northern Territory with rates well above the Australian average. Disadvantage, social isolation and lack of opportunity contribute to a sense of hopelessness within some proportion of the population, which is particularly evident in Aboriginal communities. Significant levels of mental health issues are identified throughout the NT which is also likely to be contributing to the suicide rate. Continued implementation of social and emotional wellbeing strategies and implementation of the Strategic Framework for Suicide Prevention (NTSFSP) is an important investment. The prevalence of type 2 diabetes is increasing within the NT population both Aboriginal and non-aboriginal people. This is not surprising given the challenges with social, economic, behavioural and environmental factors, including access to fresh and affordable food and drinking alcohol at harmful levels. 38 Population Health Commissioning Atlas

39 Needs and Commissioning Approach Summary and Key Considerations for Setting Priorities and Commissioning Services within the NTML The profiling in this Atlas indicates high levels of health disadvantage in the Northern Territory especially in the Aboriginal population. Literature, data and policy documents attribute the perpetuation of this disadvantage to historical factors and conditions and economic opportunity, physical infrastructure, and social conditions - ie. the social determinants of health that influence health outcomes for individuals and their communities. Education, employment, income, housing, access to services, social networks, connection to land, racism and incarceration are all manifestations of these determinants. There are high levels of infectious disease, diseases associated with the tropical climate and landscape, high levels of chronic disease including diseases previously eradicated are re-emerging due to the mobile population passing through the NT. In the NT, there are also pockets of extreme affluence and economic growth. International research indicates that bimodal profiles across a region is a determinant of health in itself and negatively impacts on overall health. 5 The young profile of the NT population and its large transient workforce is likely to support an affluent versus disadvantaged demographic and this is noted in the NTML Health Needs Assessment. 10 The NTML Commissioning Framework The NTML Commissioning Framework establishes a best practice approach to commissioning in a primary health care context by focussing on four core areas of our business: Needs Assessment: Identifying, describing and analysing primary health care needs to inform future strategies, priorities, planning, decision making and program delivery. Also includes sector consultation and engagement with stakeholders and assessment of current services. Concepts of Need Need is an important concept in public health. It is used in the planning and management of health services including health improvement, resource allocation, and equity. However, need is a multifaceted concept with no one universal definition. The need for health care should be distinguished from the need for health. The need for health is broader and can include problems over which health systems have limited ability to influence. Need for health care exists when an individual has an illness or disability for which there is effective and acceptable treatment or care. Health economists have also distinguished need from supply and demand. Need is defined as capacity to benefit; demand is defined as what individuals ask for; and supply is defined as what is provided (i.e. the services that are available). Demand is influenced by factors such as the social and educational background of an individual, the media and the medical profession. Supply is influenced by historical patterns and public and political pressure. Finally, health systems are concerned not only with maximising health, but also with the fair distribution of health. Service development: The assessment of proposed services to be delivered and service design to match primary health care needs and funding obligations. Provider engagement: Sector consultation including engagement with service providers and stakeholders, market mapping and the running of procurement processes. Evaluation: Managing contractual arrangements and conducting an evaluation of the demand, access to and benefits of the service. For Commonwealth-funded programs, there are certain expectations in relation to commissioning processes. For example, the Commonwealth Department of Health:. Prescribes guidelines for Medicare Locals to follow;. Requires Medicare Locals to retain certain core functions; and. Provides approval of service providers recommended by the NTML. In undertaking its core function of commissioning and managing the provision of local primary health care services, the NTML has a robust and transparent procurement process for the selection of appropriate providers (through competitive and non-competitive methods). The NTML Commissioning Framework and Procurement Guide and supporting material provide guidance in relation to the NTML s procurement processes. The NTML needs assessment process, as described above, is guided by the Comprehensive Needs Assessment Framework developed for the Australian Medicare Local Alliance. The NTML Health Atlas is one component of the NTML needs assessment process. Further needs are identified through consultation and engagement with a broad range of stakeholders across the NT, National and Territory