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issue 21 • April 2018


Ageing Well Maintaining strength and vitality late in life starting page 13


Managing winter's health demands


11 winning GPs

New hope for

27 Aboriginal languages

Mullumimby has a

38 women's shed!

Getting old doesn’t have to mean getting frail Head Office 106-108 Tamar Street Ballina 2478 Ph: 6618 5400 CEO: Vahid Saberi Email: Hastings Macleay 53 Lord Street Port Macquarie 2444 Ph: 6583 3600 Cnr Forth and Yaelwood Sts Kempsey 2440 Email: Mid North Coast 6/1 Duke Street Coffs Harbour 2450 Ph: 6659 1800 Email:

editor Janet Grist


elcome to the first edition of HealthSpeak for 2018. In this issue we explore the topic of Ageing Well. I had the

As Acting CEO, it’s business as usual here at NCPHN

Northern Rivers 2A Carrington Street Lismore 2480 Ph: 6627 3300 Email:

acting ceo Sharyn White

Tweed Valley 145 Wharf St, Tweed Heads 2486 Phone: 07 5589 0500 Email:

Health Speak Contacts Editor: Janet Grist Ph: 6618 5400 Email: Clinical Editor: Andrew Binns Email: Design and illustrations: Graphiti Design Studio Email: Display and classified advertising at attractive rates HealthSpeak is published three times a year by North Coast Primary Health Network. Articles appearing in HealthSpeak do not necessarily reflect the views of the NCPHN. The NCPHN accepts no responsibility for the accuracy of any information, advertisements, or opinions contained in this magazine. Readers should rely on their own enquiries and independent professional opinions when making any decisions in relation to their own interests, rights and obligations. ©Copyright 2018 North Coast Primary Health Network Magazine designed by Graphiti Design Studio Printed by Quality Plus Printers

HealthSpeak is kindly supported by

privilege of speaking to various health professionals across our region who work with seniors and they shared some great insights into how to maintain strength and vitality very late in life. There are many interventions that can be applied and it’s important to remember that it’s never too late to improve strength and fitness. I’d like to warmly thank the


t’s more than two months since former CEO Vahid Saberi’s departure from NCPHN. Having been with the organisation for over six years and worked across all areas of NCPHN has proved helpful in taking on the job of Acting Chief Executive. Since then I’ve prioritised getting out to our various offices and letting staff know that I value their support and expertise in continuing the work of NCPHN and maintaining our momentum. An organisation is only as good as its people and we are very lucky to have such wonderful staff. When I visit the regional offices it really reminds me how important the work is that they do and their absolute commitment to strong primary care. Recently I also met with service providers and our Aboriginal health partners and I look forward to working more closely with them. I am pleased to report that NCPHN has commenced development of a Reconciliation Action Plan which is

progressing well. Regular face to face workshops are being held around our footprint to develop the Plan. RAPS have been proven to strengthen the levels of trust between staff and our Aboriginal community members, and create meaningful opportunities to work together. I’m looking forward to the

The launch of our Healthy Towns program has been a highlight of the year so far launch of our 2018 Winter Strategy next month. This year’s Strategy builds on what we learned after running the program for the first time last year. We are confident we can respond even better this year to the surge in healthcare demand over winter, supporting general practice to work to reduce hospital admissions of high risk patients. We have tried to make it easier for practices, with simplified reporting and funding to allow protected time to get their systems set up and prepare for winter.

Lismore Botanic Gardens’ Volunteers Committee for providing us with our beautiful cover image. These wonderful folks are great role models in keeping active and engaged in the great outdoors. If you haven’t visited the Gardens, I can highly recommend it as a destination for a walk or picnic. Until next time, happy reading! The launch of our Healthy Towns program has been a highlight of the year so far. It’s been exciting to visit the small towns we are supporting to improve the health and wellbeing of their communities and hear their comments on the health of their community and what is working to support good health and what needs improving. Local people are very keen to be involved in this innovative program and the upcoming workshops will be an interesting exchange of ideas. It was great to welcome Senator Deborah O’Neill, Shadow Assistant Minister for Mental Health, to the Ballina office on 6 March. The purpose of her visit was to investigate the work being done at NCPHN’s suicide prevention trial sites. We hosted a teleconference to bring together the suicide prevention committee members, providing her with insight regarding the level of support needed for this work. It was heartening to hear first-hand the difference this work is making to communities. Senator O’Neill was also interested to hear about our commissioning work and the challenges we face in this new area of work for the organisation. We know that our commissioning efforts, working alongside our valued stakeholders, will continue to improve as we learn more about the process and benefit from these learnings.

Our front cover: Volunteers Marie Matthews (left) and Ros Little (right) with new volunteer Kerry Walker at work at Lismore Rainforest Botanic Gardens recently. The Friends of the Gardens meet Wednesdays from 7.30 till late morning. It is a great group of interested and interesting people who make Wednesday morning something really special. Volunteering at the Gardens is a very rewarding thing to do.


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healthspeak April 2018

NSW Parliament moves to revitalize Aboriginal languages clinical editor Andrew Binns


ccording to ‘A Community Guide to the 2009 Social Justice and Native Title Reports’, Indigenous languages are critically endangered in Australia. They continue to die out at an alarming rate. Prior to colonisation, Australia had 250 distinct languages, divided into 600 dialects. Today Australia has 100 Indigenous languages but most are becoming extinct. Cultural knowledge is carried through languages, so the loss of language means the loss of culture and of Aboriginal people’s connection to their land and ancestors. This in turn has the potential to impact adversely on loss of identity and the health and wellbeing of Indigenous people. Up until the 1970s, Australian Government policies and practices banned and discouraged Aboriginal and Torres Strait Islander people from speaking their languages. Many of those who were forcibly taken to hostels and missions under Australia’s assimilation policy lost their language. Aboriginal people were made to feel ashamed of speaking their language and some were even punished for doing so. In NSW it is estimated there were 35 Aboriginal languages and about 100 dialects spoken in NSW in 1788. Only a few languages (eg Bundjalung, Gumbaynggirr, Muruwari, Paakantyi, Wiradjuri, Yandruwandha, Yuwaalaraay/Gamilaraay) currently have enough material in a useable form for adults to begin learning the languages. However, recently NSW became the first state to introduce and pass legislation to acknowledge the unique value and importance of language to our First Peoples and to the State. Recognising this should April 2018 healthspeak

Aboriginal Elders were allowed to speak and sing in their own languages on Oct 11, 2017 in the NSW Upper House when the new legisation was passed. Picture: SBS News

Schools and pre-schools are important places where language learning is consolidated and developed lead to greater understanding of the people and history of different parts of NSW, to greater respect for Aboriginal people, and in turn more reconciliation between Aboriginal and nonAboriginal people. The NSW Government worked with Aboriginal communities, Elders and language experts to develop the new legislation that acknowledges the importance of Aboriginal languages for past, current and future generations. An Aboriginal Languages Trust, made up of Aboriginal community leaders has also been established to develop a plan that will protect and strengthen Aboriginal languages. A major barrier is having

enough teachers who speak NSW Indigenous languages. Only two NSW languages, Gamilaraay and Wiradjuri, are offered at university level. Reviving languages is a challenging task and for many of these languages, only a few words have been handed down. The last few years have seen activity in researching archives and libraries for these words. The 2009 Social Justice and Native Title Report stated that Australian governments should act to preserve and promote Indigenous languages because: 1) Evidence shows improved cognitive functioning in children who are bilingual.

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2) Minority groups who speak their languages and practice their culture enjoy better social, emotional and health outcomes than groups who do not. 3) Cultural knowledge has been proven to assist in the employment of Indigenous people in Australia. 4) There are economic and social costs associated with the loss of languages. 5) Indigenous languages have intrinsic value to the people who speak them. In 2009 the Australian Government announced Australia’s first national policy exclusively focused on Indigenous languages aimed at protecting and promoting them. State and territory governments have primary responsibility for school education and it is a major step forward for the NSW Government to now introduce this legislation. Schools and pre-schools are important places where language learning is consolidated and developed. So how much Indigenous language is taught in our schools in our region? To answer this HealthSpeak spoke with Glen Rhodes, language teacher at Goonellabah Public School who was present to witness the introduction of this legislation. Elder Irene Harrington was also present on that day. Michael Jarrett is Glen’s counterpart on the Mid North Coast. Turn to page 26 for comments on the new legislation from Glen Rhodes and from Clark Webb, Aboriginal Cultural Heritage Officer at Bularri Murrlay Nyanggan in Coffs Harbour. 3

Bidding farewell to our CEO Dr Tony Lembke Chair of the NCPHN Board


ahid Saberi has been CEO of the NCPHN and its predecessor, the North Coast Medicare Local, for the past six years. Previously he was a senior executive with the Northern NSW Local Health District. This year he decided not to renew his contact with the Primary Health Network (PHN) and consequently has now left us to serve the community in other ways. The PHN is owned by the North Coast community and clinicans and is charged with improving the accessibility, quality and integration of care. This role of health system improver is new and challenging. Vahid has been an outstanding CEO for our organisation. He has led the team with success through unprecedented change. Where the path was not always clear, he has had a strong vision for better health, informed by listening openly to those who receive care and those who provide care to learn from them what is needed.

Where the path was not always clear, he has had a strong vision for better health Establishing a learning organisation will be an achievement that he will be proud of. Vahid leaves the organisation having been instrumental in

forming a strong team, effective processes and strong relationships. The NCPHN is highly regarded nationally and has instigated a number of innovative programs that have been emulated elsewhere. Driven by a strong sense of service, no doubt Vahid will continue to contribute to better health systems nationally. We thank him for his work in the North Coast over many years and wish him and his family the very best in their future enterprises.

Sharyn White chosen as Acting Chief Executive


pon the departure of Dr Vahid Saberi more than two months ago, Ms Sharyn White was selected to act as Chief Executive until a formal nation-wide recruitment process appoints a new CEO for NCPHN. Sharyn has worked at Executive level with the organisation from its very beginning. Indeed she was very much involved at the preconception and embryonic phases of the North Coast Medicare Local, the predecessor to North Coast Primary Health Network. She will lead staff to progress and consolidate NCPHN’s work 4

with clear direction from the Board. Sharyn paid tribute to Vahid

for his leadership during challenging times. “He led us through periods of growth where we have needed to get the job done in an environment of constant change, but always with unwavering attention to our vision of Better Health for North Coast Communities,” she said. Sharyn has committed to steering the work of the PHN during this time with a minimum of interruption. “It’s business as usual and I will be ensuring that everything’s in really good shape for when the Board appoints the next Chief Executive.”

