HUNTER NEW ENGLAND AND CENTRAL COAST. An Australian Government Initiative

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1 HUNTER NEW ENGLAND AND CENTRAL COAST An Australian Government Initiative Health Planning Compass 2016 HNECC PHN acknowledges the traditional owners and custodians of the land that we live and work on as the First People of this Country.

2 Contents Page 3 4 Welcome and introduction to the Health Planning Compass Determinants of Health Concept of Need Commissioning for Health Data sources 5 Snapshot of Health across the HNECC Region overview 6 Demographics and Trends 12 Socioeconomic Indicators and Social Determinants of Health 14 Child and Maternal Health 16 Lifestyle Risk Factors 18 Chronic Disease 20 Mental Health 21 Health Status 21 Mortality 23 Prevention and screening 25 Service Utilisation and Access 26 Potentially Preventable Hospitalisations 28 After Hours 30 Health Workforce 31 Summary of Health Needs Welcome to the Hunter New England and Central Coast (HNECC) Primary Health Network 2016 Health Planning Compass This document describes the populations and provides a valuable picture of the current health and social landscapes across the Hunter, New England and Central Coast region of New South Wales. The information and findings presented have been fundamental in identifying gaps in access to health services, establishing the priority health and access needs for our communities and forming recommendations for further in-depth analysis. It provides us with the confidence to make evidence and resource based decisions and to create and source effective solutions to local problems. It will assist in planning for better primary health care and establish opportunities for health gain across our geographical footprint. What is a Primary Health Network? In July 2015, the Federal Government introduced changes to the way primary care services are managed across Australia, replacing Medicare Locals with Primary Health Networks (PHNs). The aim of this change is to strengthen primary care by redirecting funding to frontline health services improving health care for our community. 36 References Appendix Summary Matrix HNECC PHN Primary Health Networks (PHNs) have been established with the key objectives of increasing the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes, and improving coordination of care to ensure patients receive the right care in the right place at the right time Australian Government Department of Health

3 Determinants of Health Our individual health and the health of our communities is influenced by many factors. Social, environmental and economic elements connected to us and where we live, work and play, play significant roles in determining our health potential. The social determinants of health, as presented by Dahlgren and Whitehead s model below indicate that health is so much more than being able to access a doctor or hospital when unwell. Acknowledgement of traditional owners Hunter New England Central Coast (HNECC) PHN acknowledges the traditional custodians of the land we walk upon today and respect their continuing culture and the contribution they make to the life of this vast region. Altering or modifying lifestyle choices can have a positive impact on the health of communities and individuals, essentially lowering the prevalence of chronic diseases such as Type 2 Diabetes, Cardiovascular Disease, respiratory illnesses and cancers. Furthermore, how individuals and communities interact with each other and access health services and opportunities for health also impact our thoughts about our health status and the wellness of our communities. The Health Planning Compass aims to consider the many elements of health presented above. Aboriginal Nations within the HNECC region include; Anaiwan and Nganyaywana Awabakal Biripi Darkinjung Geawegal Kamilaroi Kuring-gai Ngarabai Wonnaru Worimi Concepts of Need Bradshaw (1972) suggests there are four dimensions or different types of need. It is important when undertaking a needs assessment to consider each type of need (described below) to increase the chance of constructing a comprehensive picture of community problems and ensure that real need is identified. But that s not all: we additionally consider cost containment, capacity to benefit and general demand and supply in determining best health outcomes for communities and individuals. Additionally, we look outside the remit of the health sector to ensure that need is assessed comprehensively and in context with local factors and nuances. 3

4 What is Quadruple AIM? Quadruple AIM is an approach by which planned health outcomes consider four very important factors within the health and social arena. Population Health here the health of a whole or small population subgroup is considered and investigated to ascertain where health improvements and outcomes could be achieved. Commissioning for health services Commissioning is a sophisticated process of planning and purchasing health services to meet the health needs of local populations. It involves a rigorous planning process with significant stakeholder involvement in the development of services, as well as procurement that focuses on quality, value for money and delivering health outcomes. Continual performance monitoring and evaluation of commissioned services ensures they continue to meet the needs of the population and achieve their intended aims. This decision-making process is 'cyclical' and so has been termed the commissioning cycle. The model presented below describes this process and is centred around the elements of population health, the patient experience and cost per capita. Patient experience this is considered extensively as it has a major impact on how and why people access services. The experience within the health system and how it is navigated can either act as a barrier to health or an enabler in gaining better health. Cost per head of population is a major consideration in planning for health improvement. Not only is the cost to the health system explored but the cost to the individual, their family and way of life. While some of this comes down to bang-for-buck, considering cost is an essential component to successful and meaningful service delivery. Improving the work life of healthcare providers The key personnel in the delivery and planning for health, such as the medical and wider health workforce should be a main factor in considering and applying population wide health considerations. Involving health professionals, supporting their work and industry really is essential to health provision and the continued efforts in identifying health and social gaps and potential solutions. Data Sources How do we know what we know? We use a number of valuable data sources to enhance our understanding of the health landscape across our vast region. We access, compile and analyse multiple high quality data obtained from Health Statistics NSW, NSW Ministry of Health Public Health Information Development Unit (PHIDU), University of Adelaide Australian Bureau of Statistics Our Local Health Districts (LHD), Hunter New England LHD and the Central Coast LHD Department of Planning and Infrastructure Australian Institute of Health and Welfare NSW Cancer Institute Our local GPs and health providers Engagement and consultation with communities, individuals and minority groups in our region Engagement and consultation with health professionals and organisations across a variety of sectors including Local Government, Education and Welfare. 4

5 Landscape Snapshot The HNECC region is a large and diverse geographic area incorporating 27 Local Government Areas (LGAs). HNECC is the second largest PHN in New South Wales and covers a significant geographical area (133,812 km 2 ). It reaches from just north of Sydney, across the north west of NSW, to the Queensland border. The HNECC region is serviced by Hunter New England LHD and Central Coast LHD. The estimated resident population of the HNECC region in 2013 was 1,223,245 people or 16.5% of the state population. Females accounted for 50.5% (617,890 people) of the total population and males accounted for 49.5% (605,356 people). Break it down The HNECC region is comprised of the following subregions and Local Government Areas (LGAs); New England LGAs include; Armidale Dumaresq Glen Innes Severn Gunnedah Guyra Gwydir Inverell Liverpool Plains Moree Plains Narrabri Tamworth Regional Tenterfield Uralla Walcha Hunter LGAs include; Cessnock Dungog Gloucester Greater Taree Great Lakes Lake Macquarie Maitland Muswellbrook Newcastle Port Stephens Singleton Upper Hunter Shire Central Coast LGAs include; Gosford Wyong Health Services Some of the main workforce and services supporting and promoting health across the region are presented right. The LGAs which appear to have greatest GP to population stress include; Dungog, Tenterfield, Gunnedah, Liverpool Plains and Cessnock. The greatest presence of GPs per population is seen in Gloucester and Armidale Dumaresq. General Practitioners Service details 1322 (FTE varies) General Practices 401 Aboriginal Medical Services 9 Local Health Districts 2 Public Hospitals 22 District Hospitals 7 Multi-Purpose Services 10 Mental Health Psychiatric Hospitals 2 Pharmacies 285 Fast Fact The HNECC region is geographically the size of England! 5

6 At a Glance Demographics and Trends The following pages present data related to the demographics of the people of the HNECC region. Population growth The graphic below illustrates population growth and estimated resident population by LGA across the HNECC region. Towards 2031, the HNECC region will grow to well over 1.4 million people with some Local Government Areas (LGAs) showing substantial annual growth while others will experience declines in population. The LGAs experiencing these declines include: Moree Plains, Gwydir, Glen Innes Severn, Walcha, Gloucester and Dungog. Those LGAs which will experience the most growth to 2031 include: Maitland, Port Stephens, Cessnock, Wyong and Armidale Dumaresq. Median Age Median ages across the HNECC region s LGAs vary greatly. From our oldest populations in Great Lakes LGA (53.6 yrs.), Gloucester (50.8 yrs.) and Tenterfield (49.8 yrs.) to our youngest in Armidale Dumaresq (33.9 yrs.), Muswellbrook (34.1 yrs.), Singleton (35.1 yrs.) and Moree Plains (35.3yrs). An understanding of median age assists in planning for health and potential resource allocation based on likely disease burden and levels of dependency. 6