strategic directions, and analysis of other data including primary health care service capacity and service utilisation information. Figure 7.1 details the Commissioning Cycle, including the needs assessment component (quadrant 1). Figure 7.1 Commissioning Cycle Source: Australian Medicare Local Alliance 129 Commissioning Cycle (Figure 7.1) The Medicare Local commissioning cycle consists of four core components - needs assessment, service development, provider engagement and evaluation and is directly linked to both strategic and annual planning cycles. One of the key strategic objectives of MLs is to identify the health needs of local areas and develop locally focussed and responsive services. This Population Health Commissioning Atlas provides a tool by which the NTML can build a specific population health profile to inform health needs assessment, including information on the determinants of health, as a means to help establish priorities for service development. It also assists in the identification of key areas in which it can work in partnership with a wide range of stakeholders to strengthen the primary health care system. 129 the PHCAtlas Population Health Commissioning Atlas 39

40 Section E Data Qualifications and Limitations Glossary ABS ACCHS ACE AEDI AHMAC AHW AIHW AMS AMSANT ARB ASDR ASR ATAPS ATSI BMI CBT CHS COPD CVD DALY DoHA ED EHR ESKD FTE FWE GP GPMHP HBW HSD ICD IHD IRSAD IRSD Australian Bureau of Statistics Aboriginal Community Controlled Health Services Angiotensin-Converting-Enzyme Australian Early Development Index Australian Health Ministers' Advisory Council Aboriginal Health Worker Australian Institute of Health & Welfare Aboriginal Medical Service Aboriginal Medical Services Alliance Northern Territory Angiotensin II Receptor Blocker Age Standardised Death Rate Age Standardised Ratio Access to Allied Psychological Services Aboriginal and Torres Strait Islander Body Mass Index Cognitive Behavioural Therapy Community Heath Service Chronic Obstructive Pulmonary Disease Cardiovascular Disease Disability Adjusted Life Years Department of Health & Ageing (Federal) Emergency Department Electronic Health Record End Stage Kidney Disease Full Time Equivalent Full Time Workload Equivalent General Practitioner / General Practice General Practitioner Mental Health Plan High Birth Weight Health Service District International Classification of Diseases Ischemic Heart Disease Index of Socio-Economic Advantage and Disadvantage Index of Relative Socio-Economic Disadvantage Data Qualifications and Limitations A broad range of data sources are used throughout this Atlas, including the Australian Bureau of Statistics (ABS), Medicare Australia, the Australian Institute of Health and Welfare (AIHW) and various other Territory and Commonwealth reports. In order to provide benchmarking of MLs, the majority of the prevalence maps generated for this Atlas rely on a data set for Medicare Locals provided by the Public Health Information Development Unit (PHIDU) using synthetic (modelled) data estimates. These estimates should be used with caution and treated only as indicative of the prevalence of each health indicator in a Statistical Local Area (SLA). Data is readily available at SLA level for urban areas and in a lot of cases the data for remote areas is limited due to the difficulty collecting reliable data across a dispersed population. Within the matrix on page 18 a colour coding system is used for the quintiles for ease of visualisation. The darker the colour, the greater the health need, relative to other MLs. Within this Atlas the NTML is compared to the other 60 MLs for a range of NHPA Key Performance Indicators, by ranking and assignment within a quintile range the highest ranked position having the greatest health need. While the PHIDU data set has been used extensively to assist with the benchmarking of the ML, the data used for this ranking can be a number of years old (2008 onwards). Where possible, newer data is referred to within the text on each page. While in a number of instances new data is available, this data is only generally available at the state level and is not broken down any further than the state boundary, so it can not be used to compare areas within the NT. While ideally the NT would be represented the same across the whole Atlas, due to variations in collection boundaries for various data sources, different methods have been used to represent the NTML region. SLAs are the boundaries most used within this Atlas, however due to the large number of SLAs within Darwin a number of them have been clustered together in order to create an area which contains sufficient population to report on; these regions are Palmerston, Darwin North West, Darwin North East and Darwin South West. In both the Aboriginal and Health Workforce sections, the NT Health Service Districts (HSD) have been used as boundaries to show the variation across the NT. As the HSD boundaries are not an exact match for the SLA boundaries used in the general section of the document (as the HSDs are based on older geographic boundaries) the best approximation of SLAs within a HSD has been used for a consistent look throughout the maps. A number of limitations exist within the data sets used throughout this Atlas, in particular the data around chronic disease risk factors. While data is readily available and can be considered reliable for urban areas of the NT, data collected in remote areas of the Territory is not necessarily reliable. While remote communities are regularly studied and surveyed the data collected it is not routinely shared. With widely dispersed populations data collected in one community does not necessarily correlate with other communities in the same SLA. In much of the NT the majority of primary health care is carried out within an ACCHS or NT Government Primary Health Centre where often a nurse or AHW is providing the care to patients, these episodes of care do not routinely have Medicare items claimed. Service utilisation reporting is based around medicare claims and in areas where this is not the norm, statistics may not provide the complete picture. 40 Population Health Commissioning Atlas