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New member joins NCPHN Board of Directors This year North Coast Primary Health Network welcomed a new member to its Board of Directors - Naree Hancock. Naree has worked in senior business administration roles in health care, education and the corporate sector for 28 years and has attained a Masters of Business Administration. A graduate of the Australian Institute of Company Directors and a Certified Practice Manager, Naree’s primary focus in her position at the University Centre for Rural Health is Rural Health Workforce Planning. She is also involved in strategic planning and student curriculum development. With key strengths in leadership and people management, Naree is committed to improving the integration of services and communications between health care settings to enhance patient outcomes and make the best use of limited resources. Naree replaces Malcolm Marshall who served on the North Coast Medical Local Board and the North Coast Primary Health Network Board for a period of six years. NCPHN Acting Chief Executive Sharyn White expressed the company’s appreciation for Malcolm’s long service on the Board. “Malcolm’s financial expertise, breadth of experience and good humour were greatly valued and we wish him all the best for the future.”

healthspeak April 2018

Senator visits NCPHN to learn about our Suicide Prevention Trial


n Tuesday March 6, Senator Deborah O’Neill, the Shadow Assistant Minister for Mental Health, visited our Ballina office to learn about the work being done in our Suicide Prevention Trial. NCPHN is one of 12 trial sites involved in this important program around the country and Senator O’Neill has visited each one on a fact-finding mission to see how the trial is progressing and what further support is needed to make it a success. Manager, Mental Health, Liz Davis, organised a teleconference in the boardroom with relevant NCPHN staff and input from those involved in Suicide Prevention Training around the

The Senator was touched by the experiences talked about by community members in the teleconference North Coast. The trial sites on the North Coast are Kempsey, Clarence, Lismore and Tweed. The Senator displayed a thorough knowledge and empathy towards the complexities of the trial during her questions to staff, service providers and suicide prevention committee

Senator O’Neill (white jacket centre) with Acting CE Sharyn White to her right and other NCPHN staff involved in the teleconference.

members including a school Principal and a police officer. The information she drew out of those taking part in the teleconference painted a picture of what service providers and people in the community are coming up against in the trial. Acting Chief Executive

Sharyn White said both she and the Senator were touched by the experiences talked about by community members in the teleconference. “I am sure she gained some great insights into both the importance and challenges of this work,” said Sharyn.

Property and my Self-Managed Super Fund (SMSF) By Michael Carlton CEO & Senior Adviser, PECUNIA Private Wealth Management Directly held property makes up about 19% of SMSF assets and it’s often considered to be an important part of a diversified portfolio. There are numerous ways for property to form part of an SMSF’s investments. Investment strategy first! Before any investment decision, it is a legal requirement that you as an SMSF trustee consider your investment strategy. Your strategy should detail such things as how much exposure you would like to the property market, the form of exposure and how appropriate it is. A well-diversified portfolio is essential to provide retirement income and spread investment risk. Direct investment Here you invest directly into property - residential, commercial or industrial. Important considerations: • Your asset allocation and diversification. • Potential rental income and property expenses. • When is retirement and the need for liquidity for pensions. • Unless the property is a business real property, you or related parties cannot use it

April 2018 healthspeak

Limited Recourse Borrowing Arrangements (LRBA) These are complex borrowing structures which allow you to borrow from a thirdparty lender. The SMSF trustee uses these funds to purchase a property to be held on trust. An LRBA should only be included in an SMSF under specialist advice. Important considerations: • Can your SMSF maintain the loan repayments over a long period considering asset returns, interest rates, liquidity, and contributions caps? • Evaluating set-up costs and structures. • Is your property valuation accurate? • You cannot use borrowed money to improve the asset or change the nature of the property • Do you meet the strict bank lending requirements? • Typically, lenders require the SMSF to have minimum net assets of $200,000 and a loan to value ratio below 70%. Indirect investment This includes vehicles such as listed investment companies and exchange traded funds. Managed investment trusts are also a common investment to gain exposure to property. Investing indirectly may suit your SMSF needs more than buying a property because it is relatively simple and won’t cost


a great deal. It also allows your SMSFs to get exposure to large value properties such as office blocks and shopping centres that would otherwise be out of reach. Investing in these products should be accompanied by SMSF specialist advice. To find out more, we offer you a complementary appointment. Contact us on 1300 112 676 or

Important information and disclaimer This publication has been prepared by Michael Carlton, an Authorised Representative (AR No: 239724) and Carlton Family Trust ABN 51 283 954 577 t/a PECUNIA Private Wealth Management a Corporate Representative (CAR No: 1233485) of Dover Financial Advisers Pty (AFSL No: 307248). His advice is general in nature and readers should seek their own professional advice before making any financial decisions.

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Getting ready for the surge in health demand over winter


fter a successful 2017 Winter Strategy in Northern NSW last year, NCPHN in partnership with the Mid North Coast and Northern NSW Local Health Districts is rolling it out again this year. On the Mid North Coast this year’s inaugural program is known as the Seasonal Demand High Intensity Patient Care Initiative Program. The Strategy aims to support people with long-term conditions to stay as well as possible, manage their conditions better and stay out of hospital over the winter period. NCPHN is providing a suite of resources to general practices to enhance primary care management of those most at risk of hospitalisation. General practices will be paid for preparing their practice for the program, registering patients, care planning and enhanced service delivery. The elements of the program have been developed through an extensive co-design process which has involved the active engagement of community members and clinicians. The 2018 programs will build on the successes of last year, with updates based on valued feedback from GPs and practice staff. Last year 646 patients connected to 24 general practices took part in the full Winter Strategy program. Bernadette Carter, NCPHN’s Program Manager for the Winter Strategy said that feedback from GPs was that the Strategy, was worth them being involved in again but that some of the rollout problems needed to be ironed out. “Practice nurses told us they enjoyed being part of it and that it was satisfying to be able to spend more time with patients and get involved with them at a deeper level to support them. Patient feedback was that they really appreciated the sick day action plans and knowing what to do if their health condition 6

Nurse home visits to high risk patients will help keep older folks out of hospital over winter.

changed. “They felt more empowered and their carers felt more empowered too. Because people who are chronically ill don’t want to wind up in hospital. Patients and practices nurses appreciated the opportunity to focus on practical ways to keep as well as possible and prevent hospitalisation where they could.” Registration for practices wishing to take part this year opened on 5 March. Already orientation evenings have been held in Northern NSW to inform general practices taking part about the program stages, milestone and reporting. In addition, the evenings outlined the resources NCPHN will have available to better meet seasonal demand. And on the Mid North Coast, health professionals and community members discussed the issues around Seasonal Demand surges in summer and winter in a workshop that NCPHN held across the Mid North Coast in 2017. The focus was on how to keep high-risk patients healthy and in their homes for longer. Representatives from MNC Local Health District, general practices, other primary health

And on the Mid North Coast:

The focus was on how to keep high-risk patients healthy and in their homes for longer care providers and the community provided valuable insight into the challenges. As a result of a comprehensive co-design process with stakeholders, these aims were identified: In Northern NSW:

1. Improve respiratory hygiene, slowing the seasonal epidemic of infectious respiratory conditions using a population-wide campaign. 2. To support people with long term conditions to manage their conditions better, stay as well as possible and stay safely at home through winter. 3. Establish an efficient and effective process for transfer of care from hospital to community during winter.

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1. Improve respiratory hygiene and vaccine uptake, slowing the seasonal epidemic of infectious respiratory conditions using a population wide campaign. 2. Establish a process for supporting patients experiencing social issues 3. Provide support and assistance to general practice to facilitate planned and proactive management of high risk patients in the community. The Northern NSW Winter Strategy and the Mid North Coast Seasonal Demand Initiative will run from May 28 for 16 weeks. Up to 35 general practices across both regions will be funded and supported to take part. If you have questions about the Winter Strategy 2018 in Northern NSW, contact au or phone Bernadette Carter Program Manager on 6618 5400. And if you have queries about the Seasonal Demand Initiative on the Mid North Coast, contact Siobhan Breedon, Senior Project Officer, on sbreedon@ncphn. healthspeak April 2018

NCPHN’s Reconciliation Plan is taking shape


orth Coast Primary Health Network (NCPHN) is excited to be developing a Reconciliation Action Plan (RAP). The first meeting of interested staff and Aboriginal and Torres Strait Islander community members from across Northern NSW and thr Mid North Coast was held in February. Reconciliation Australia’s RA program provides a framework for organisations to support the national reconciliation movement. When the RAP is complete it will be endorsed by Reconciliation Australia and the NCPHN Board.

From left to right: Tony Seto, Kim Gussy, Uncle Barry Hoskins, Sarah Bolt, Mathan Maglaya, Aunty Sue Follent, Susan Parker-Pavlovic, Geeta Cheema, Wendy Pannach, Uncle Roger Duroux, Uncle Michael Roberts, Aunty Lenore Parker and Rhiannon Mitchell. Apologies: Scott Monaghan and Dr Tony Lembke.

• It provides practical actions to contribute to reconciliation • It supports organisations to develop respectful relationships and create meaningful opportunities with Indig-

What is a RAP?

• It supports organisations to contribute to reconciliation both internally and externally

enous communities At the first NCPHN RAP meeting, it was decided that Work Group members would meet regularly for four-hour workshops in Grafton to develop the Plan.

It will then be sent to Reconciliation Australia for feedback. NCPHN’s Acting Chief Executive Ms Sharyn White said that RAPS were having a positive impact across Australia. “Reconciliation Australia’s Report shows that people in RAP organisations have much higher levels of trust between each other (71 per cent compared to 13 per cent); are far less prejudiced (9 per cent compared to 70 per cent); and have greater pride in Aboriginal and Torres Strait Islander cultures (77 per cent compared to 51 per cent). “These are all great achievements. But not only are RAPs changing workplace culture and attitudes, they are laying the foundation for significant economic and social outcomes for our Aboriginal communities,” she added.

Dementia Health Literacy Toolkit now available The Dementia Toolkits aim to support people with dementia and their families and carers. The Toolkits are available for Tweed, Mid North Coast, Clarence Valley and Hastings/Macleay. They contain: • A Dementia Support Kit: a comprehensive guide to local support services • Important Contacts Fridge Magnet • Delirium Action Plan:

supports people to identify and act early The Toolkits are available from the website https:// or via GP resources through the Cognitive Impairment pathway in HealthPathways to print out and provide to patients. HealthPathways is at www. (user: manchealth; password: conn3ct3d)

The Kit increases people’s health literacy about dementia, empowers people to make decisions about their future care early in their dementia journey and supports people to navigate the health system, including My Aged Care. The Kit has been developed after extensive community consultation and through a co-design process with people and service providers.

The information is also available on the National Health Services Directory at Subscribe to the NCPHN Practitioner Newsletter for updates about the Toolkit and local versions. Go to: practitioner-newsletters If you have questions, contact HealthLiteracy@

SOME THINGS ARE BETTER SEEDLESS Easy, Safe, Male Contraception Dr Greg Anderson | MB BS(Qld),Dip RACOG,FRACGP.

Providing vasectomies since 1993

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Call 07 5530 2822 a publication of North Coast Primary Health Network

Suite 5 Bell Place Cnr Bell PL and Link Way, Mudgeeraba


Communities embrace NCPHN’s healthy towns program


orth Coast Primary Health Network’s Healthy Towns program was launched in four small towns in March – Casino, Evans Head, Maclean and Woolgoolga. Launches in South West Rocks and Lake Cathie will take place in April. Healthy Towns is partnering with these North Coast communities in 2018 to design local initiatives to improve health and wellbeing. These towns were selected to be part of the program based on their particular town characteristics and the findings of last year’s North Coast Primary Health Network’s Needs Assessment. Regional communities often have unique strengths and challenges that influence the health and wellbeing of the people who live there. “Regional towns have a strong sense of identity and belonging which provides a great platform for working together,” explained Sharyn White, NCPHN’s Acting Chief Executive. “Research demonstrates that initiatives developed by local people are more successful in improving health and wellbeing outcomes. They also make use of local infrastructure and can improve the way agencies work together for that community,” she added. NCPHN staff have already begun engaging local residents and services and there has been a great response. A community survey has been distributed to build on initial findings. Hard copy surveys are available at community meeting places around the towns. The online version of the survey is at: The next step will be Community Action Planning Workshops to be held in May and June. Residents and service organisations will be presented with findings from the survey and community consultations. Workshop participants will have 8

Regional communities often have unique strengths and challenges a direct say in identifying health and wellbeing priorities. Local initiatives to address priorities will be collaboratively designed by the community, North Coast Primary Health Network and service partners. It will be exciting to see some of the ideas put forward by these communities come to fruition over the course of this year. NCPHN will support communities to implement solutions. “We will focus on actions that support health and wellbeing, develop connections and address gaps in services. Support will include funding, commissioning new services and building partnerships,” said Healthy Towns Program Coordinator Sarah Robin.