7 Demographics and Trends HNECC and NSW Male and Female age comparisons Age Structure Based on 2013 ERP, 18.3% of the population living in the HNECC region were over the age of 65 years, which is higher than the NSW proportion (15.2%). The LGAs with the highest proportion of the population aged 65 years and over include: Great Lakes (32.1%) Gloucester (27.5%) Gwydir (23.9%) Tenterfield (23.8%) Greater Taree (23.5%). There was a correspondingly low proportion of people aged in these areas, which creates cause for concern in relation to ongoing workforce availability and the need for more health services for an ageing population. % of Population Local Government Areas with the highest proportions of young people (0-14 years) across the region include: Centre for Epidemiology and Evidence 2015 Moree Plains (22.7%) Narrabri (22.1%) Muswellbrook (21.9%) Maitland (21.7%) Upper Hunter Shire (21.4%). Population Density The population density varies substantially across this vast region from 0.5 people/km 2 in the LGA of Walcha to people/ km 2 in Lake Macquarie LGA. Similarly, the population of the various LGAs range from 3,098 people in Walcha to 202,676 people in Lake Macquarie. 7

8 Aboriginal and /or Torres Strait Islander Population In 2011 there were 48,002 people in the HNECC region who identified as being Aboriginal and/ or Torres Strait Islander, equivalent to 4.2% of the resident population. This proportion is greater than the average across NSW and Australia, both at 2.5%, placing HNECC as having the seventh highest Aboriginal and/or Torres Strait Islander population amongst the 31 PHNs across Australia. Demographics and Trends Aboriginal and/or Torres Strait Islander % of Population, 2011 The map to the right shows the population distribution for Aboriginal and Torres Strait Islander people across the region. The LGAs with the highest resident Aboriginal and/or Torres Strait Islander populations are located in the northern part of the region and include: Moree Plains (20.8%) Gunnedah (11.3%) Liverpool Plains (10.9%) Narrabri (10.7%) Guyra (10.1%). The age distribution of the Aboriginal population compared to the non-aboriginal population across the region is shown right. The Aboriginal population has a considerably younger age profile than the non-aboriginal population. It is noted that; 56.8% of the Aboriginal population are aged under 24 years, compared to 30.9% of the non- Aboriginal population. ABS 2015 Only 4.2% of the Aboriginal population are aged over 65 years, compared to 18.9% of the non- Aboriginal population. Centre for Epidemiology and Evidence

9 Demographics and Trends Socio-economic Indicators and Social Determinants of Health Socio-economic Disadvantage - SEIFA, 2011 Socio-economic Disadvantage Socio-Economic Indexes for Areas (SEIFA) scores are a measure of advantage and disadvantage compiled by the Australian Bureau of Statistics (ABS). The Census variables used to calculate the SEIFA indexes cover a number of domains and include household income, education, employment, occupation, housing and other indicators of advantage and disadvantage. The map left highlights SEIFA Index of Relative Socio-Economic Disadvantage (IRSD) by LGA in the HNECC region, ranging from the most disadvantaged at 914 (experienced in the LGA of Greater Taree) to the least disadvantaged at 1013 (experienced in the LGA of Singleton). 'Inequities in health, avoidable health inequalities, arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. The conditions in which people live and die are, in turn, shaped by political, social, and economic forces' (Commission on Social Determinants of Health 2008) ABS

10 PHIDU 2014 Demographics and Trends Country of Birth People born in predominantly NES countries People born overseas reporting poor proficiency in English HNECC Highest rates Lowest rates NSW 4.5% 0.4% Newcastle 7.8% Armidale Dumaresq 6.9% Newcastle 1.1% Armidale Dumaresq 0.8% Guyra 1.3% Gwydir 1.3% Glen Innes Severn 0.1%, Cessnock 0.1% 18.6% 3.4% Culturally and Linguistically Diverse Communities (CALD) The majority of residents (84.4%) within the HNECC Region were born in Australia (NSW 68.6%). Those who were born in predominantly non-english speaking (NES) countries account for 4.5% of our population with the highest proportions in Newcastle and Armidale Dumaresq. Those born overseas reporting poor proficiency in English account for 0.4% of the region s population compared to the NSW rate of 3.8%. Centre for Epidemiology and Evidence 2015; PHIDU 2015 Languages spoken Languages Number % of PHN Italian German Mandarin Greek Spanish Cantonese Macedonian Arabic Tagalog Dutch French Polish Afrikaans Korean Thai Filipino Hindi Croatian Vietnamese Japanese Over the past 10 years there has been substantial growth in the population who identify as being from a CALD background. The top 5 languages spoken are Italian, German, Mandarin, Greek and Spanish. Interpreter services are available for people who do not speak English as a first language. Refugees There is a small refugee population in the HNECC region. Most people originate from Southern Sudan, with some from other African countries, such as Sierra Leone and Liberia. The national language of Sudan is Arabic, with most new arrivals learning English. In Newcastle the most common other language is Dinka. Many refugees are learning to support themselves, with the income they receive from the government. They are also supported by family and community members there is a Sudanese Community Association and most church groups continue to be very helpful. Support also comes from TAFE, ACE and public, private and Catholic schools. Northern Settlement Services is a frequent source of support and referral for all refugees and migrants. Northern Settlement Services

11 Demographics and Trends Carers There are over 114,000 (12.3%) people aged 15 years and over providing unpaid assistance to persons with a disability in the HNECC region (NSW 11.4%). The highest rates are in Gwydir (14.8%), Dungog (14.1%), Gloucester (14.0%) and Greater Taree (14.0%). A lack of carer recognition, a lack of respite services and a decrease in the number of volunteers, have been identified as challenges in the disability sector in our region. Disability The rate of profound or severe disability across our region (5.8%) is higher than the state average of 4.9%. 19 of our 27 LGAs sit above the state rate, with the highest rates being in Greater Taree (7.7%), Great Lakes (7.5%), Gwydir (7.3%), Glen Innes Severn (7.0%) and Tenterfield (7.0%). Profound or severe disability is more common amongst people 65 years and older (18.3% in NSW). The prevalence amongst this cohort in our region ranges from 13.1% in Uralla, to 21.8% in Cessnock. 11

12 Socio-economic Indicators Socio-economic Indicators and Social Determinants of Health Further indicators of socio-economic disadvantage or stressors can be seen by examining the indicators presented in the table right. Across the HNECC region rates of single parent families are high in 23 of the 27 LGAs, compared to the state population. Rates of children in jobless families are also high in Tenterfield, Greater Taree and Great Lakes LGAs. Similarly, the percentage of welfare dependent, low income families across the region are also high and are especially noted in the LGAs of Tenterfield, Greater Taree and Great Lakes. Moree Plains, Great Lakes and Greater Taree LGAs have the highest rates of single parent payment beneficiaries with each more than double the NSW rate. Of those receiving a single parent payment, the percentage of female sole parents is greatest in the Moree Plains, Inverell and Liverpool Plains LGAs, in fact, 26 out of the full 27 LGAs within the HNECC area have a rate of female sole parents higher than the NSW figure. The percentage of low income households across the region which experience mortgage or rent stress, compared to the NSW rate is not significant with only the LGA of Armidale Dumaresq sitting above this rate. Unemployment rates in March 2015 were highest in the LGAs of Cessnock, Glen Innes Severn, and Tenterfield. These were all well above the NSW rate of 5.7%. Factors which impact health % Single parent families with children under 15 years, 2011 % Jobless families with children under 15 years, 2011 % Low income welfare dependent families, 2013 % Single parent payment beneficiaries, 2012 % Low income households under financial stress from mortgage or rent, 2011 % Unemployment rates, (smoothed) March 2015 HNECC Highest Rates Lowest Rates NSW Aus Greater Taree 32.7 Great Lakes 32.6 Wyong 30.7 Tenterfield 27.0 Greater Taree 26.5 Greta Lakes 23.1 Tenterfield 44.2 Greater Taree 38.8 Great Lakes 38.4 Moree Plains 12.7 Great Lakes 10.2 Greater Taree 10.1 Armidale Dumaresq 35.8 Wyong 32.5 Muswellbrook 32.1 Cessnock 12.8 Glen Innes Severn 12.3 Tenterfield 11.7 Singleton 18.3 Gwydir 19.9 Upper Hunter Shire 20.2 Singleton 8.9 Upper Hunter Shire 10.2 Dungog 12.5 Singleton 15.7 Upper Hunter Shire 17.8 Newcastle 20.6 Singleton 4.5 Newcastle 5.0 Upper Hunter Shire 5.1 Walcha 13.5 Liverpool Plains 17.7 Guyra 17.8 Gosford 5.5 Uralla 5.9 Upper Hunter Shire 5.9 Australian Government Department of Employment 2015; PHIDU Internet Access In 2011, in the HNECC region 24.7% of dwellings were without internet connection. This was greater than the state proportion (20.1%). The main pockets with no internet connection encompass a sizeable portion of the New England North West sub-region and the Gloucester, Greater Taree and Great Lakes LGAs. Specifically, Gwydir LGA had the highest number of households without internet connection (38.1%) and Singleton the least (19.9%). Geographical Classification Within the Australian Standard Geographical Classification Remoteness Areas (ASGC-RA), which was developed to allow for quantitative comparisons between city and country, the HNECC region has populations falling within the categories of: Major Cities Inner Regional Outer Regional Remote AIHW