41 Appendix References 1. NHPA - National Health Performance Authority (NHPA). Performance and accountability framework. 6.3 Initial indicators for Medicare Locals. [on line]. Available from: Content/PAF~PAF-Section-6~PAF-Section-6-3 (accessed 25 September 2013). 2. World Health Organization (WHO). Closing the gap in a generation: health equity through action on the social determinants of health (final report of the Commission on Social Determinants of Health). Geneva: WHO, Dahlgren G, Whitehead M, Policies and strategies to promote social equity in health, Copenhagen: World Health Organization, Australian Health Ministers Advisory Council. Aboriginal & Torres Strait Islander Health Performance Framework 2012 Report. Canberra: AHMAC, Social determinants of health: solid facts. Marmot M, Wilkinson, R (eds) Copenhagen: WHO, National Public Health Partnership (NPHP). Preventing chronic disease: a strategic framework. Melbourne: NPHP, Department of Health and Ageing. 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42 References Disclaimer This Publication is Copyright. This PHCAtlas has been developed by Healthfirst Network to provide population health information relating to the NTML region, including text, maps and various forms of data and information obtained from both government and non-government sources. All of the material published in this publication [or on any related website] is together referred to hereafter as "the information". In those circumstances, no responsibility is accepted for the accuracy, completeness, or relevance to the user's purpose, of the information and those using it for whatever purpose are advised to verify it with the relevant Commonwealth or State government department, local government body or other source and to obtain any appropriate professional advice. If this information has been accessed via a related website, then no warranty is given that the information is free of infection by computer viruses or other contamination, nor that access to the website or any part of it will not suffer from interruption from time to time, without notice. Any links to other websites that have been included on this website are provided for your convenience only. Healthfirst Network does not accept any responsibility for the accuracy, availability, or appropriateness to the user's purposes, of any information or services on any other website. Healthfirst Network, its officers, employees and agents do not accept liability however arising, including liability for negligence, for any loss resulting from the use of or reliance upon the information and/or reliance on its availability at any time. 46. Zhang X, Condon J, Douglas F, Bates D, Guthridge S, Garling L, Enciso G and Chondur R. Women s cancers and cancer screening in the Northern Territory. 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Darwin: Department of Health, Cobbold, T. NAPLAN Results Highlight the Failure of Governments to Address Education Disadvantage, [on line] accessed from: Australian Bureau of Statistics, ABS National Aboriginal and Torres Strait Islander Social Survey, Australian Bureau of Statistics, ABS National Aboriginal and Torres Strait Islander Health Survey Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander health performance framework 2006 report: detailed analyses. Cat. no. IHW 20. Canberra: AIHW, Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework 2010: detailed analyses. Cat. no. IHW 53. Canberra: AIHW, Wang et al. Mortality in the Northern Territory Health Gains Planning Information Sheet, Dec Darwin: Department of Health, Georgatos G. Time on country instead of in prisons. 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43 References 90. Northern Territory. Department of Health. Market Basket Survey Darwin: Department of Health, Australian Institute of Health and Welfare. Indigenous housing needs 2005: a multi-measure needs model, AIHW Cat. no. HOU 129, Canberra: AIHW, Booth, AL & Carroll, N. Overcrowding and Indigenous health in Australia, Centre for Economic Policy Research, Australian National University. Canberra: ANU, Australian Institute of Health and Welfare. Housing and homelessness services: access for Aboriginal and Torres Strait Islander people. Cat. no. HOU 237. Canberra: AIHW, de Costa CM & Wenitong M. 'Could the Baby Bonus be a bonus for babies?'. Medical Journal of Australia, 2009; 190(5): Australian Institute of Health and Welfare. Healthy Development Breastfeeding. [on line] Available from: aihw.gov.au/child-health/healthy-development/ 96. Annamalay AA et al. 'Prevalence of and risk factors for human rhinovirus infection in healthy Aboriginal and non- Aboriginal Western Australian children'. The Pediatric Infectious Disease Journal, 2012; 31(7): National Health and Medical Research Council. Nutrition in Aboriginal and Torres Strait Islander peoples: an information paper. Canberra: National Health and Medical Research Council, Burns J & Thomson N. Review of nutrition and growth among Indigenous peoples [online] available from Williams CJ & Jacobs AM. 