Top: Dignitaries at the launch of Healthy Towns in Casino. Above: The launch of Healthy Towns in Woolgoolga.

Low back pain: Lancet series tackles the issues The Lancet has published three papers on low back pain, by an international group of authors led by Prof Rachelle Buchbinder from Monash University. The papers address the issues around the disorder and call for worldwide recognition of the disability associated with the disorder and the removal of harmful practices. In the first paper, colleagues draw our attention to the complexity of the condition and the contributors to it, such as psychological, social, and biophysical factors, and especially to the problems faced by low and middle income earners. In the second paper,

Nadine Foster, Christopher Maher, and their colleagues outline recommendations for treatment and the scarcity of research into prevention of low back pain. The last paper is a call for action by Rachelle Buchbinder and her colleagues. They say that persistence of disability associated with low back pain needs to be recognised and that it cannot be separated from social and economic factors and personal and cultural beliefs about back pain. This important series can be viewed here: http://www.

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healthspeak April 2018

Aboriginal art & healing project now region-wide


he first year of the Art on Bundjalung Country project culminated in an exhibition of works created during the project’s workshops at Lismore’s Regional Gallery in December. It was a wonderful night with good attendance from the community and a real feeling of celebration around what had been achieved. NCPHN, Arts Northern Rivers, Lismore Regional Art Gallery, Bulgarr Ngaru and UCRH North Coast were partners and sponsors of the Art on Bundjalung Country project in 2017. It’s well documented that the creative arts can enhance health and wellbeing, a sense of belonging, and build resilience. Art on Bundjalung Country allows community members to identify with their culture through art and nurturing new and emerging artists. Art on Bundjalung Country grew out of two Aboriginal art exhibitions held at the Lismore City Hall in 2004 and 2009. They were inspired by local doctors working in Aboriginal Medical Services.

The artworks on show at the Gallery exhibition were chosen from those created during workshops held by skilled Aboriginal facilitators in Lismore, Ballina, Brunswick Heads, Maclean, Casino and Tweed Heads in 2017. Art forms included painting, basket-weaving and ceramics. NCPHN is excited to report that the project is set to expand across the region and will be known as Art on Country: Connecting Art and Health. Art on Country’s Senior Project Officer Sarah Bolt said learnings from last year’s project

had set the way forward. “This year we are looking for locations where we can run art workshops for Aboriginal people on Country. This will alleviate issues of transport and child care that came up last year when we ran the workshops in towns. “Creating art on Country also strengthens people’s connection to their land and culture and provides further healing through artistic expression,” she said. It’s anticipated that workshops will be held in smaller communities this year and talks will be held with each community to find out what art forms they’d like to explore. It’s also likely that more partnerships will be built to further expand Art on Country’s reach. It’s an exciting year ahead for this innovative project.

You can read HealthSpeak online anytime at So, get up to date with the latest HealthSpeak or have a look at our past issues at your leisure.

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Top: The exhibition opening featured Indigenous dancers celebrating the occasion. Left: Some of the artworks created during workshops for Art on Bundjalung Country.

First step to a national Rural Generalist Pathway The announcement of the Collingrove Agreement drawn up in February between the Royal Australian College of General Practitioners and the Australian College of Rural and Remote Medicine has paved the way for the RACGP and ACRRM to develop a national rural generalist pathway. A rural generalist is a medical practitioner who is trained to meet the specific current and future healthcare needs of Australian rural and remote communities. This is done in a sustainable and costeffective way, by providing both comprehensive general practice emergency care, and components of other medical specialist care in hospital and community settings. The two Colleges are determined to secure a strong, sustainable and skilled national medical workforce to meet the needs of rural and remote communities. 9

Getting our region ready for expansion of My Health Record

Amanda Wilkinson

Vicki McGowan

Tony Browne

Michelle King


s the Australian Digital Health Agency (ADHA) ramps up its commitment to expand digital health, North Coast Primary Health Network (NCPHN) has been funded to prepare healthcare providers and consumers for the big change. By the end of 2018, everybody in Australia will have a My Health Record (MyHR), unless they opt out. In late March NCPHN’s first Region Ready event was held in Ballina. It brought together general practice staff, pharmacists, allied health, specialists, hospital staff and the wider community to explore how My Health Record will work when everyone plays their role. Another Regional Ready event will be held in Coffs Harbour in early April. Cliff Coleman from North Coast Podiatry said the event was valuable as he learnt how MyHR will simplify things for practitioners and increase the quality and safety of health care information delivery. “My practice manager and I were concerned about the security of MyHR but our concerns were resolved by lunch time,” he added. “We were also convinced of the role of MyHR in increasing the quality and safety in primary health care.” As the MyHR opt out period draws nearer, NCPHN’s MyHR Community Engagement and Communications Officers will ensure consumers are aware of the benefits of having a MyHR and know the process to opt out if they choose to. 10

Lynne Parnell

We were convinced of the role of MyHR in increasing the quality and safety in primary health care

From left: Amanda Wilkinson (NCPHN), Kate Ellis (Pharmacist, ADHA), David Guest (GP, Goonellabah Medical Centre), Kris Hazelwood (Senior MyHR Educator, Primary Care - ADHA)

The team is ready to assist providers to understand how MyHR works and provide training and support in using MyHR and help with provider registration.

Located in four offices across the North Coast region, the team is: Vicki McGowan in Tweed Heads region (07) 5589 0510, Tony Browne in Northern Rivers and

Clarence Valley (02) 6618 5405, Lynne Parnell in Coffs Harbour (02) 6659 1821, Michelle King in Port Macquarie (02) 6583 3600 and Amanda Wilkinson, the My Health Record Program Manager in Ballina on (02) 6618 5400. The team welcome your contact should you need help or further information.

AMSs to pilot healthy kidney project Five Aboriginal Medical Services (AMSs), across Northern NSW will be part of a 12-month pilot Healthy Kidney Project run jointly by NCPHN and NNSWLHD. The project aims to help reduce hospital admissions for Aboriginal people with kidney disease. The AMSs implementing the pilot are Bulgarr Ngaru in Casino and Grafton, Bugalwena General Practice at Tweed Heads, Bullinah at Ballina and Jullums in Lismore. Clinical Nurse Consultant Kylie Wyndham will implement the pilot and clinical expertise and

guidance will be provided by Clinical Nurse Practitioner Graeme Turner. The project will focus on early identification of kidney disease and interventions to improve kidney health, preventing the onset of chronic disease. It will also build the capacity of health workers to educate patients and make

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them aware about the early warning signs of chronic kidney disease. Health literacy principles will be used to run a culturally appropriate education campaign about kidney disease. Governance for the pilot will come from the Integrated Aboriginal Chronic Care Governance Committee. An evaluation will follow the 12-month project and key learnings be written up. A pilot will be rolled out on the Mid North Coast in partnership with the Mid North Coast Aboriginal Health Authority following the Northern NSW pilot.

healthspeak April 2018

Grafton doctor wins Registrar of the Year


r Sally Gillespie who works at the Queen Street Clinic in Grafton has been named North Coast Registrar of the Year 2017 by GP Synergy. Nominated by practice manager Yvonne Byrnes, Sally told HealthSpeak that the accolade came as a total surprise. “I didn’t even know I’d been nominated, it was so lovely and such an unexpected honour.” Yvonne said that it was an absolute delight to have Sally working at the Clinic. “She has managed to complete her GP training and pass her fellowship exams – all while working full-time. “Sally loves training and takes it upon herself to mentor others around her. We love having Sally in our team and feel very blessed to have kept her,” she said. In a strange twist, Sally couldn’t attend the awards ceremony as she and her fiancé

were eloping in New Zealand. “It was very funny as GP Synergy were about the only ones apart from us who knew what we were up to,” Sally said. Sally said she really enjoyed working at Queen Street and living in the Northern Rivers. “I feel very supported and we have a lovely patient population. I’m going to stay on in Grafton indefinitely.” Congratulations also go to GP Synergy North Coast Supervisor of the Year, Dr John Vaughan. John, who supervises junior doctors at the Ocean Drive Family practice in North Haven has been mentoring younger medicos for 30 years. His skill and commitment to training is such that it’s been suggested Dr Vaughan needs to be cloned. And congratulations too to GP Synergy North Coast Practice Manager of the Year, Leanne

Innovation Series makes a comeback in Kempsey


CPHN’s Copernican Inversion Series (CIS) made a welcome return with its first breakfast event for 2018 in Kempsey in mid-March. CIS gives clinicians, service providers, administrators, consumers, policy makers and educators a chance to come together to learn about programs doing excellent work. The event at Kempsey Macleay RSL Club heard from three local programs/businesses with a particular aspect they wished to share with participants. They were Hayley Hoskins of Baylin’s Gift – a mentor/buddy system for children struggling with gender issues; Michael Kemp from allied health company Keystone Health which makes April 2018 healthspeak

Sally loves training and takes it upon herself to mentor others around her

encouragement and guidance to registrars, make her a practice manager that others feel privileged to work with.

Ward from Toormina Medical Centre. Leanne’s leadership qualities and her dedication to staff – offering support,

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the call to ‘Live for 5 minutes in the patient’s shoes’; and Jade Sinclair and Julie Dunn from The WISER Culture Change Project. They presented on the Montessori Approach to Dementia. Each CIS event aims to send you off to work feeling inspired and with an innovative hat on your head. For the next Copernican Inversion Series event, go to: https://ncphn.