13 Socio-economic Indicators and Social Determinants of Health In 2011, 17.5% of the HNECC population participated in voluntary work for an organisation or group compared to 16.9% of the NSW population. The highest rates of participation occurred within the LGAs of Walcha (31.7%), Gwydir (31.1%) and Uralla (29.4%). The lowest participation occurred in Cessnock (12.5%), Wyong (13.7%) and Maitland (14.8%). Source: PHIDU Social Health Atlas of Australia, 2016 Age Dependency Ratios 2013 Age dependency ratio (proportion of aged dependents per 100 working-age population) Child dependency ratio (proportion of child dependents per 100 working-age population) Total age dependency ratio (proportion of all dependents per 100 working-age population) Source: PHIDU Social Health Atlas of Australia, 2016 Highest Rates Lowest Rates NSW Aus Great Lakes 60.9 Gloucester 49.3 Gwydir 41.4 Narrabri 36.0 Moree Plains 35.4 Guyra 34.8 Great Lakes 89.6 Gloucester 79.1 Gwydir 72.9 Singleton 16.1 Muswellbrook 16.4 Maitland 20.0 Newcastle 24.9 Armidale Dumaresq 28.3 Great Lakes 28.7 Singleton 47.0 Newcastle 47.8 Muswellbrook 49.1 Community Strength Community strength Community strength is an important indicator of the level of social cohesiveness within a population. This impacts how the community deals with unforeseen events or crisis and how they support members of their community in times of need. It additionally impacts how safe people feel in their communities and their acceptance of other cultures. Age dependency ratios The table to the left presents data on dependency within the HNECC area. This measures the pressure (economical, social, and welfare) on the working portions of the population. The rates of aged dependency in the LGAs of Great Lakes, Gloucester and Gwydir are considerably higher than the NSW rates indicating that a smaller proportion of the working population is available to support the aged members of these communities. This is potentially a ratio which is likely to increase given the ageing population in the HNECC region. The child dependency ratio is highest within the LGAs of Narrabri, Moree Plains and Guyra. Children in the HNECC Region The map to the left presents data on the development of children in their first year of school across a number of domains. These domains include: Communication Language Emotional Social Physical Across the region 20.7% of children were considered vulnerable on one or more domains. The LGAs of Moree Plains, Tenterfield, Armidale Dumaresq and Greater Taree show the greatest percentage of developmental vulnerability on one or more domains of the index. Walcha, Dungog, Upper Hunter Shire and Gloucester present the lowest rates of developmentally vulnerable children for the region. 13

14 Immunisation Rates The rates of immunisation across the HNECC region on the whole are generally better than the national rates. Child and Maternal Health Children fully immunised % aged from 12 months to 5 years. Data processed end June 2015 While improvement in all immunisation rates would be beneficial it is the Aboriginal and/or Torres Strait Islander childhood immunisation rates, particularly within the New England North West subregion which need further attention and consideration. By Statistical Area Level 3 (SA3) those areas which have lower rates of childhood immunisation include: Great Lakes Moree-Narrabri Armidale Newcastle The SA3s with higher participation rates include: Maitland Taree-Gloucester Tamworth-Gunnedah Vaccinations included when measuring childhood immunisation status. NSW: Children Fully Immunised HNECC Region total Highest Rates Lowest Rates NSW Australia 1yr Fully Immunised 93.1% Lake Macquarie East 97.4% Great Lakes 97.1% Wyong 97.1% Moree-Narrabri 91.1% Lake Macquarie West 91.4% Inverell- Tenterfield 91.4% 92.2% 92.3% 1yr Fully Immunised Aboriginal 92.4% No Data No Data 91.2% 88.7% 2yrs Fully Immunised 91.3% Newcastle 94.0% Great Lakes 93.2% Port Stephens 93.0% Upper Hunter 89.4% Lower Hunter 89.7% Taree-Gloucester 89.9% 89.1% 89.3% 2yrs Fully Immunised Aboriginal 89.9% No Data No Data 88.5% 86.2% 5yrs Fully Immunised 94.8% Maitland 98.0% Lower Hunter 97.7% Tamworth- Gunnedah 97.4% Great Lakes 92.7% Taree-Gloucester 93.1% Gosford 93.3% 93.0% 92.6% 5yrs Fully Immunised Aboriginal Girls turning 15 years in 2013 who were Fully Immunised against HPV 95.7% No Data No Data 95.3% 93.9% 71% No Data No Data 69.7% 73.1% ACIR

15 Child and Maternal Health Measure Central Coast Hunter Infant and young child mortality rate Deaths per 1000 live births % Smoking during pregnancy , all women % Smoking during pregnancy , Aboriginal and Torres Strait Islander women % Low birth weight babies, , all women % Low birth weight babies, , Aboriginal and Torres Strait Islander women New England North West Aus Healthy Mums and Bubs It is well known that the health of mothers and children are extremely significant when assessing the health status of a community. Healthy mothers deliver healthy babies who in turn become healthy children and healthy adults. There are a number of risks or lifestyle factors that may affect the health outcomes for the mother and child. These include risky behaviours during pregnancy such as smoking or delaying health checks. For children, poor nutrition, inadequate shelter or a failure to immunise may increase the chances of a child developing diseases that can result in premature mortality. Child and Infant Mortality Deaths occurring before 5 years of age are considerably higher in the New England North West sub-region of the HNECC area (6.1 deaths per 1000 live births compared to the national rate of 4.4 deaths per 1000 live births). The rate in the Hunter subregion is also above that of the nation. % Antenatal visits in the 1 st trimester, all women % Antenatal visits in the 1 st trimester, Aboriginal and Torres Strait Islander women NHPA 2015a Smoking During Pregnancy The rates of smoking while pregnant across the HNECC region are far from ideal with all three sub-regions reporting rates higher than the national average. For Aboriginal and/or Torres Strait Islander women, the rates of smoking while pregnant are alarming at 42% for the Central Coast, 48.9% in the Hunter and 55.1% in the New England North West (National rate: 51.7%). Aboriginal and/or Torres Strait Islander Infant and Young Child Mortality Infant and young child mortality rates for Aboriginal and/or Torres Strait Islander children have declined over the past decade with 42% of the decline in infant mortality rates due to a decrease in sudden infant death syndrome (SIDS) and 25% due to a fall in deaths from certain conditions originating in the perinatal period. External causes (injury and poisoning) account for just over half of all deaths of Aboriginal and/or Torres Strait Islander infants and young children. However, between 2006 and 2010 Aboriginal and/or Torres Strait Islander infant and young child mortality rates were still double the non-indigenous rate, as were infant mortality rates (8 deaths per 1,000 live births compared with 4 deaths per 1,000 live births). NHPA 2015a Low Birthweight Babies The New England North West sub-region within the HNECC area has higher percentages of low birthweight babies compared to the national rates for all women and Aboriginal and/or Torres Strait Islander women. These rates are higher than the Hunter and Central Coast subregions. Antenatal Visits The percentages of women participating in antenatal visits within the first trimester, for all women, and Aboriginal and/or Torres Strait Islander women across the entire HNECC area substantially greater than the national percentage rates. This is a fantastic result which has major positive impacts on the health of the mother and child. 15