'The impact of otitis media on cognitive and educational outcomes'. Medical Journal of Australia, 2009;191(9):S Australian Institute of Health and Welfare. Ear and hearing health of Indigenous children in the Northern Territory. Cat no. IHW 60. Canberra: AIHW, Australian Institute of Health and Welfare. Dental health of Indigenous children in the Northern Territory, Bulletin 102. Canberra: AIHW, Williams S, Jamieson L, MacRae A, Gray C. Review of Indigenous oral health. [on line] 2009 accessed from healthinfonet.ecu.edu.au/oral_review 103. Rychetnik L,Webb K,Story L & Katz T. Food Security Options Paper: A planning framework and menu of options for policy and practice interventions, NSW: Centre for Public Health Nutrition, Browne J, Laurence S, Thorpe S. Acting on food insecurity in urban Aboriginal and Torres Strait Islander communities: Policy and practice interventions to improve local access and supply of nutritious food Ge KY, Chang SY. Definition and measurement of child malnutrition. Biomed Environ Sci, 2001;14(4) 106. Vos T, Barker B, Begg S, Stanley L & Lopez AD. 'Burden of disease and injury in Aboriginal and Torres Strait Islander Peoples: the Indigenous health gap'. International Journal of Epidemiology, 2009;38(2): Cancer Council Australia. Preventing cancer. [on line]. Available from: nutrition-and-physical-activity/food-and-nutrition.html. (accessed 23 November 2013) 108. Tropical Health in the Top End: An Introduction for health practitioner, Darwin: Top End Division of General Practice, Tindall H. Scabies Control in a Remote Aboriginal Community in the Northern Territory, Australia. In: Canyon R, Speare R, editors. Rural and Remote Environmental Health I. Brisbane: The Australasian College of Tropical Medicine, Australian Institute of Health and Welfare. Rheumatic Fever and Rheumatic Heart Disease. [on line] Available from: Australian Indigenous HealthInfoNet (2008) Summary of tuberculosis among Indigenous peoples. Retrieved from National Public Health Partnership (NPHP). The National Aboriginal and Torres Strait Islander Safety Promotion Strategy. Canberra: NPHP, Chondur R, Wang Z. Alcohol use in the Northern Territory, Health Gains Planning Information Sheet, Oct Darwin: Department of Health, Northern Territory Government. Safer Road use: A Territory Imperative, NT Road Safety Taskforce Report, June Mental Illness Fellowship of Australia. 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The Northern Territory Clinical School and University departments of rural health at Northern Rivers, Tamworth and Tasmania 124. Australian Institute of Health and Welfare. Allied health workforce National health workforce series no. 5. Cat. no. HWL 51. Canberra: AIHW, Ridoutt L & Wong A. Recruitment and Retention of Allied Health Professionals in Victoria A Literature review. Melbourne: Department of Human Services, Boxall P, Macky K & Rasmussen E. Labour Turnover and Retention in New Zealand: The Causes and Consequences of Leaving and Staying with Employers. Asia Pacific Journal of Human Resources 2003;41: Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander health services report : Online Services Report key results. Cat. no. IHW 104. Canberra: AIHW, Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework 2012: detailed analyses. Cat. no. IHW 94. Canberra: AIHW, Australian Medicare Local Alliance. Primary Health Care Commissioning Framework. Australian Medicare Local Alliance Wilson E et al. Developing a prioritisation framework in an English Primary Care Trust. Cost Effectiveness and Resource Allocation Zhao Y, Connors C, Wright J, Guthridge S, Bailie R. Estimating chronic disease prevalence among the remote Aboriginal population of the Northern Territory using multiple data sources. Australian and New Zealand journal of publich health. 2008;32(4): Wise S. Improving the early life outcomes of Indigenous children: implementing early childhood development at the local level. Issues paper no. 6. Produced for the Closing the Gap Clearinghouse. Canberra: Australian Institute of Health and Welfare & Melbourne: Australian Institute of Family Studies, 2013 Copyright and Citation This Publication is Copyright. Other than for the purposes of and subject to the conditions prescribed under the Copyright Act 1968, no part of it may in any form or by any means [electronic, mechanical, microcopying, photocopying, recording or otherwise] be reproduced, stored in a retrieval system or transmitted without prior written permission. Inquiries should be addressed to the Healthfirst Network. Suggested Citation: Northern Territory Medicare Local (2014): Northern Territory Population Health Commissioning Atlas. Healthfirst Network Publication; Population Health Series (NTML) Acknowledgements PHCAtlas [Population Health Commissioning Atlas ] is a trademark of Healthfirst Network. The Healthfirst Network PHCA Team: Manager Population Health - Carmel Williams Public Health Physician / GP - Dr Peter Del Fante Research Officer - Alf Martin Senior Data Analyst - Ross Vivian Health Data Manager - Debbie Stratford Graphic Design - Jacqueline Haseldine Funding This version of the PHCAtlas was prepared for and funded by the Northern Territory Medicare Local. the PHCAtlas Population Health Commissioning Atlas 43

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