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Initial findings from after the flood survey


he University Centre for Rural Health (UCRH) released the initial findings of its After the Flood survey on 22 March, showing the impact of the 2017 flood on people’s mental health and wellbeing. Co-ordinator of the survey Dr Veronica Matthews said 2500 people across the Northern Rivers region responded to the survey six months after the flood. The findings did show increased risk of depression, anxiety and post-traumatic stress for those affected by the disaster. “The risk to people’s mental health was higher for those who experienced flooding in a number of sites, such as their suburb, their home, a friend’s home or a business. “The survey also found that the longer someone was displaced from their home, the greater their risk of experiencing post-traumatic stress. “And four per cent of those who responded to the survey were still displaced six months after the flood,” Dr Matthews said. At a seminar in late March UCRH researchers presented the initial findings and took questions from the audience. The success of the survey was the result of a major collaborative effort from a team

It was important that the survey information be used to better prepare for and respond to future natural disasters

within UCRH and many other organisations and people in the community. UCRH Director Ross Bailie said it was important that the survey information was used to better prepare for and respond to future natural disasters. “We have briefed our state MPs and other community leaders about the initial survey findings and highlighted the importance of mental health impacts of natural disasters to planning and policy making. “Our community advisory groups, made up of represen-

Tai Chi beats aerobics to reduce fibromyalgia pain


tatives of business, residents, groups, volunteers, government and non-government agencies have begun working on their responses to this research.” Professor Bailie said while the survey provided a lot of interesting information, it also raised a lot of new questions. “So we’ll now be teasing out some of the issues that are beyond the first pass of the findings that have come out of the survey,” he said. One rich vein of information that will be looked at closely is the 70,000 words that people

US researchers have found that tai chi is more successful than aerobic exercise to reduce pain and improve wellbeing in patients with fibromyalgia. The study published in the BMJ 2018 onlin found that tai chi exercising conducted at the same level and duration as aerobics achieved clinically important improvements in symptoms. These included reducing pain and the use of analgesics. Patients taking tai chi had significantly better scores than those doing aerobics

a publication of North Coast Primary Health Network

wrote in the survey in addition to answering the questions. This is expected to provide more information about people’s experience of the flood, and how they experienced the response to the flood from emergency and community organisations. Survey responses about people’s community involvement and personal resilience factors are also being analysed. The researchers are working to secure resources to go back to around 1500 survey respondents over the next couple of years to keep track of their mental health and wellbeing over this post flood period. An online version of the initial survey response is available at: uploads/2018/03/UCRH-FloodInfographic.pdf

when evaluated with a tool covering pain, physical functioning, fatigue, anxiety, depression and difficulty working. The best results were among those attending a one-hour tai chi session once or twice a week for 24 weeks, compared with those only taking classes for 12 weeks. Patients continued to take recommended drug therapies throughout the trial including NSAIDS, narcotics, antidepressants, benzodiazepines and muscle relaxants.

healthspeak April 2018

Ageing Well More and more people are living into their 90s. But, the gift of a longer life span doesn’t necessarily equate to an improved 'health-span'. And understanding how to age long and well is

challenging. HealthSpeak approached a number of health professionals working on the North Coast for their take on how we can support elders to maintain a fulfilled and vital life.

Staying well: observations from a geriatrician


Lismore-based geriatrician Dr Alison Semmonds generously shared with HealthSpeak readers what she’s learnt from her 85-year old plus patients about ageing well. She pointed out that her observations are backed up with solid evidence.

Holistic health

“Trying not to focus on one isolated symptom or sign out of context with the whole person can help avoid polypharmacy and its pitfalls.” Strength training

Alison is a big advocate for the Centre for Strong Medicine in Sydney. She trained with this centre as a registrar. They have a purpose built gymnasium where older folks do progressive strength training twice a week. “They have amazing results with arthritis, chronic pain, depression and diabetes. Such training also reduces falls and improves gait.” Visit Centre for Strong Medicine at: http://www.strong-medicine.

Vision and hearing

“Regular checks to ensure these senses are working well is imperative to ageing well.”

April 2018 healthspeak

Keeping active & social


“People often want a pill or a quick fix, but exercise is so effective in keeping well mentally and physically. If you are sedentary you are not going to age well. Keeping in touch with family and friends is important. People who do really well are up to something.”

Not smoking and drinking

Positive attitude

“Probably the most important factor in people’s quality of life as they age, especially in the 90s and in centenarians. It’s important to get on top of anxiety and depression promptly. And remember that suicide rates among men are greatest from 85 onwards.

Old need not mean frail

“In the gym program I met a lady in her mid-80s. Three years before she’d had a great grandchild and couldn’t bend over into the cot to pick up this baby because she was frail. And she thought, ‘oh well, I’m in my 80s, this is life’. She entered this program of weight training and I saw her three years later. That baby was a toddler and she could actually bend down and throw the toddler up in the air!”

Stimulating the brain

“People who age well are doing things, trying out new challenges. In our local area there’s a There’s a 90-year old who is skydiving which is an extreme example. One of my 97-year-old ladies is still driving, sewing beautiful bags and having luncheons.”

“Fewer medications can make you healthier as you get older. It’s also important to make sure that patients understand what you are telling them about their medications.”

“No more than 1 to 2 drinks a day. If there’s brain dysfunction or health issues, less or none is best but you also have to be happy!”

Manage conditions quickly

“When people get health problems, it’s important to sort them out promptly. Without treatment, there will be consequences and we have to keep moving. Someone with arthritis in the knee will find their balance deteriorates, and if left for years they lose muscle bulk around the joint, lose confidence and independence and have falls.”

Eating well

“Eating simple food, unprocessed, with lots of variety. If you are in Byron Bay it seems you have apple cider with everything! Good evidence that the Mediterranean diet is good for the brain and CVD. “A lot of older people need help with access to food, meal preparation and dental hygiene.”

Health assessments

“Regularly reviewing patients can reduce nursing home admissions, falls etc. There’s lots of evidence that health assessments make a difference.”



Ageing Well NCPHN developing Exercise as Medicine program EVERYONE knows that exercise is important as a health measure and helps keep older people healthy and feeling well. And yet it’s often neglected as a treatment. NCPHN’s Clinical Advisor Dr Dan Ewald is part of a team working to encourage GPs to prescribe exercise programs with proven benefits to their patients. NCPHN is developing its Exercise as Medicine program which will be funded from July this year. “Exercise as an intervention is what We’re planning a we’re going to focus workshop where on. Studies have shown local people can doing a specific pitch their ideas exercise for a specific about exercise time for long-term possibilities health conditions has a positive impact on those conditions. So like prescribing a pill, we prescribe the exercise. “Exercise can have a positive impact on common conditions such as depression and osteoarthritis. It’s also works to improve the quality of life of patients with heart failure, diabetes, chronic lung disease, back or joint pain and can prolong survival for those going through treatment for cancer.”

NCPHN’s Clinical Council members are keen to see Exercise as Medicine become part of general practice. Because currently there’s a big gap between the number of people who could benefit from this treatment and those who are getting it. While there are care plans and allied health subsidies offered through Medicare these are limited in scope to deliver long-term doses of exercise, which are needed to support patients with chronic disease. “We’re planning a workshop where local people can pitch their ideas about exercise possibilities. Then we’ll have those ideas critiqued by academic experts and then discuss the best way forward to

implement Exercise as Medicine across our region,” Dan explained. A program like a six-minute regular walk is simple for anyone to do. NCPHN is looking for sustainable exercise routines; cost efficient ways of getting a bigger group of people connected to exercise to improve their quality of life. The program will be evaluated by allied health practitioners and experts. To find out more about exercise as a medical intervention, here’s a link to a study titled Prescribing Exercise Interventions for Patients with Chronic Conditions: cmaj.150684

The 75-year health assessment: an important benchmark

It’s a great way to gain some insight into how the patient is managing at home


THE Medicare rebated health assessment of patients aged 75 years and over provides a structured way of identifying health issues and conditions that are potentially preventable or amenable to interventions in order to improve health and/or quality of life. HealthSpeak spoke to a keen advocate of the assessment - practice nurse Maree Taylor at Lennox Head Medical Centre. Maree said she and the Centre’s other practice nurses sat down with the patient and went through the health assessment form together. Then the patient spends


time with the GP so the relevant follow ups and referrals can be made. “It’s a great way to gain some insight into how the patient is managing at home and it alerts us to what the GP might need to follow up. The section on nutrition, mobility, exercise, depression and vision and hearing can be particularly important as we can often improve the patient’s quality of life by working on these areas.” The assessment also acts as a snapshot of where the patient is at and is a valuable benchmark for later assessments.

April 2018 healthspeak

Ageing Well

Combination of Yoga and OT supports healthy ageing OCCUPATIONAL therapist and yoga therapist Maria Kirsten says her mission in life is to get the world to embrace yoga as a way of proactively managing our physical, mental and spiritual health and maximising our healthspan. After 18 years as a yoga teacher and therapist, at the age of 51 Maria recently completed her Occupational Therapy (OT) Degree at Southern Cross University (SCU). “I wanted credibility within the health care community and there were gaps in my knowledge. At SCU I was trained to be a health professional, the OT process and the incorporation of evidence-based practice and research has made a difference to my approach. Maria’s specialty is her brand – Yoga for Grown Ups - and she teaches in a spacious airy room atop Lennox Head Surf Club in Northern NSW. Her clients are older people wanting to safely keep active and be empowered to manage their ageing process. She synthesises her knowledge of the aging process, health conditions and injuries, and health promotion best practice to safely support older individuals. Maria is excited about making her kind of yoga a new occupation. “I want to train yoga teachers and fitness instructors to prevent falls through activities that build strength, balance and agility safely, but not treat people

April 2018 healthspeak

like they are old. “It’s important to not only offer choices and modifications, but to also educate them to make informed choices. By becoming aware of their bodies they can better determine when it’s safe to challenge themselves and when they need to rest more. Yoga for Grownups supports students of any age to grade and adapt the poses so they can challenge themselves without injury or stress.” Maria’s light-hearted approach and sense of humour are appreciated by her clients. “I tell them how to die – if you rest too much you get weak and then you fall over and then you die. Or if you do too much then you get injured, then you

have to rest and then you fall over and then you die. So it’s about self-management – today I’m tired and I’m going to do less. Today I feel like a tiger and I can do one more. My goal is to help them make good self-management decisions.” Part of her approach is to give clients’ yoga ‘snacks’ – short routines they can incorporate into regular activities such as waiting for the kettle to boil. “Doing yoga or exercise once a week isn’t enough. The ‘snacks’ are so that people start to realise they only need to do five minutes. People think that unless they do 15,000 steps it isn’t exercising. But a US study by LM Fishman (2009) - confirmed by a later study -demonstrated I want to train that doing 12 to 15 yoga teachers and minutes of strengthfitness instructors to ening yoga poses prevent falls through every day builds activities that build bone density.” strength, balance Maria’s way of and agility safely, working is very new but not treat people and she’s learning all like they are old the time. “I’ve been amazed at people’s capacity. I have a guy with Parkinson’s, he’s a full minute behind my instructions but doesn’t want help. He chooses what to do and modifies things. By creating an environment where it’s okay to be different people feel safe. I ask the class to sample variations of the pose and decide which version is best for them. This week students asked for ways to support sore shoulders.” As part of her mission, Maria is passing on her knowledge to other Continued page 29

Maria Kirsten is amazed at the capacity of her older students



Ageing Well Tweed OA clinic improving patients’ quality of life A SPECIALISED Osteoarthritis Screening Clinic (SOS Clinic) was launched in June last year at the Tweed Hospital’s Physiotherapy Department. It provides assessment, management and monitoring services for holistic health issues affecting joint pain. Knee and hip osteoarthritis is a cause of hip and knee pain, but this is only part of the picture. Excessive weight, weakness, stress and environmental factors also play a role. At the Clinic an experienced musculoskeletal physiotherapist provides GPs and clients with a report and recommendations based on assessment, physical fitness and function, quality of life, weight and other findings. The care to patients is ongoing to help sustain osteoarthritis health and self-management strategies. Referral Criteria:

1. NOT on waiting list for joint replacement surgery 2. Hip or knee joint pain 3. Diagnosis of osteoarthritis (OA) Referrals for patients in the Tweed/ Byron can be made by GPs, specialists and allied health professionals. Refer-ral forms are available via the NCPHN website resources The service model is based on The ACI Osteoarthritis Chronic Care Pro-


1 Month

3 Months

Pain (out of 10)





19 (severe)

30 (mild)

40 (satisfactory)

30 secs sit to stand

9 (stands)



40m fast paced walk

38.7 s

30.7 s

28.7 s

Timed up and go

8.9 s

6.8 s

6.5 s

- 62% reported their joint (‘in general’) had improved - 76% reported reduced pain out of 10. On average from 5.3/10 to 3.2/10 - 76% Oxford (hip/knee function) score improved by 8 points (out of 40) gram model. Where appropriate, clients seen through the ‘SOS’ will be referred to the ‘myOA’ program - a targeted group OA exercise and education group program to improve physical health, weight loss and help with lifestyle changes to decrease pain and improve joint health and function. It aims to ‘kick start’ positive exercise and lifestyle changes and give participants confidence and tools to self-manage their condition. In January this year the 100th client was seen at the SOS Clinic after referral from a GP or specialist. Service highlights include (after 3months): - 62% reported improvement in walking

Patient story

A 40-year-old female with a 20-year history of knee pain. Moderate osteoarthritis on X-ray. No change post steroidal injection. Referral to Orthopaedic specialist made. Referred to SOS Clinic by specialist. Patient reporting

- “Walking much more regularly for exercise” - “Less fearful and apprehensive of stairs” - “Much more confident to get moving” For more information contact physiotherapist Evan Bryant on 07 5506 7541.