16 Lifestyle Risk Factors Smoking, high risk alcohol consumption and excess weight are major risk factors for death and disease in Australia. Smoking is linked to numerous health problems, including: coronary heart disease; stroke; peripheral vascular disease; and cancer. Smoking rates are high across the region, with all LGAs above the NSW average, and Moree Plains as much as 1.5 times the NSW rate. High risk alcohol consumption is considered to be an average daily consumption of seven or more standard drinks for males and five or more standard drinks for females; and more than 43 standard drinks per week for males, and more than 29 standard drinks per week for females. This has been linked to: cirrhosis of the liver; cancer; stroke; inflammatory heart disease; hypertension; road accidents; memory lapse; falls; suicide; and drowning. With the exception of Armidale Dumaresq LGA, all LGAs across our region are above the NSW average for risky alcohol consumption. A person who is considered to be overweight has a BMI (body mass index) of 25 to less than 30, and a person who is classified as obese has a BMI of 30 or greater. Excess weight increases the risk of developing diseases such as: cardiovascular disease, Type 2 diabetes, musculoskeletal conditions, and cancer; the risk of which increases with weight gain. As shown in the table to the right, rates of overweight and obesity are high in the HNECC region compared to the average rates for NSW. Twenty of our region s 27 LGAs have levels of overweight greater than the NSW rate of 34.6%. Three in every ten people in the HNECC region are classified as obese. All LGAs in our region have rates of obesity that are well above the NSW rate of 26.4%. The Upper Hunter Shire and Narrabri LGAs had the highest rates with one third of the population obese. LGA Armidale Dumaresq Lifestyle risk factors Estimated Population with Lifestyle Risk Factors (ASR/100)ASR / 100 Smoking Overweight (not obese) Obese High Risk Alcohol Physical Inactivity Cessnock Dungog Glen Innes Severn Gloucester Gosford Great Lakes Greater Taree Gunnedah Guyra Gwydir Inverell Lake Macquarie Liverpool Plains Maitland Moree Plains Muswellbrook Narrabri Newcastle Port Stephens Singleton Tamworth Regional Tenterfield Upper Hunter Shire Uralla Walcha Wyong HNECC n.d NSW PHIDU 2013; 2014 PHIDU 2013; 2014 AIHW 2007; 2015a AIHW

17 Lifestyle risk factors and Chronic Disease Lifestyle Risk Factors The map to the left indicates that across the HNECC region there are high proportions of people participating in unhealthy behaviours. As noted previously these lifestyle risk factors are associated with poorer health outcomes and the development of diseases which can lead to premature death. Using this measure, the highest rates are noted in the LGAs of: Tenterfield Glen Innes Severn Guyra Cessnock The lower rates are noted in the LGAs of: Gosford Lake Macquarie Singleton Armidale Dumaresq Chronic diseases are the leading cause of illness, disability and death in Australia, accounting for 90% of all deaths in Chronic Disease Estimates HNECC Highest Incidence Lowest Incidence NSW Population, aged 18 years and over, with diabetes mellitus (ASR/100) Population, aged 18 years and over, with high blood cholesterol (ASR/100) Population, aged 2 years and over, with circulatory system diseases (ASR/100) Population with hypertensive disease (ASR/100) Population with asthma (ASR/100) Population with chronic obstructive pulmonary disease (COPD) (ASR/100) Population with arthritis (ASR/100) For Australians aged 45 64, levels of overweight and obesity rose from 70% to 73% between and However, the proportion of daily smokers fell from 19% to 17% over the same period. AIHW 2014 Gwydir 5.5 Inverell 5.4 Maitland 5.4 Muswellbrook 35.2 Moree Plains 34.6 Uralla 34.6 Moree Plains 20.4 Narrabri 19.9 Armidale Dumaresq 19.3 Inverell 11.3 Armidale Dumaresq 11.1 Muswellbrook 11.1 Maitland 12.7 Great Lakes 12.7 Armidale 12.6 Cessnock 3.2 Greater Taree 3.2 Wyong 3.2 Greater Taree 18.9 Cessnock 18.9 Inverell 18.6 An increase in chronic diseases is also to be expected because of an ageing population. Walcha 4.1 Dungog 4.3 Uralla 4.3 Gloucester 31.0 Gwydir 31.1 Inverell 31.3 Muswellbrook 17.8 Upper Hunter Shire 17.9 Dungog 18.0 Great Lakes 10.0 Dungog 10.3 Gloucester 10.3 Walcha 10.3 Newcastle 10.5 Gosford 10.6 Walcha 2.6 Uralla 2.7 Guyra 2.7 Uralla 15.5 Singleton 15.5 Walcha Chronic Disease Diabetes is a chronic disease characterised by high levels of blood glucose. This is due to either an inability to produce insulin or to use insulin effectively. Type 1 Diabetes is an autoimmune disease affecting approximately 12% of diabetes sufferers. Type 2 Diabetes accounts for an estimated 86% of diabetes cases and can generally be prevented by maintaining a healthy lifestyle. In an estimated 243,637 people in New South Wales had Type 2 Diabetes at a rate of 3.5%. At this time, with the exception of Gosford and Singleton LGAs, all LGAs in this region had rates of Type 2 Diabetes equal to or higher than the NSW average. With the highest being Moree Plains, Cessnock, Guyra, and Tenterfield LGAs. Chronic Obstructive Pulmonary Disease (COPD) is a debilitating condition characterised by severe shortness of breath and coughing due to reduced airflow in the lungs. The primary cause of COPD is smoking. In the prevalence of COPD in New South Wales was 2.6%. At this time there were an estimated 39,140 people suffering COPD within our region at a rate of 3.0%. The greatest prevalence was estimated within the Cessnock, Greater Taree and Wyong LGA s (3.2%), and the lowest in Walcha (2.6%), Uralla and Guyra (2.7%). In approximately $929 million was spent on COPD in Australia. PHIDU 2014 AIHW 2015a 17

18 Cancer Incidence Chronic Disease Cancer type Highest Incidence, LGA (ASR / 100,000) Lowest Incidence, LGA (ASR / 100,000) NSW Incidence (ASR / 100,000) Mortality Highest rate, LGA (ASR / 100,000) Mortality Lowest rate, LGA (ASR / 100,000) NSW Mortality (ASR / 100,000) Prostate Breast Melanoma Lung Colon Rectal Non-Hodgkins Lymphoma Kidney Walcha (184.4) Gunnedah (145.9) Glen Innes Severn (143.7) Gwydir (77.0) Great Lakes (70.2) Gosford (68.9) Walcha (112.1) Tenterfield (83.2) Gwydir (79.2) Uralla (65.9) Narrabri (62.4) Moree Plains (61.9) Gloucester (63.3) Uralla (59.1) Moree Plains (54.9) Walcha (34.9) Muswellbrook (34.4) Dungog (29.3) Liverpool Plains (27.5) Armidale Dumaresq (27.0) Narrabri (26.5) Cessnock (20.7) Gwydir (19.8) Muswellbrook (19.7) Wyong (77.4) Gosford (80.8) Muswellbrook (86.8) Gunnedah (45.0) Uralla (45.7) Liverpool Plains (47.5) Gunnedah (31.6) Glen Innes Severn (35.3) Liverpool Plains (39.5) Gloucester (28.0) Tenterfield (31.0) Dungog (33.5) Guyra (27.5) Tenterfield (27.6) Muswellbrook (29.3) Gunnedah (13.6) Uralla (14.4) Gwydir (15.4) Gwydir (12.8) Moree Plains (13.7) Tamworth Regional (15.6) Upper Hunter Shire (10.6) Liverpool Plains (12.0) Tenterfield (12.3) Upper Hunter Shire (23.4) Inverell (22.5) Gunnedah (20.3) Muswellbrook (20.7) Moree Plains (20.4) Liverpool Plains (19.2) Gloucester (12.9) Glen Innes Severn (10.1) Port Stephens (9.8) Narrabri (56.5) Uralla (52.3) Muswellbrook (50.4) Uralla (25.1) Gloucester (25.0) Moree Plains (24.0) Muswellbrook (19.6) Moree Plains (17.2) Dungog (16.8) Liverpool Plains (14.8) Cessnock (11.0) Muswellbrook (10.4) Cessnock (11.2) Gloucester (10.5) Tenterfield (10.5) Tenterfield (10.2) Maitland (11.1) Gosford (12.4) Inverell (7.6) Gunnedah (8.2) Greater Taree (8.5) Cessnock (4.3) Inverell (4.5) Maitland (5.6) (Gloucester 21.9) Guyra (22.3) Tenterfield (23.3) Liverpool Plains (12.1) Upper Hunter Shire (13.4) Gosford (14.1) Narrabri (6.1) Great Lakes (6.3) Port Stephens (6.5) Tamworth Regional (3.7) Great Lakes (5.2) Newcastle 5.8) Gosford (3.1) Greater Taree (4.1) Tamworth Regional (4.3) Cancer Institute NSW 2015: incidence and mortality data Cancer is a leading cause of mortality in the HNECC region. The incidence of melanoma and prostrate cancer is more than twice the NSW average in some LGA s. Prostate and melanoma cancer rates tended to be higher in the New England sub-region. For breast, lung, and colon cancer there were more isolated pockets of high incidence. As indicated in the above right table, Walcha and Gwydir LGAs in particular have consistently high rates of cancer incidence. Chance of Surviving at Least 5 years When Newly Diagnosed ( ) Prostate 93% Breast 90% Melanoma 90% Colorectal (bowel) 67% Lung 14% Cervical AIHW 2015a Cervical Cancer incidence is highest in Port Stephens (5.5%); and lowest in Great Lakes (2.3%) 18