Registrations for North Coast Aged Care Symposium are open! THE THEME for the 2018 symposium is “Running the Race Against the Time Clock of Ageing”. It’s an opportunity to get up to date with the complex presentations and management associated with ageing and chronic disease. Experts in the field will present new and emerging practices and treatments for this complex client group. The Symposium in Ballina on 19 and 20 July includes inter-


national guest speaker Dr Antonio Fernando, who will present on Compassion in Medicine. Other topics include Parkinson’s Disease, Movement Disorders, Osteoporosis, Falls, Chronic Disease and Ageing. There’ll also be a hypothetical discussion on The Meaning of Life. And for the first time the Symposium will hear from an expert on Spirituality and Ageing. Conference convenor Anne

Moehead, nurse practitioner in Psychogeriatrics, said that when elderly people come to hospital it’s about ascertaining the meaning of life for that individual, “We need to find out what they value as quality of life and not be dismissive based on the person’s age. You can get a 40-year-old person with a chronic disease who is frail and a 96-year-old who is active and


growing veges and some major health event will happen. The message is ‘what’s important for that person?’ Don’t be one size fits all … work with them to provide the best outcome for that person.” Book early to avoid disappointment as the Symposium is always oversubscribed. To book email karen.walsh@ncahs.

April 2018 healthspeak

Ageing Well The many benefits of stepping on STEPPING ON, the falls prevention program run throughout the North Coast, is a free program of strength and balance training to encourage active living and the maintenance of independence in older people living at home. Who can join?

• Need to be 65 years and over • Living at home • Able to walk independently (with or without a walking stick) • Fearful of falling or had a fall recently • Don’t have a neurological condition , poor memory, dementia or behavioural issues The seven-week program gives people the skills and confidence to do their daily activities without the fear of falling. Participants attend weekly two-hour group sessions. They also learn about safe footwear, medication management, vision, nutrition, and reducing home hazards from guest speakers. Maryann Anderson from the MNC Local Health District Health Promotion team is a Stepping On Program Coordinator. She said that often participants haven’t exercised at all before the program. “So Stepping On is a gateway to a healthier journey for them. I visit the groups part way through the program and let them know of the other exercise opportunities available to them so they can get involved with other activities

after the program ends. “And some have now started going to their local gym. Stepping On is also a great social opportunity where people can make new friends.” Maryann said that one woman who took part in Stepping On’s Aboriginal Program stated in her feedback that she didn’t normally join groups and often felt isolated from the community. After completing Stepping On she said she doesn’t feel as lonely as she used to. She has met some of the Elders and made friends. Shelley Lowe is a facilitator of Stepping On around Coffs Harbour. She said she enjoyed seeing participants gain confidence as the program progressed. “They gain heaps more confidence, they feel a trust in the group straight away and understand that other people have had a fall and also need to get stronger. People start to tell their stories and realise everyone else is in the same position. It’s empowering as they gain leg strength and function,” said Shelley. Facilitator Di Simpson runs the program in Macksville and Nambucca. Di echoed comments about participants becoming more socially connected. She also enjoys hearing back from participants further down the track and helping them with other health issues that might crop up in the family. “They might want to know more about making some lifestyle modifications at home or they might have a partner with dementia and need help with respite. They’ve made the connec-

tion with us during Stepping On and have the trust in us to reconnect.” For more information about Stepping On, contact the Mid North Coast Health Promotion team on 6588 2750 or via email and on the North Coast phone Freyja Smith on 6620 2553.

My Health Record a boon for seniors AUSTRALIAN Digital Health Agency CEO Tim Kelsey says the expansion of My Health Record this year will potentially deliver many benefits for older patients. “My Health Record can reduce the risk of medical misadventures by providing treating clinicians with up-to-date

April 2018 healthspeak

information. Digital health can improve and help save lives,” Mr Kelsey said. Many older Australians who have seen the numerous advantages, are getting on board early. They are using the My Health Record to manage their prescriptions and list their allergies while having their

medical conditions and test results viewable by their health care professionals. Individuals themselves can also add to the online record which can help in emergency situations. “My Health Record provides me with an opportunity to upload a copy of my Advance Care Plan so I know that my

wishes will be respected, if I were to find myself in a position where I’m unable to communicate”, said Dot Price a 70 year old retired teacher. For more information about My Health Record, contact Program Manager Amanda Wilkinson at NCPHN on 6618. 5436.



Ageing Well Easy Lifestyle changes can reduce the risk of dementia WITH MORE than 435,000 Australians

living with dementia (the second leading cause of death), it’s important to let patients know that although there are things they can’t change such as their age and genetics, there’s a lot that can be done to help keep the brain healthy. And it’s good to know that while some things naturally decline with age – memory and speed of processing, other things such as word knowledge and our problem solving ability improve with age. HealthSpeak spoke to Clinical Neuropsychologist Dr Lynne Ridgway who works at Ballina Hospital. Lynne is keen to help older folks live longer, happier, healthier and brighter (as in cognitively well). To easily achieve positive lifestyle changes, Lynne recommends a new book by a neuropsychologist colleague Dr Nicola Gates – A Brain for Life: How to optimise your brain’s health by making simple lifestyle changes. Lynne explained how the four steps that Dr Gates recommends can reduce the risk of dementia. 1. Boost brain health - Eat a healthy diet – which im-

proves gut and heart health. Eat a wide variety of fruit and vegetables, plus protein, good oils and low GI carbohydrates to get all essential micro nutrients. - Sleep well – Lynne explained that sleeping for at least seven hours each night is important as it allows



the brain to rejuvenate and not be fatigued. The Sleep Health Foundation has some useful fact sheets to improve sleep at: 2. Build brain reserve - Exercise – According to Lynne,

there’s fascinating new research on how exercise improves brain health and capacity. Indeed, through exercise it’s possible to grow bigger and healthier brains. “Even brief episodes of exercise will demonstrate a change in an important protein called Brain Derived Neurotropic Factor or BDNF. With exercise you get a burst of BDNF and a big Canadian study showed that 42% of people who did regular cardiorespiratory exercise had improved cognition afterwards. And lots of other studies also show the direct, positive effects of exercise. “So exercise is helpful because it increases the BDNF which improves the volume of the hippocampus, where memory is stored. And exercise preserves and enhances our


artery wall elasticity, which means the blood can pump through better and faster,” said Lynne. - Socialising – “It’s one of the big factors to aid healthy ageing because it improves mood and we know that depression is linked to dementia.” - Mental stimulation – “People in relationships are known to be more stimulated and stimulation is a good thing. Doing cognitively challenging activities enhance brain health. So learning something new, learning a language or a musical instrument. Something that’s new and slightly challenging. Just travelling to new places and having new experiences have direct effects on our reward and pleasure centres. Dopamine is released which improves attention and new learning,” Lynne said. 3. Reduce brain burden - Reduce stress, depression and neurotoxins

“Make sure you get treatment for depression and stress. We know that too much cortisol is not good and stress hormones interfere with brain function – you won’t be thinking clearly and making good decisions. Getting treatment for depression also reduces your risk of dementia later on. “It’s also important to look after medical conditions such as hypertension and make sure you are on the right combination of medications.” Reducing drug and alcohol intake is important as these substances are neurotoxic and the less consumed the better. 4. Develop a wise mind - Lead a satisfying lifestyle – Keep

connected with friends and the community through regular outings or volunteering. Having a purpose adds meaning to life, improves mood and can ward off depression. - Mind style – Dr Gates recommends that we all practice self-compassion. We need to be kind and nurture ourselves and let go of self-criticism and negative self-talk. Use of relaxation techniques and meditation can really improve quality of life.

April 2018 healthspeak

Ageing Well How GPs are using My Health Clinic at Home to help make better clinical decisions SUPPORTING more than 500 clients

through My Health Clinic at Home, Feros Care’s telehealth program is helping GPs to make more informed data-driven decisions. Provided with a touch-screen computer and measuring devices, Feros Care Clients have their vital signs captured and recorded (BP, oxygen levels, temperature, blood sugars and weight) each day. These results are securely shared to a trained Telehealth Registered Nurse for review. The 12-week program allows clients to monitor their health and wellness at home and discuss results with their nurse via a videoconference or telephone call on any weekday. HealthSpeak visited Feros Care’s LifeLink Operations Manager Anthony Bacon at their impressive aged assist technology showroom at Tweed Heads to find out about the health benefits of this program. “My Health Clinic at Home is about building trending data. With this program, clients take their blood pressure reading every day, weigh themselves, take their oxygen saturation reading and their BSL. At the end of a 30-day period or two weeks, whatever the doctor feels they need to see, they can get a clear picture of the vital signs of their patients. It helps GPs make better informed decisions.” Before linking the client up with the program, a nurse interviews the client, going through their complete history, medications, diagnoses, who their GP is, and which specialists they are seeing. Feros Care then sends letters to all clinicians to explain which vital signs and ranges the client is being triaged on and giving them the option to change the ranges. “We are wanting to work with health professionals and supply as much supporting information about their clients as we can gather. Indeed, the study of the pilot we conducted from 2013-2015 of 200 clients concluded that one of the biggest outcomes of this technology was saved hospital admissions.”