19 Dementia Dementia is a leading health concern in Australia. In dementia affected over half of the residents of Government funded aged care facilities. Dementia predictions for our region are available by Commonwealth Electoral Division areas only. In 2011, Lyne, Robertson and Paterson ranked in the NSW Top 10 for dementia prevalence, with Lyne and Robertson making the National Top 10. Paterson and Lyne are expected to rank in the National Top 10 for dementia prevalence in Dementia in Australia Chronic Disease 342,800 Australians were estimated to have dementia in Based on projections of population ageing and growth, the number of people with dementia will reach almost 400,000 by 2020, and around 900,000 by AIHW 2016 Commonwealth Electoral Divisions for HNECC Region Parkes AIHW 2012; Deloitte Access Economics

20 Mental Health Mental Health and Behavioural Disorders In it was estimated that 13.6% or 3.0 million Australians had mental and behavioural problems. The map to the left presents data related to those experiencing chronic mental and behavioural problems within the HNECC region. HNECC PHN region has higher rates than the state average for self-reported mental health and behavioural problems. The highest rates are noted for the LGAs of: Great Lakes Greater Taree Gloucester Lower rates of those experiencing chronic mental or behavioural problems are within the LGAs of: Singleton Upper Hunter Shire Walcha Around 45% of Australian adults (7.3 million) will experience a mental disorder sometime in their lifetime. In approximately $7.2 billion was spent on mental An estimated 20% of adults health services in (3.2 million) have Australia. experienced a mental disorder in the previous 12 months. AIHW 2014 Furthermore, LGAs within the HNECC region experiencing high or very high rates of psychological distress are presented in the below table. Highest and Lowest Rates of High or Very High Psychological Distress in the Last 4 weeks for People Aged 18 years and over (ASR/100) Greater Taree 12.6 Glen Innes Severn 12.4 Tenterfield 12.4 Guyra 9.4 Muswellbrook 9.1 Walcha 8.8 HNECC 11.2 NSW 10.5 PHIDU 2014 Rates of hospitalisation for intentional selfharm for this region are well above that of NSW. LGAs with rates that were significantly higher than the state over the period 2009/ /14 include: Cessnock, Great Lakes, Greater Taree, Inverell, Lake Macquarie, Newcastle, Port Stephens, and Tamworth Regional. Centre for Epidemiology and Evidence

21 Health Status When assessing the health status of an individual or community, factors such as life expectancy and self-reported health are considered. Self-assessed rates of health are linked to actual health status, with people experiencing chronic physical or mental illness reporting fair or poor health at higher rates than the rest of the population. In 2010, there was a greater proportion of persons aged 15 years and above assessing their health as fair or poor in the HNECC PHN region (15.1%) than in Australia (14.6%). LGAs with the highest rates (over 20 per 100) were Cessnock, Glen Innes Severn, Great Lakes, Greater Taree and Tenterfield. The lowest were Armidale Dumaresq and Gosford LGAs at less than 16 per 100. Life expectancy In 2011, the average life expectancy for people living in NSW was 84.6 years for women and 80.3 years for men. The data for our region from indicates a lower than the state average life expectancy for men and women. Premature Mortality Premature mortality refers to deaths that have occurred before their due time, which is currently considered to be before 75 years of age. Sub - Region Central Coast ( ) Adults Reporting Excellent / Very Good / Good Health Health Status Adults Reporting Having a Long-Term Health Condition 84% 56% Hunter ( ) 85% 50% New England North West ( ) 84% 45% HNECC ( ) 84% 54% All PHNs ( ) 81-90% 41-61% Sub - Region Life Expectancy at Birth (years) ( ) Females Males Central Coast Hunter New England North West Australia Life expectancy for people of Aboriginal and/or Torres Strait Islander heritage in NSW is alarmingly low, 74.6 years for women and 70.5 years for men. Causes of Premature Mortality The average life expectancy at birth for the HNECC region is 80.7 years. For males this is 78.4 years and for females this is 83.2 years AIHW 2015a; Centre for Epidemiology and Evidence 2015 Premature Mortality Average Annual ASR / 100,000 NHPA 2015a Life expectancy in Australia has increased significantly this past century due to decreased mortality from infectious diseases, and cardiovascular disease. Unfortunately, the average number of years lived in ill-health has increased simultaneously. In future, higher life expectancy may be countered by a greater burden of disease and disability. HNECC Highest Rates* Lowest Rates* Aus Ischaemic heart disease (coronary heart disease) which includes both heart attack (acute myocardial infarction) and angina, accounts for the highest rates of premature mortality across our region, and is well above the national average. Lung cancer is our next highest cause of premature mortality, with particularly high rates in Walcha and Narrabri LGAs. Ischaemic Heart Disease 29.5 Lung Cancer 25.2 Breast Cancer 16.7 Suicide and Self- Inflicted Injuries 13.4 Moree Plains (57.0) Narrabri (57.0) Walcha (55.9) Narrabri (46.2) Moree Plains (29.7) Glen Innes Severn (26.8) Gloucester (32.2) Tenterfield (28.9) Gloucester (16.7) Uralla (16.9) Liverpool Plains (12.0) Great Lakes (20.5) Armidale Dumaresq (10.8) Great Lakes (13.1) Gunnedah (8.8) Singleton (11.6) PHIDU 2014 Cerebrovascular Diseases 10.2 Cessnock (15.9) Tamworth Regional (15.5) Maitland (7.6) Port Stephens (8.2) 8.9 Chronic Obstructive Pulmonary Disease 10.2 Walcha (22.2) Gloucester (20.3) Lake Macquarie (6.5) Great Lakes (6.9) 7.8 Colorectal Cancer 9.5 Muswellbrook (18.3) Gloucester (16.7) Inverell (6.0) Narrabri (7.2) 9.6 Road Traffic Injuries 5.7 Tenterfield (33.8) Dungog (15.7) Maitland (3.0) Newcastle (3.6) 6.0 Diabetes 5.2 Moree Plains (21.6) Cessnock (12.9) Port Stephens (3.9) Gosford (4.2) 6.0 *Data not available for all LGA s. PHIDU

22 Premature Mortality Premature Mortality During the period, as presented in the map to the left, premature mortality was highest in the LGAs of; Moree Plains Narrabri Cessnock Upper Hunter Shire Lower rates were experienced in the LGAs of; Uralla Gloucester Great Lakes Port Stephens Premature deaths, as a whole are further categorised as avoidable or unavoidable. Deaths considered as avoidable can be further classified into two categories depending on whether or not these deaths were additionally preventable or treatable. The graphic presented left further explains which diseases, conditions or causes of death fall into these categories. AIHW 2014 Potentially avoidable deaths vary across populations for many reasons. One of these may be related to where you live and how far away from regional centres or major cities you are. The graph to the left indicates that the more remote you live, the greater the incidence of potentially avoidable death occurring. Some of these rates are related to distance from health services, socioeconomic status and the travel that occurs over vast geographical distances. Centre for Epidemiology and Evidence

23 Influenza and Pneumococcal Disease Immunisations The graph to the right indicates that in 2014, the Hunter New England LHD had 79.2% of persons aged 65 years and over immunised against influenza, and 54.5% immunised against pneumococcal disease. Prevention and Screening The Central Coast LHD, for the same time period reported 78% immunised against influenza and 53.1% immunised against pneumococcal disease compared to 72.5% and 47.9% respectively for all NSW LHDs. Cancer Screening Australia has three national cancer screening programs, all of which aim to reduce illness and mortality from cancer through a systematic approach to screening. In order to achieve the greatest benefit to our population from these programs, high participation rates are needed. Centre for Epidemiology and Evidence 2015 National Cervical Screening Program With early detection, cervical cancer is highly preventable and curable. As a whole, cervical cancer screening participation rates are low across the HNECC region. Whilst many LGAs are equal to or above the state rate for cervical screening participation, some areas including Tenterfield, Narrabri, Moree Plains, Cessnock, Liverpool Plains, Gunnedah and Great Lakes have much lower participation. Regular Pap smears are essential for all women aged years as the HPV vaccine does not prevent all cervical cancers, and an estimated four in five women who have ever been sexually active are likely to have already had a HPV infection at some time and are therefore still at risk of developing cervical cancer. N= Number of intact women in population Centre for Epidemiology and Evidence 2015 NSW Cancer Institute

24 Prevention and Screening BreastScreen Australia Breast cancer is a serious health concern for women in Australia. As shown in the graph to the left, Walcha, Narrabri, Tamworth Regional, and Uralla LGAs recorded high rates of participation in the BreastScreen program, well above the NSW average of 50.9%, unlike Moree Plains, Gosford and Wyong and LGAs. NSW Cancer Institute 2015 NSW: 50.9% In both and , more than 1.4 million women aged had a screening mammogram through BreastScreen Australia, which is around 55% participation. NSW Cancer Institute 2015 N= Number of women in population Breast Screening Mammographic screening is seen as the best population-based method to reduce mortality and morbidity attributable to breast cancer, by detecting early-stage breast cancer. The NSW Cancer Plan includes a target to increase participation in the age group years so that over 70% of women aged years will have 2 yearly mammograms It is estimated that bowel cancer will claim the lives of 2,190 men and 1,930 women in Australia in 2015 National Bowel Cancer Screening Program This program aims for early detection of polyps or cancer when treatment is easier and the likelihood of cure is greater. LGAs in our region with particularly low rates of participation in the National Bowel Cancer Screening program include: Moree Plains, Liverpool Plains, Tenterfield, Narrabri and Guyra. Across NSW greater numbers of women participated in the National Bowel Cancer Screening program than men, 35.3% and 31.0% respectively. This difference was more marked across our region. Seven percent of people who participated in the National Bowel Cancer Screening Program in NSW during , returned a positive test result. Across our region, positive results were more common, with over half of the LGAs rating above the state average for percentage of positive results returned. The highest scoring LGA was Walcha (12.1%), followed by Gwydir (10.4%) and Moree Plains (10%). Inverell, Narrabri and Gunnedah LGAs also scored above 9%. NSW Cancer Institute 2015; AIHW 2015a NSW Cancer Institute 2015 N= Number of eligible population 24

25 Access to Health Services GP Services Service Utilisation and Access HNECC PHN Australia Timely and affordable access to health services, workforce, after hours, geographic location, and culturally friendly services are key determinants of health outcomes, particularly for disadvantaged groups in the local community. Primary Care There is much variability across the HNECC region in terms of general practice utilisation and access. Our primary care workforce will be challenged in coming years by the projected population growth, projected growth in numbers of people aged 65 years and older, and increasing rates of chronic disease. Percentage of Adults Who Saw a GP in the Past 12 Months Average Number of GP Attendances per Person (agestandardised) Percentage of GP Attendances Bulk-Billed Percentage of People who Waited Longer than they felt Acceptable for a GP Appointment 81% 81.4% % 82.3% 25% 23.6% NHPA 2015a Average number of GP attendances per person in our region in (by SA3) range from 4.0 in Tamworth-Gunnedah to 6.1 in Wyong. NHPA 2015a Percentage of GP attendances bulk-billed in our region in (by SA3) range from 70.2% in Maitland to 90.1% in Great Lakes. NHPA 2015a 25

26 Potentially Preventable Hospitalisations Potentially Preventable Hospitalisations Potentially preventable hospitalisations (PPH) are separations from a specified range of conditions where hospitalisation is considered to be largely preventable by timely and effective provision of nonhospital or primary health care prevention. Rates of PPHs across our region are similar to the NSW averages. The most common causes of these and the rates for HNECC are outlined below. Most Common Causes of Potentially Preventable Hospitalisation HNECC region (ASR/100,000) Cellulitis COPD Dental Conditions Urinary Tract Infections Congestive Cardiac Failure Diabetes Complications Angina Convulsions & Epilepsy COPD accounted for 25,996 hospital bed days Congestive cardiac failure accounted for 23,391 hospital bed days Cellulitis accounted for 19,435 hospital bed days The highest rates of PPH s in our region are noted for the LGAs of: Narrabri Gwydir Moree Plains Lower rates of PPH s are within the LGAs of: Lake Macquarie Gosford Port Stephens HealthStats NSW 26

27 Large Hospitals Service Utilisation and Access Emergency Department Presentations Triage 1 Resus. Triage 2 Emergency Triage 3 Urgent Triage 4 Semi- Urgent Triage 5 Non- Urgent Total Presentations Armidale & New England Hospital Belmont Hospital Calvary Mater Newcastle Cessnock District Hospital Gosford Hospital Gunnedah District Hospital Inverell District Hospital John Hunter Hospital Kurri Kurri District Hospital Maitland Hospital Manning Base Hospital Moree District Hospital Muswellbrook District Hospital Narrabri District Hospital Singleton District Hospital Tamworth Base Hospital Wyong Hospital Triage Triage Triage Total Small Hospitals or MPS s Triage 2 Triage 4 5 Presentations 1 Emergency 3 Semi- Non- Resus. Urgent Urgent Urgent Barraba MPS Bingara MPS Boggabri MPS Bulahdelah Hospital Denman MPS Dungog Hospital Emergency Department Presentations Semi-Urgent and Non-Urgent ED attendances are often considered best managed in the general practice setting. Emergency Departments can be a preferred option for care for some people if a timely appointment is not available, and for those community members who are financially disadvantaged, as medications and diagnostic services are provided at no cost in a single visit. A heavy reliance on emergency departments leads to higher health care costs. Barriers to Access The rates of difficulty accessing services are high in our region, with only 5 LGAs below the NSW average. Highest rates are found in Moree Plains, Inverell and Glen Innes Severn, where approximately 38% of people experience difficulty accessing services. In NSW in 2010, it is estimated that 11.1% of people delayed medical consultation because they could not afford it. Substantially greater numbers of people across our region are predicted to experience financial barriers to health services, with Port Stephens and Gosford being the only LGAs better than the state average. Limited access to a GP outside normal operating hours has been reported as a barrier, particularly in rural areas. Lack of transport is another substantial barrier to service access in our region, this is particularly notable in the LGAs of Greater Taree, Tenterfield and Cessnock. PHIDU 2015 Glen Innes Hospital Gloucester Hospital Guyra MPS Manilla Hospital Merriwa MPS Quirindi Hospital Scone Hospital Tenterfield Hospital Tingha MPS Tomaree Hospital Vegetable Creek MPS Walcha MPS In , the 2.9 million (12.5%) Australians who were very high and frequent GP attenders (12+ GP visits) included a diverse range of people from different age groups and who lived in areas with different socioeconomic backgrounds. People in these groups were more likely to be older and live in areas with the most socioeconomic disadvantage, and had the lowest rates of private health insurance coverage. NHPA 2015a Warialda MPS Wee Waa Hospital Werris Creek Hospital Wilson Memorial Community Hospital (Murrurundi) NHPA 2015b

28 Service Utilisation and Access After Hours After Hours Services Average number of after-hours GP attendances per person, age-standardised Expenditure on after-hours GP attendances per person, age standardised HNECC PHN Australia $12.25 $20.92 After Hours There is a lack of and limited access to GPs outside normal operating hours, particularly in rural areas where there is no assigned after hours service. Lack of awareness of local after hours services, limited information about the availability of after-hours GP services, and a lack of workforce coordination and collaboration to share after hours availability is a barrier to providing after hours care in rural and regional locations. Percentage of adults who saw a GP after hours in the preceding 12 months Average number of after-hours ED attendances per 1,000 people, by place of residence 8.0% 7.9% Urgent After-Hours Services Delivered by GPs & Medical Practitioners July 14 Jun 15 Central Coast 2,768 NHPA 2015a Hunter 36,987 New England North West 1,919 Australian Government Department of Human Services 2015 Average number of after-hours GP attendances in (by SA3) ranged from 0.06 in Armidale to 0.33 in Gosford. NHPA 2015a 28