April 2018 healthspeak

Anthony gave an example of a patient whose oxygen saturation medication was revised as a result of the home readings. “The patient went in to see her GP and the trend report we had supplied was completely different to what he was seeing, prompting a call to us to question our system. The GP explained he’d been measuring the patient’s levels for six months when she came to the clinic and they’d all been normal during her visits. “I explained that we use a TGAapproved oximeter, providing the brand and model number. We discussed how and when the client was taking her readings based on her normal everyday movements. We confirmed how long the client would wait before seeing the doctor, usually a 40-minute wait. This proved the difference. The client relaxed for 20 minutes before her reading, accounting for the difference in readings taking throughout her day.” The telehealth readings were done after the client had been walking around, doing the laundry, making breakfast etc and after that level of exercise her oxygen saturation levels had greatly decreased. “The doctor listened carefully and asked the patient to do some walking around the surgery. She came back and he did the reading again. He told me he’d changed her medication on the spot, because he could see she was really struggling with shortness of breath. And as a

result, he’s now changed the way he takes all the readings for such patients.” Another benefit of the program is the confidence it gives the client and their family knowing that someone is keeping a close eye on their health without having to constantly attend appointments. The biggest challenge to increase the One of the biggest use of My Health outcomes of this Clinic at Home is technology was convincing GPs to saved hospital get on board. admissions “Some GPs have seen the service as a threat to their business and are concerned that clients won’t go to see their doctors when they are unwell, but that’s the furthest thing from our minds. We want to work with the GP to improve patient outcomes – their role is not compromised by us being able to provide this daily data.” “Generally patients will be healthier and they won’t have a list of patients needing to come in for regular readings. My Health Clinic at Home can provide better information for the GP to make improved clinical decision,” said Anthony. To find out more about My Health Clinic at Home, phone Feros Care/LifeLink on 1300 851 771. Or visit

Feature continues page 29



Goori Grapevine Diagnosing and treating Rheumatic Fever and Rheumatic Heart Disease By Dr Jane Jeffs Communicable Diseases Officer, North Coast Public Health Unit

(Editor’s note: In late February a roundtable of experts, convened by the Indigenous Health Minister Ken Wyatt, laid the foundations for Australia’s first comprehensive roadmap to end rheumatic heart disease. The Federal Government is allocating $23.6 million under the Rheumatic Fever Strategy over four years. It is also working to address the underlying social and cultural determinants including poor housing. RHD is almost uniquely suffered by Indigenous people so eliminating it is crucial to Closing the Gap in health equality.)


heumatic fever, scarlet fever, St Vitus’s dance, Sydenham’s chorea and rheumatic heart disease are all terms that are generally thought to be relegated to the past. Unfortunately, both acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are conditions that are still diagnosed in general practice, particularly in the Northern Territory and by our near neighbour, New Zealand. These conditions are not common in NSW but are considered important because of the populations they affect and because these are preventable diseases. Both ARF and RHD became notifiable by the diagnosing doctor in October 2015. ARF is a notifiable condition in persons of any age and RHD in persons aged less than 35 years of age. The notification form can be found here au/Infectious/rheumatic/Documents/acute-rheumatic-fevernotification-form.pdf 20

Since October 2015, 42 newly diagnosed cases of ARF and 38 cases of newly diagnosed RHD have been notified in NSW. Over 80% of ARF/RHD cases in NSW have been in people aged less than 25 years, with about half of all cases reported in children aged between 5 and 14 years. More than 80% of cases occurred in people from populations that are considered high risk for ARF and RHD, including: 43% in Aboriginal and Torres Strait Islander people, 39% in people reporting Maori and Pacific Islander ancestry and 5% in people born in other countries with a high RHD prevalence such as South-east Asia and Africa. The timely and appropriate detection and treatment of sore throats in our high-risk populations can greatly minimise the risk of ARF. Skin infections due to group A Streptococci can also be a trigger for ARF and should also be promptly treated. People with ARF may present with one or more of the following: fever, a non-itchy rash, painless skin lumps; weakness, tiredness, abnormal body movements or twitching (chorea), chest pain, shortness of breath and tachycardia. Swelling, red or painful joints

can also be an indication of ARF. Recurrent bouts of untreated ARF can lead to permanent mitral and/or aortic valve damage or RHD. Unfortunately, there is no single laboratory marker to diagnose ARF. Instead a comprehensive assessment by the clinician, a number of diagnostic tests and use of the Jones diagnostic criteria is required for ARF diagnosis. RHD is diagnosed by echocardiogram. Prevention of group A streptococcal infections to limit its impact in high risk communities is an important first step. This can be achieved by treating such infections in individuals promptly and by administering regular pro-

New Close the Gap guide for health professionals Minister for Indigenous Health, Ken Wyatt AM, has launched the updated third edition of the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people. The guide provides

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phylactic antibiotics to those who have had an episode of ARF to prevent the development of RHD. NSW Health has established a voluntary register for people with ARF and/or RHD to improve their long-term clinical care, in particular monitoring that the patient is receiving benzathine penicillin G every 21 to 28 days and to facilitate follow-up of these patients if they move. The consent forms and other resources to aid diagnosis can be found here: Infectious/rheumatic/Pages/rhdhealth-professionals.aspx Please contact your local Public Health Unit for further assistance.

GPs and other health professionals with an accessible, user-friendly guide to best practice preventive healthcare for Aboriginal and Torres Strait Islander patients. 'Prevention is always better than cure,' said Minister Wyatt. View the guide: https:// Documents/Guidelines/ National-Guide.pdf

healthspeak April 2018

Looking at the value of dose admin aids in the Aboriginal population


round-breaking research into the efficacy of the use of Dose Administration Aids among the North Coast’s Aboriginal and Torres Strait Islander people is being conducted at the University Centre for Rural Health in Lismore. Dose Administration Aids include Webster packs, pill packs and sachet packaging. UCRH Academic Lead, Aboriginal Health, Emma Walke presented preliminary findings from the first stage of data collection in February. Emma’s research is being supported by pharmacist Lindy Swain. She also acknowledged the assistance of Professor Lesley Barclay, Lindy Swain; Larisa Barnes, Jenn Johnson and Jo Longman. Emma said that when she embarked on her project she did a literature search on the use of Dose Administration Aids (DAAs) and found almost nothing around her topic focusing on the Indigenous community. “We found there was more talk about the limitations of DAAs but not how they could be used as a solution to improve compliance.” She explained to the audience that as there had been concerns that funding which provides DAAs to Aboriginal people free of charge might be withdrawn, she believed it was important to conduct her research to put the topic on the radar. To get her research started, Emma consulted with Elders and others in the community to ensure that everyone was happy for Emma to be tackling this subject. “I took with me the first draft survey and asked how this might work. The Elders made a few changes in terms of language or further questions and off I went.” Emma planned to work with NCPHN staff working in the CCSS program at five locations, inviting new CCSS clients to be April 2018 healthspeak

Survey Responses

Emma Walke

part of the research. However, due to changes in her employment Emma went back to the community to ask what they thought about her conducting focus groups. “Initially we thought that after the surveys were done, one at three months and another at six months, that we could chat with people in focus groups who’d completed the survey. I wanted to know things like ‘why didn’t they use DAAs, how the use of DAAs affected them and what their experience was of using them. I

I wanted to know why didn’t they use DAAs, how the use of DAAs affected them and what their experience was of using them wanted to know if they’d stopped using DAAs, why they’d done so,” she explained. The first focus group was run in Ballina in January and was so successful that Emma is going to continue to run focus groups to flesh out her research information. The validated survey tool Emma is using is the Morisky Scale. The responses are scored to define whether or not people were more medication compliant using DAAs.

The 21 responses so far were from one person in Tweed Heads, nine in Port Macquarie, one in Coffs Harbour and 10 from Cabbage Tree Island (near Ballina). Emma’s goal is to get 40 or 50 survey responses and to move around the region to speak to those who took part. - 3 people were technically compliant in taking their meds - Most take medication three or four times a day - 8 said they had difficulty taking their meds once in a while or sometimes - 14 said it was helpful or very helpful to have a pharmacist manage their scripts - 13 said they found DAAs somewhat or very helpful with taking their medications - More than half said they’d sometimes forget to take their meds - Most think about stopping their meds when they are feeling better - 20 said they took all their medications the day before Focus Groups

From the focus group information Emma learned there was a general dislike of taking medications and that more conversations were needed around this topic. “Essentially most people are non-compliant according to the scale which is interesting because when we talked to people in the focus group they thought they were doing really well.”

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Some of the comments given about why people don’t take their medications included: - If I have a few beers, then I don’t drink. This might be for a night or two. Not that often but I don’t take my tablets and drink together. - If I’m in a rush I tend to forget. Emma asked the focus group what they would do if funding for DAAs ceased. A lot said they’d stop taking their tablets. “It seems that removing supports would mean they’d be less likely to take or purchase their medications. Most said they could not afford the $400 a year it would cost to obtain their own DAAs, which is one more barrier to people taking their medications,” she said. One participant had multiple chronic diseases and said that years ago when DAAs and support were not available Aboriginal people didn’t look after themselves very well. But since the health support programs such as CCSS and QUMAX had come in he’d noticed a big difference in how he looked after himself and in others he spent time with. Emma said more education was needed around the value of talking to your pharmacist as earlier research had shown that most Aboriginal people considered a pharmacy just to be a shop where they purchased medications and other stuff. Emma’s research is continuing and will be followed by analysis and completion by mid-2018. Email Emma at: emma.walke@ 21

Diabetics visit dentists less


eople with diabetes and prediabetes visit their dentists less often than people without these conditions, despite their greater need for dental care, researchers say. Published online on March 31 in the Journal of the American Dental Association, the study shows an overall decline in dental visits among adults with and without diabetes. People with diabetes are at an increased risk for periodontal disease, and periodontal disease interferes with blood glucose control, contributing to the progression of diabetes. "Regular dental visits provide opportunities for prevention, early detection, and treatment

of periodontal disease, which can potentially help with blood glucose control and preventing complications from diabetes," said senior author Bei Wu. The study could not identify the reasons for a decline in dental visits or determine why people with diabetes and prediabetes might be less likely to visit their dentists than others. However, the researchers note that a previous study found people with diabetes were more likely to cite cost as a barrier to dental care. They conclude by calling for measures to reduce financial barriers to dental care, especially for people in disadvantaged groups with diabetes.

Colonoscopy linked to appendicitis


S researchers say there’s evidence to suggest that colonoscopy can ‘prompt’ appendicitis up to one week after the procedure in certain patients. In an article in JAMA Surgery, Dr Marc Basson, senior researcher at the University of North Dakota, said after exploring Veterans Administration national data, which identified 400,000 veterans who had experienced colonoscopy between 2009 and 2014, their records were tracked for subsequent procedures. Dr Basson said it turned out that the rate of appendicitis and appendectomy in the

first week after a colonoscopy was at least four times higher compared to these patients’ next 51 weeks. Although the reasons why there is a correlation are unclear, theories include alteration of colon bacteria during preparation for colonoscopy in ways that increase the likelihood of inflammation, or that the increased air pressure caused by colonoscopy might affect the colonic mucosa that predispose people to appendicitis. “More research is needed as there is clearly more going on with the appendix than we thought there was 100 years ago,” said Dr Basson.

SCU now offers courses in eight health professions By Professor Iain Graham Dean, School of Health and Human Sciences Southern Cross University


new academic year is now with us. The School of Health & Human Sciences has seen a new enrolment of students eager to enter one of the School’s practitioner or science courses. Southern Cross University now offers courses in eight health professions and the opportunity to become a health scientist in either bio-medical or psychological science. I mustn’t forget to mention those students who have continued their studies in one of those areas or commenced research training with 22

us or post-graduate study. Of course coming to a university to pursue these studies is only part of the experience. All of our students undergo a variety of industry based learning engagements in order to equip them with the knowledge, skill and capability needed when they become qualified. To ensure we provide the right types of experience, the academic team from within the School has been working hard to establish a variety of placements from our regional community. As a consequence you may well see students in schools, community services, primary care settings, in special agencies such as CHESS or Red Inc, as

well as aged care and hospital services. The need to prepare a health workforce capable of working outside of hospital or within institutional settings is now seen as appropriate. The aging population, the impact of the NDIS and improving the health and wellbeing of socially disadvantaged children is driv-

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ing curriculum change and development. These services, along with the School’s own University Clinic help to provide students with inter-professional learning experiences so that they are better prepared to work in the health and social care teams society needs. The School has now a student population of approximately three and a half thousand over its three campuses. Plans are underway to add to the course portfolio for 2019 and to offer our courses at new campus sites. However, whatever we do, the need to work in partnership with the industries of care in our region is essential as we go forward into the future.

healthspeak April 2018

Reinventing bereavement By Del Marie McAlister Chaplain and Bereavement Consultant

T he advice we give grievers has changed. It’s more compassionate. It’s more honest. It’s more REAL. We now speak of embracing bereavement by regarding grief not as a problem to be borne, but as an expression of love. We use the word heal and not recover. People do not recover from the death of someone dear to them. Instead we promote healing which speaks of consoling, comforting, soothing, and the easing of pain over time. Bereavement is not something we get over, it’s something we work through.

Stages of grief

The old way: There are five stages of grief. They are denial, anger, bargaining, depression, and acceptance. The new way: The expectation of visiting various stages or ticking the boxes of a step-by-step process completely undermines the reality that grief is a uniquely personal experience. Throughout many years of caring for the bereaved, I am yet to find someone who has experienced grief in accordance to any specific prescribed model. Each individual responds to, and experiences grief, differently. No two people grieve the same way. There’s no onesize-fits-all when it comes to grieving. Bereavement timeframe

The old way: Some psychologists are taught that if a person is still grieving six months after the loss, it is considered abnormal and ought to be treated as a disorder. Someone else invented the myth that grieving takes two years. The new way: Obviously, the people who conceived the notion that grieving takes six months or two years have never lost a beloved partner, a dear friend, a close sibling, or one of their own precious children. Those of us who have lost someone close discovers that grief becomes woven into the fabric of our lives, and remains there forever.

April 2018 healthspeak


The old way: The ‘keep calm and carry on’ idea weaved its way into becoming the correct way to mourn. Strong men don’t cry, and women needed to stay strong for everyone else. The new way: Instead of encouraging people to put on a brave face, and continue on as if nothing has happened, we encourage them to plunge into the depths of sorrow and feel the pain of loss. It is important grievers identify the emotions they experience, find ways to articulate and express them, and then seek ways to ease and soothe the intensity of their pain. Resilience

The old way: Keep a stiff upper lip, and suppress your grief. The new way: In the context of bereavement, resilience is not the suppression of grief, rather it is the strength that enables us to face it, embrace it, and process it. Resilience provides the power to counteract the desire to curl up in a corner and remain there forever. Resilience enables us to absorb sadness, and then empowers us to discover ways to live with it. Talking about death and loss

The old way: Talking about dying, death and bereavement was deemed inappropriate and morbid. Besides talking about these things has the potential to make people feel extremely uncomfortable, therefore many feel it’s best to avoid having these conversations. The new way: Human beings are not designed to internalise emotions, particularly the intense feelings associated with grief. A grieving person will need to get in touch with his or her feelings and then talk about them to someone who cares. At a visit to a Bereavement Centre in East London, Prince William told a child who’d recently lost her father, “Do you speak about your Daddy? It’s very important to talk about it. Very, very important.” Continued next page

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The old way: Very few people discussed the need for comfort therapy when someone is bereft. The new way: As a person embarks upon, and then travels along their unpredictable grief journey, it is vital they discover ways to be comforted. What works for one person, may not work for another so I encourage people to try different things until they find what brings them comfort. Some ideas include going for walks in serene places, listening to soothing music, engaging in enjoyable hobbies, enjoying a pet, praying, meditating, practicing mindfulness, gardening, or artwork. Rituals

The old way: Once the funeral is over, it is appropriate to visit the grave once or twice a year. And that’s it. The new way: Mourning rituals are important. They can be public or private. They may include listening to a particular song, lighting a candle, decorating the grave, or planting a tree. One ritual I promote is to create a special, sacred space in their home, or in their garden where they feel safe, relaxed, and comfortable, and visit it regularly. The poet John Donne once stated, “He who has no time to mourn, has no time to heal.” Journaling

The old way: We should leave the past behind and not keep thinking about the death of a loved one. The new way: I believe each griever needs a blank journal. This can be used to draw pictures, write poetry, record their story, use as a diary, transcribe memories, create a scrapbook, or whatever they choose. Journaling in whatever form it is expressed, is an important and helpful tool for healing a heart shattered by loss, and is recommended by many leading psychologists including Dr Phil. Cliches

The old way: People responded to grief-stricken people with clichés such as, “It must have been God’s will”, “He/she had a good innings”, “God never gives you more than you can handle”, “You are strong; you can handle this”, “Only the good die young”, “Time will heal your pain”, “Always look on the bright side,”etc. The new way: It’s better to say, “I’m truly sorry for your sad loss”, “I’m here for you,” “It’s so


hard to understand, isn’t it?”, “If you ever need a shoulder to cry on, mine is available,” Or “What can I do for you?” And then perhaps make some suggestions. Self-Care

The old way: Very few people addressed bereavement from a holistic perspective. The new way: Grievers need to be reminded to stay hydrated, exercise, eat a healthy diet and have plenty of sleep. It is absolutely vital that each grief-stricken person discover ways to slow down and enjoy some pampering from time to time. We nurture ourselves by indulging in things that enhance our wellbeing. Watching the sunset is very therapeutic, and doesn't cost a cent. Continuing Bonds

The old way: People need to say good-bye, let go, find closure and move on. The new way: I strongly promote the concept of continuing bonds, whereby we remain connected to our dear ones after they’ve died. I learned about it mainly from the stories my clients have shared; stories of mystery, magic, and intrigue that extend far beyond what most would deem as coincidences. I encourage people to remain open to continue to feel the bond of love in unexpected, personal, and special ways. “Your sad loss does not mark the end of your life; it’s the beginning of a new season. While fraught with unimaginable heartache, you have the blank canvas of your future which you may paint any way you choose. I encourage you to pick up your paintbrush and allow rays of light to seep through the shadows.” Del Marie McAlister works as a chaplain in aged care. She is the former chaplain of Ballina District Hospital and was a suicide bereavement responder with the Standby Program. Del Marie is also a funeral celebrant. Email: Del also runs a Bereavement Support Group meeting/lunch on the first Saturday of each month, excluding January, from 11am at St Mary’s Anglican Church in Ballina. Attendance by donation. To book phone 6686 2094. Facebook support at: Forever-in-my-Heart-216515541832930/

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healthspeak April 2018

Using a Fluid Diuretic Regimen keeps heart failure patients out of hospital


Ps in Northern NSW can expect to see their heart failure patients bringing along a new, easy to follow Daily Fluid Management Book in upcoming practice visits. It’s a tool that’s been proven to prevent readmissions to hospital. The new Daily Fluid Management Book with enclosed Flexible Diuretic Regimen is an update on previous booklets. The new version has been coordinated by Heart Failure Liaison Nurse, Francesca Leaton, as part of the Integrated Care drive on the North Coast. The Daily Fluid Management Book has been written using health literacy principles, it’s user friendly, clear and easy to apply,” Fran told HealthSpeak. Working closely with ACI, GPs, Southern Cross and Sydney Universities, Francesca has been conducting post-graduate research into the use and benefits of heart failure patients using Fluid Diuretic Regimens. She is a keen advocate for this tool. Francesca’s research has shown that this simple book can help prevent heart failure readmissions.

“In my initial research I looked at 150 heart failure patients. Of that 150, 81.3% were admitted with fluid overload and 90% of that cohort had symptoms ranging from two to 30 days prior to admission. “This shows us that a lot of work can be done in the community to help prevent heart failure admissions. I’ve been working closely with GPs, the PHN and the NNSWLHD for a number of years now to reduce heart readmission rates. And I’m happy to say in the fourth audit (n=50), there’s a significant reduction in heart failure admissions. This can be directly attributed to using Fluid Diuretic Regimens. That’s a great finding.” How does it work?

The Daily Fluid Management Book can be accessed by GPs on HealthPathways. Look under Medical, Cardiology, Heart Failure, then Patient Resources and you will see the Daily Fluid Management Book. GPs can access this Book with their heart failure patients to up-titrate diuretics for short term symptom manage-

ment. Of course Francesca would be more than happy to support your patients with further education if GPs feels this is necessary. Francesca also provides referred inpatients with the Daily Fluid Management Book which the patient then takes to their GP appointment after discharge. Francesca will follow-up inpatients usually within two weeks of discharge and writes to patients’ GPs outlining a Heart Failure Action Plan. This often includes implementing a Flexible Diuretic Regimen. GPs are asked to complete the Flexible Diuretic Regimen on page 3 of the Daily Fluid Management Book and sign and date it for patients’ future use. My take home message is that Flexible Diuretic Regimens work - it’s a win/win situation. The patient benefits by staying well longer at home and at the same time heart failure readmissions are reduced. Currently Francesca is working with inpatient doctors and nurses trialling an ‘Acute Heart Failure Clinical Pathway’ in Tweed Hospital’s Coronary Care Unit. Once this is up and running GPs

Autistic kids less likely to be vaccinated


ew research from the USA has found that children with autism and their younger siblings are less likely to be fully vaccinated than neurotypical children and their siblings. The study published in the journal MAMA Pediatrics showed that of children aged seven and older, 94 per cent of neurotypical children had received all the necessary vaccinations for kids aged four to six. April 2018 healthspeak

For those with autism, the rate was 82 per cent. The study included 3729 children with autism and 582,907 neurotypical children based on

age, sex and location. Researchers reviewed what proportion of each group had received the vaccines recommended at four to six years and 11 to 12 years. “We found that after children received an autism diagnosis, the rates of vaccination were significantly lower when compared with children of the same age who did not have an autism diagnosis,” said lead author Ousseny Zerbo.

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can expect to see the Flexible Diuretic Regimen, on page 3 of the Daily Fluid Management Book completed by the Medical Team prior to discharge.

Lifehouse Head & Neck Cancer Clinic has moved Chris O’Brien Lifehouse in Port Macquarie has moved to 2 Clarence Street. They wish to remind GPs about how to refer. Simply phone 814 0432 and fax 9383 1033. Email: Conditions that may be referred include: - Advanced skin cancer of the head and neck - Neck Lumps: thyroid/parathyroid; salivary glands (parotid/ submandibular); lymph nodes and other - Head/Neck Cancer: Mouth, tongue, jaw, voice box, tonsil, nose and sinuses Contact the clinic by phoning Lydia Zammit on 8514 0432 or email: headand


Legislation paves the way for Aboriginal language revival In October last year the NSW Parliament passed landmark legislation that recognises and aims to revive Indigenous languages for the first time in Australia’s history.



s part of the new legislation - The Aboriginal Languages Bill – the NSW Government will appoint an independent panel of Aboriginal language experts and establish a new languages centre. About 1800 people speak Aboriginal languages in NSW. HealthSpeak spoke to two significant Aboriginal educators about the change. Glen Rhodes

Aboriginal Language

Glen is a teacher in the Bundjalung Culture Nest at Goonellabah Public School in Northern NSW. The school has a long and proud history of teaching Aboriginal language. HealthSpeak visited Glen to find out the history of language teaching there and what the new legislation will mean. “About 30 years ago the late Uncle Mick Walker began sharing his knowledge, wisdom and language at this school. He worked with Dyonne Anderson, a local Bundjalung Gumbaynggir woman who worked in the classroom,” said Glen. “There were a few people who collated all this language information and made up some resources to teach language. All of it was here when I arrived at the school and I’ve kept it and still use some of it,” he explained. Glen showed us some of these older resources including a reading strategy, a language teaching strategy and a nation map. He also produced an old exercise book of a student who studied Basic Bundjalung at the school 26

about 20 years ago. He explained that the language teaching began with lists of words and then signs were made and placed around the schools in language and the momentum grew from there. “Uncle Mick taught the language and passed on the knowledge to Ricky Cook who was the Aboriginal Education Assistant here. They were really close before Uncle Mick passed away. And Ricky continued to teach language. And it all started at this school.