29 Aged Care Services Residential aged care places within the HNECC region vary considerably. The map presented right indicates that the areas with the lowest care places per 1000 people aged 70 years and over are the LGAs of Maitland, Dungog and Liverpool Plains. Similarly, Tamworth Regional, Muswellbrook and Gloucester LGAs also experience low rates of care places for their aged populations. Service Utilisation and Access Total residential aged care places per 1,000, aged 70 years and over, 2011 NSW: 87.5 Home and Community Care Program Greatest Proportions Lowest Proportions NSW Total Clients (ASR/1,000) Gwydir (70.1) (522 clients) Gloucester (68.9) (574 clients) Gosford (32.9) (7,672 clients) Tamworth Regional (33.9) (2,292 clients) 35.6 Home and Community Care Services (HACC) Clients Living Alone (%) Clients with a Carer (%) Armidale Dumaresq (50.2) (513 clients) Gunnedah (48.9) (274 clients) Dungog (81.7) (445 clients) Maitland (64.9) (1,915) Tenterfield (33.1) (178 clients) Greater Taree (35.9) (1,075 clients) Walcha (3.9) (7 clients) Gunnedah (9.7) (54 clients) Data on total instances of assistance under the HACC program indicates that in NSW 58.2 services were delivered per 1,000 residents during There were only two LGAs in our area with rates lower than this, Gosford (49.3) and Lake Macquarie (59.1). Across our region, rates of HACC service delivery are above the state average, with the highest being in Dungog (183.1), Gwydir (138.7) and Gloucester (133.2) LGAs. Indigenous Clients (%) Total Instances of Assistance (ASR/1,000) Moree Plains (32.3) (210 clients) Tenterfield (22.2) (120 clients) Dungog (183.1) (1,829 instances) Gwydir (138.7) (1,042 instances) Upper Hunter Shire (1.8) (16 clients) Dungog (2.0) (11 clients) Gwydir (2.0) (10 clients) Gosford (49.3) (11,701 instances) Wyong (56.4) (11,484 instances) PHIDU 2015 PHIDU

30 Health Workforce Workforce There is substantial variation in the primary health care workforce across the region, with generally lower numbers of clinicians in rural areas. As shown in the map to the left, there are particularly low rates of GPs in the LGAs of Uralla, Liverpool Plains and Dungog. Some clinician groups are also poorly represented in metropolitan or urban districts of the region, as well as when compared to NSW as a whole. Challenges facing the primary health care workforce include: Ageing workforce Changing hours of work for younger GPs Reliance on international medical graduates in areas of shortage An expansion of corporate general practices often requiring additional support for nonvocationally recognised doctors These challenges also impact on small hospitals where GPs often provide VMO and procedural services. LGA Armidale Dumaresq Number of General Practices Number of GPs Number of Nurses in General Practice Number of Dentists Number of Pharmacies ERP Cessnock Dungog Glen Innes Severn Gloucester Gosford Great Lakes Greater Taree Gunnedah Guyra Gwydir Inverell Lake Macquarie Liverpool Plains Maitland Moree Plains Muswellbrook Narrabri Newcastle Port Stephens Singleton Tamworth Regional Tenterfield Upper Hunter Shire Uralla Walcha Wyong HWA 2014 Workforce is a key component of health planning. It is impacted locally by the national and state economies, as well as by regional and local plans and developments. Aboriginal Medical Services Pat Dixon Medical Centre, Armidale (not currently operational) Tobwabba Aboriginal Medical Service, Forster Armajun Aboriginal Health Service, Inverell & Glen Innes Pius X Aboriginal Corporation, Moree Awabakal Newcastle Aboriginal Cooperative, Newcastle Walhallow Aboriginal Corporation, Quirindi Tamworth Aboriginal Medical Service, Tamworth Biripi Aboriginal Corporation, Taree (2 locations) Yerin Aboriginal Health Services, Wyong 30

31 What are the health needs and issues of the HNECC region Summary of Health Needs We have combined information obtained from engagement activities with community members, health consumers, government services and primary health care providers, with the data presented in this compass to gain a better understanding of our region s health needs. The health needs and issues identified across our region can be broadly grouped into three categories presented in the diagram on the right. Access and Equity Health Literacy Low levels of health literacy, particularly in vulnerable and disadvantaged populations, are experienced across the region. The ability to access and use health information is an important skill allowing people to make informed decisions about their health and helping them to maintain their basic health. Supporting data suggests that more than half of Australians may be unable to successfully access, understand, evaluate and communicate health information in a way that enables them to promote, maintain and improve health. Low levels of health literacy are more common in people aged over 65 years, and those from culturally and linguistically diverse populations and socioeconomically disadvantaged populations. A range of community and service providers in the HNECC region recognised low levels of health literacy as a major challenge in working towards better health outcomes for clients, particularly those from vulnerable and disadvantaged communities, and those in rural locations. Of note was a general lack of knowledge about services and how to access them, along with issues in navigating health services, and a lack of computer literacy. People with low levels of health literacy have poorer levels of knowledge and understanding about their health condition, and are less likely to make and attend appointments; take their medication as required; and follow health behaviour advice. People with low health literacy are not able to effectively exercise their choice or voice when it comes to making health care decisions. Services insensitive to low levels of health literacy create barriers to access unintentionally. This is an issue across the health and social sector. We have a high proportion of people aged 65 years and over (18.3%) compared to the state (15.2%) and this population is projected to increase. We have LGAs with particularly high rates including: Great Lakes (32.1%), Gloucester (27.5%), and Gwydir (23.9%). It is projected that by 2025 almost a quarter (22.9%) of the HNECC population will be aged 65 years and over. Service provider consultation has revealed that older people in the community can experience difficulties accessing health and community care services. Barriers to accessing GPs for older people including cost, transport and time to wait for an appointment. Residents in aged care facilities also often struggle to access GP services, allied health and mental health services, which can result in poorer health outcomes and unnecessary visits to hospital emergency departments. Stakeholder engagement identified workforce capacity as a major gap and challenge in working towards better health outcomes, particularly for people who are disadvantaged or vulnerable. The need for multidisciplinary teams to ensure better health Care for an Aged and Ageing Population outcomes and greater ability to attract and retain skilled qualified people in aged care were highlighted. Particular workforce issues include, low wages, an ageing workforce, and a lack of understanding or expertise in the existing workforce. New models for providing primary care to residents in aged care facilities are required. 31

32 Summary of Health Needs More than 48,000 people (4.2% of the population) in the HNECC region are of Aboriginal and/ or Torres Strait Islander descent. HNECC has the 7th highest proportion of the population from Aboriginal and Torres Strait Islander background out of all PHNs. Many of our rural LGAs such as Moree Plains (20.8%), Gunnedah (11.3%), and Liverpool Plains (10.9%) have very high proportions of Aboriginal populations. The Aboriginal population has a considerably younger age profile than the non-aboriginal population. Low socioeconomic status and disadvantage have an impact on local Aboriginal people who are more vulnerable to poor lifestyle choices and illness. Aboriginal people have notably higher rates of behavioural risk factors, poorer antenatal and infant health, and experience far worse health outcomes than non-indigenous people with earlier onset of chronic disease, and higher rates of hospitalisations and mortality. Aboriginal and Torres Strait Islander Health It has been reported at a national level that Aboriginal people are not benefiting from mainstream health services as much as other Australians due to barriers accessing services or issues of cultural acceptability. We heard from Aboriginal and/or Torres Strait Islander health service providers and community organisations that the delivery of, and access to, culturally appropriate health initiatives and services were perceived as areas of need across the region. Other barriers identified included access to after hours GP services for Aboriginal people particularly where upfront fees are required as well as access to GPs and outreach services in rural areas. Closed books and waiting times have been identified as barriers to booking timely appointments with GPs, both at Aboriginal Medical Services and General Practices for the Aboriginal population. Both the cost of appointments and the cost of medications were considered to be major barriers to accessing a GP, despite a number of programs in place to reduce the costs of health care for Aboriginal and/or Torres Strait Islander people. System complexity, particularly in the provision of health services and initiatives to Aboriginal people with complex needs, was also identified as an area of need. Maternal, Child, Youth and Family Health Service providers report a significant gap in the region of affordable and timely services for children aged 5 to 12, particularly related to mental health services, dental services and for family based therapies. Barriers include cost, waiting periods, transport and lack of suitable services. A large number of young people do not have adequate family and social support networks. Consequences of this can include presentation to services in crisis, homelessness, disengagement from family and failure to complete education, all of which can lead to future adverse health and social outcomes. Lack of available mental health services, suicide and risky drug and alcohol behaviours are a concern for communities across the region. Community members and service providers also report a lack of understanding of the range, type and availability of health services in the region as well as no central point for accessing this information. There is a need to increase integrated care for young people across the region. There is a younger maternal age (<19 years) for Aboriginal women compared to non-aboriginal women within the region and higher non-compliance rates for vaccinations amongst the Aboriginal population. Concerns for this population also include geographical isolation and child care arrangements, rates of smoking during pregnancy and low birth weight babies, oral health for children, services and education. The region has a higher proportion of women who smoked during pregnancy and low birthweight babies compared to NSW. These rates are significantly higher in rural areas. Over 66,000 (5.8%) people in the HNECC region have a severe or profound disability. This is a higher proportion compared to the state. There are also over 114,000 (12.3%) people aged 15 years and over providing unpaid assistance to persons with a disability, which is higher than the state proportion. This was highest in the rural LGAs of Gwydir, Dungog, and Greater Disability Taree. Home and Community Care representatives identified a lack of carer recognition, a lack of respite services and a decrease in the number of volunteers in the sector as challenges. They also identified a need for additional programs for active individuals with mild cognitive impairment. There are capacity issues in smaller rural communities, limited residential facilities and an ageing workforce/carers. Service providers, consumers and carers reported concerns about the potential impact on accessibility of services for people living with a disability with the implementation of the National Disability Insurance Scheme (NDIS) including: need that is currently not visible (e.g. elderly parents that have always cared for their child without seeking help) placing demands on the system; lack of capacity and skilled workforce in the NGO sector to take on this type of work; change for service providers from a focus on service delivery to brokering and negotiating with clients and families; and loss of a skilled Allied Health workforce in the NDIS transition. 32

33 Summary of Health Needs Delivering primary health care to rural regions, where the population is dispersed and the health problems diverse, presents many challenges. GPs, practice nurses, dentists and private allied Rural Access health providers are not spread evenly across the region, with fewer health professionals per head of population in some of our rural areas. Geographical location and isolation in rural areas limits access to face-to-face services and is seen as a major gap and challenge in working towards better health outcomes, particularly for people who are disadvantaged or vulnerable. Common barriers to accessing care in the rural areas include difficulty getting an appointment, transport and the time taken to travel to services. Developing our knowledge of the distribution of primary care services in our rural communities will help us coordinate our support to develop services where they don t currently exist and enhance service provision in areas of limited access. We cannot change the distance between our cities and towns, however we can work with our rural service providers to help develop and maintain integrated models of care to ensure the best systems are in place to maximise access to the existing providers. Limited access to a GP outside normal operating hours was highlighted as a barrier in our region, particularly in rural areas where there are no assigned after hours clinics such as GP Access After Hours, currently operating in Newcastle, Maitland and Lake Macquarie. A Hunter based survey identified that over a quarter of people in rural areas reported that after hours services were not available in their area, and half believed that the current range of local after hours services did not meet their needs. These residents were far more likely to present to their local hospital emergency department in the after hours period for problems that did not require emergency treatment. There were also fewer rural residents that knew how to contact an after hours GP service After Hours Access compared to their urban counterparts. Nearly a quarter of respondents in the rural areas believe that a lack of awareness of local after hours services was a barrier to access. Interviews with service providers identified a lack of after hours GP services; limited information about the availability of after hours GP services; and a lack of workforce coordination and collaboration to share after hours availability, as barriers to providing after hours care in rural and regional locations. Transport Access to transport has a significant impact on the health and wellbeing of the population. Limited transport was consistently identified as a significant barrier to accessing health services in our region, particularly for Aboriginal communities, for older persons and those residing in rural areas. Transport was highlighted as a particular concern by the social and community services sector working with people experiencing disadvantage and by organisations supporting people with chronic illness. A specific challenge involves the coordination of transport services with timing of medical appointments. Health Behaviours and Health Outcomes There are high rates of health risk behaviours, contributing to chronic disease and hospitalisations, in our region. Over one third of our population are overweight and three in every ten are obese. These rates are higher than the state rate. Only half of the population are consuming the recommended amount of fruit and only one in ten consuming the recommended amount of vegetables. Smoking, high risk alcohol intake and physical inactivity rates are also above the NSW average. A reduction in these risk factors will promote health and wellbeing and prevent hospitalisations and chronic disease. Community consultation indicates presence of a gap in knowledge about where and how to access healthy lifestyle programs and advice, and gaps in availability of drug and alcohol services. Engagement with community members, NGOs and LHD Health Risk Behaviours professionals identified cost of healthy food, easy access to fast foods, advertisement of fast foods, limited options for healthy takeaway, awareness of where to shop, and knowledge of how to cook, as barriers to good nutrition. Limited areas designated to exercise, knowledge of gyms, feeling unsafe exercising, and working hours were identified barriers to physical activity in some communities in the region. Services that prevent illness or the formation of long term health conditions, or assist in the early detection of health problems within the region are limited for some population groups. There is reported restricted capacity for service providers to provide prevention or early intervention. Ongoing and targeted health promotion and prevention is required to maintain and improve health outcomes. 33

34 Summary of Health Needs Mental Health Mental health is an area of concern in our community, with high rates of chronic mood and behavioural problems for both males and females, as well as high rates of reported psychological distress. Rates of hospitalisations for intentional self-harm for the HNECC region are also well above that of the state. Stakeholder engagement with multicultural community and refugee service providers, and Aboriginal community organisations identified mental health needs within Aboriginal communities, new arrivals and young people. We heard from the community that there were a number of barriers to accessing mental health services including: time, cost, distance and lack of transport. There also appears to be a lack of knowledge of available services and where to seek help. Limited access to mental health services reported, particularly in the rural areas, corresponds to the low numbers of mental health service providers in rural areas. There appear to be low numbers of social workers, psychologists and psychiatrists in rural areas. In particular there are few or no (< 5) clinical or general psychologists in private practice in Gloucester, Guyra, Gwydir, Liverpool Plains, Moree Plains, Muswellbrook, Narrabri, Tenterfield and Walcha. Community organisations also noted gaps in services for youth mental health and suicide prevention services. Concerned community members also note the need for ongoing training of health professionals in suicide prevention. System complexity and poor coordination of services have also been identified as barriers to accessing mental health services. Referral pathways are unclear and mental health services are administered in silos, with poor access to health records. This lack of coordination of services and the shortage of services in some regions have been blamed for high levels of acute mental illness. Lifestyle related chronic diseases such as diabetes, cardiovascular disease and airways disease are pressing issues for our communities and are leading to increased hospitalisations in the region. We have one of the highest rates of airways disease - chronic obstructive pulmonary disease (COPD) (2 nd highest rate out of the 30 PHNs) and circulatory system disease (6 th highest rate out of 30 PHNs) in Australia. High rates of chronic disease are placing a burden on the health of our community and on the health system, resulting in an increase in hospitalisations, and in particular hospitalisations which could have been prevented if the chronic disease had been treated and managed within the community or primary care setting. COPD was the number two cause of potentially preventable hospitalisations in our region in , and diabetes the 6 th Chronic Disease highest. Hospitalisation rates for diabetes for Aboriginal and/or Torres Strait Islander people are around five times greater than those for the non-aboriginal population and twice as high for COPD. In our discussion with Aboriginal and/or Torres Strait Islander health service providers, increasing chronic disease within Aboriginal communities was highlighted as an area of concern. Service providers report in the area of chronic disease management, that patient compliance and motivation can be low, impacting on patient outcomes. There appears to be limited access to chronic disease management programs in rural areas, and there is limited health workforce available to fill this gap. Cancer As a whole there are low participation rates for cervical, breast and bowel cancer screening across our region. Whilst many LGAs in our region have screening rates which are equal to or above the state rate for cancer screening, there are LGAs that have much lower participation. There are high incidence and mortality rates for melanoma, lung and colon cancer across the HNECC region. There is a need for prevention in the community, and facilitation of early screening and detection within the primary health care setting. The aged and ageing population in the Hunter sub-region presents increased health needs particularly around dementia, with predicted dementia prevalence exceeding state and national increases. There are three Commonwealth Electoral Division Areas in the HNECC region ranked in the NSW top ten for dementia prevalence and two in the national top ten. Dementia predictions will also see these Commonwealth Electoral Division Areas in the national top ten in Engagement with Home and Community Care representatives identified a lack of dementia awareness, dementia specific services and GP involvement in dementia care as gaps in working towards better health outcomes. Dementia 34

35 Summary of Health Needs System Integration, Coordination and Capacity Health Workforce Our primary care workforce will be challenged in coming years by the projected population growth; projected growth in numbers of people aged 65 years and older; and increasing rates of chronic disease. In addition to this, a number of workforce capacity issues have been identified in our region, including a limited number of health professionals and an ageing workforce. We have a workforce that is inequitably distributed across our region, in some areas we have fewer health professionals including GPs, practice nurses, dentists and allied health practitioners than other areas. Medical workforce shortage and geographical distribution are critical factors in accessing primary health care. It is recognised that a lack of integration and coordination of services and information exchange in the health system is making the system difficult for patients to navigate and affecting continuity of care, particularly for those living in regional and rural areas. Patients, health professionals and other stakeholders highlighted the lack of collaboration occurring between services and individual providers across the region particularly multiple agencies working in 'silos', and poor communication between hospitals and primary care services. There is a need to improve the patient journey, enhance information management and information sharing, and increase service integration and coordination. Poor Integration of Health Services 35

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