So this boy had all the cultural knowledge within him but the classroom didn’t tap into it

“I think that’s why they established the Bundjalung Culture Nest here because of the strong language history associated with it. This is my base school and I go out to other schools and communities in the Bundjalung Nation.” Basic Bundjalung is taught to all the students of Goonellabah Public School. About half of which are Aboriginal. Enthusiasm to learn language is so strong that Glen has three schools waiting for Aboriginal language students to teach their pupils. Glen said if a school wants to teach an Aboriginal language or dialect he makes contact. All schools choose a dialect from their community, and he emphasised that it has to be what the community wants.

Glen Rhodes with his grandson Khiarn King-Cullinane, who’s a pupil at Goonellabah Public School.

“I engage with the community and they have a conversation about what they want to do. It builds from there and most schools run the program for the whole year and all the kids in the school learn a language.” Glen is excited about the new legislation. “What this will do is awaken the language. So hopefully learning Aboriginal language will be well supported in government agencies and community organisations. “It shows the NSW Government is acknowledging that

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there are first languages and that’s the most important thing for us as Aboriginal people. Glen explained that the next phase of the legislation is to establish an Aboriginal Languages Legislation Establishment Advisory Committee. This body will run until June 2019 and their job is to establish the Aboriginal Languages Trust and the guidelines and framework for the Trust. So it’s possible that before too long anyone in the community will have access to learning the local Aboriginal dialect, which healthspeak April 2018

April 2018 healthspeak

first time she’d seen him really engaged in conversation. These kids need to be who they are.” Glen said he was confident that data will show over time that Aboriginal student language outcomes are the same or better than the rest of the state in NSW. And he knows that with the legislation the language project can go a lot further and be more driven by the students themselves. “There’s a whole new team of people on board in the Aboriginal Education Community Engagement Directorate of the NSW Department of Education and the current manager is keen to let people know what’s happening in classrooms like ours because up to now the Department hasn’t known what’s going on. We need to showcase what we are doing.”

Clark sees the new legislation as a step in the right direction. But ideally, he’d like the Aboriginal community to have more of a say in the Aboriginal Languages Trust. “At the moment the Board will be all Aboriginal people, but they will be hand-picked by the Minister. And the activities of the Trust will be answerable to the Minister for Aboriginal Affairs.” Clark is optimistic some of these mechanisms can be fixed within the first year of the Trust. He would also like to see the scheme acknowledged as a

reparation rather than simply government funding. “That it’s acknowledged by Government that irreparable damage has been done to our language and our culture through the Stolen Generations. If it’s considered in that light, it changes the way things could be done. So if the compensation was made we wouldn’t have to be answerable to how we choose to deliver our language programs,” he explained. And while Clark would like to see Gumbayngirr taught in the wider community, right now for him it’s important to prioritise Aboriginal people to learn their language and empower people to become teachers. “But also to prioritise learning on Country and in our setting. With the community class we have a few non-Aboriginal people who come along and they come into our space and that’s the way we’d like to see it happen. “It’s also important to recognise that when I go into schools the Aboriginal students then share what they learn with their peers. This means they are seen as experts in something, and that’s another empowering way forward.” Overall, Clark has high hopes for the new legislation and is pleased that the significance of Aboriginal languages has been formally recognised by the NSW Government.

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Clark Webb

Clark Webb is the Aboriginal Cultural Heritage Officer at Bularri Muurlay Nyanggan (Two Paths Strong) in Coffs Harbour. Clark conducts cultural awareness training and teaches seven Gumbayngirr culture and language classes each week in high schools and primary schools and runs community classes at Wongala Estate Aboriginal Reserve. He also runs an advanced class for people training to be teachers themselves. Although Clark said kids are often bombarded with negative

perceptions around Aboriginal language and culture, he said there’s a massive pride when kids and older folks are on Country. “But it’s hard when their peers are making fun of what they are doing and that can be damaging.”

It’s also important to recognise that when I go into schools the Aboriginal students then share what they learn with their peers


would be provided through community organisations. But getting back to the benefits of language learning in schools, Glen said becoming immersed in their own language gives Indigenous students a sense of their identity and a sense of pride. “Research shows if you learn two or three different languages you are able to think more creatively and achieve more in life. It’s also helping Aboriginal students to know who they are and to feel part of their community. “Some kids don’t even know who their family or community are. I was talking to a Year 2 class a few weeks ago and I was talking about my grandfather and the Protection Era and the fact that he needed permission to leave Cabbage Tree Island to work on the railway for about 40 years. I had a photo of my grandfather in the middle of the display. And this little boy got up and said ‘Yea, my pop told me about living in Moree where they weren’t allowed to swim in Moree Baths. “So this boy had all the cultural knowledge within him but the classroom didn’t tap into it. This gave him an opportunity to say who he was. And when he got the opportunity to talk about his Pop he just beamed. And after I finished another teacher told me that that little boy was really naughty in class and that was the

Clark Webb (right) with Elder Uncle Bing.

Aboriginal Language

Some pages from the 20-year old exercise book Glen found among old language resources.

Oral health assessment tool for older people By Dr Brendan White

Ageing can also mean an increase in the use of medications that have side effects and these can impact on oral health


eeping their natural teeth is a key part of quality of life for older people. And in these times it’s more likely that older people seen in general practice will retain a greater number of natural teeth as they age. Fortunately, complete loss of teeth has more than halved. Around 80% of people over 65 and 72% over 75 will have kept some natural teeth. However it’s sobering to learn that in Australia in 2013/14 there were 8000 hospital admissions for people aged 65 and over linked to oral health, and these conditions were considered preventable. Better oral health in seniors has multiple benefits. As well as the many pluses of retaining your own teeth, good oral care ensures better overall health and saves the health system a great


Intermittent fasting reduces CVD risk A study in the British Journal of Nutrition shows that intermittent energy restriction diets, such as the 5:2 Diet, clear fat from the blood quicker after eating meals than daily calorie restriction diets. Thus reducing an important risk factor for cardiovascular disease. Researchers from the University of Surrey examined the impact of the 5:2 diet on the body’s ability to metabolise, as well as clear fat and glucose after a meal and they compared it to the effects of weightloss achieved by a more conventional daily calorie restriction diet. During the study, overweight participants were assigned to either the 5:2 diet or a daily calorie


deal of money. Ageing can also mean an increase in the use of medications that have side effects and these can impact on oral health. There is often too a reduced capacity to perform oral hygiene on a daily basis. The risk of periodontal disease also increases with age and reduced income also leads to increased risk of oral disease.

restriction diet and were required to lose five per cent of their weight. Those on the 5:2 diet ate normally for five days and for their two fasting days consumed 600 calories. Researchers found that participants who followed the 5:2 diet cleared the fat (triglyceride) from a meal given to them more efficiently than those who undertook the daily diet. Although there were no differences in post meal glucose handling, researchers were surprised to find variations between the diets in c-peptide (a marker of insulin secretion from the pancreas) following the meal, the significance of which will need further investigation. The study also found a greater reduction in systolic blood pressure (the pressure in your blood vessels when your heart beats) in participants on the 5:2 diet.

How can GPs and RNs help?

It’s possible to carry out an oral health assessment of older patients using an effective tool. It’s easy to use and both doctors and nurses could carry it out as needed.

The Oral Health Assessment tool can be downloaded at: Photoshopped-oral-health-tool. jpg.

Clarification on Prescribing Cannabis


Cannabis Medicines Advisory Service has been established by the NSW Government. The service provides expert advice and support to NSW doctors who are considering prescribing a cannabis medicine. The service includes a telephone hotline that doctors can call to discuss their patient’s condition, what treatments they have attempted and why they think a cannabis medicine would be a suitable next step. The Service can assist with • Understanding the latest evidence around cannabis medicines • Understanding the regulatory requirements for cannabis prescription • Considering tools to monitor a patient’s progress while using cannabis medicines • Provision of protocols to facilitate cannabis medicine prescribing • Information about dosing and titration in individual patients

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The Service is available to NSW doctors and health professionals. It operates Monday to Friday from 9am to 5pm. Contact the service by email at HNELHD-CMAS@hnehealth. or phone (02) 4923 6200. Download a fact sheet here: healthspeak April 2018

Ageing Well Programs to make healthy normal in older folks STAFF at both the Mid North Coast and

Northern NSW Local Health Districts have a number of ways to encourage people over 50 to maintain a healthy weight, increase fitness and strength, improve self-esteem and mental health, reduce the risk of heart disease, reduce risk of falling as well as maintain independence. And, the added bonuses of these programs are social inclusion and enjoying a sense of belonging in your local community. Stepping On is a free seven-week pro-

gram designed for Aboriginal or Torres Strait Islander people aged 45 years and over and non-Aboriginal people aged 65 years and over who have fallen or are fearful of falling. Stepping on teaches practical exercises to improve strength

and balance. For more information please contact the Mid North Coast Health Promotion team on 6588 2750 or via email and on the North Coast phone Freyja Smith on 6620 2553. Get Healthy Service is a free and confidential phone based service which can help individuals to make lifestyle changes about being physically active, healthy eating, alcohol reduction and maintaining a healthy weight. For more information, please call 1300 806 258. Heart Foundation Walking groups

are led by volunteer walk organisers across the Mid North Coast. Joining a Heart Foundation Walking group in your local area can help you stay motivated to exercise regularly. Walking for

HealthPathways to support seniors Go to: https://manc. au/index.htm Username: manchealth Password: conn3ct3d HealthPathways Depression in Older Adults Antidepressants for Older Adults Cognitive Impairment and Dementia 5 Minute Neurological Examination for Patients with possible Dementia Starting Cholinesterase Inhibitors (CHEIs) Behavioural and Psychological Symptoms in Dementia Driver Assessment of Patients with Cognitive Impairment

April 2018 healthspeak

which assesses patient’s fitness to drive and provides a referral link to: • OT Therapy Driving Assessment • Advance Care Planning Action Plans Diabetes

Service Pages Healthy Lifestyle Support Community Nutrition Programs Physical Activity Support Hydrotherapy Falls Prevention Programmes Osteoarthritis Chronic Care Chronic Care Exercise Physiology Physiotherapy Aged Persons Care Assessment

Non-Acute Aged Care Assessment Aged Care ShortTerm Rehabilitation Support Non-acute Adult Mental Health Assessment Medication Review Services Adult Audiometry Assessment Nursing and Home Support Dietitian Services Adult Occupational Therapy Assessment Podiatry Assessment Rehabilitation Assessment Social Work Referrals Adult Speech Pathology Assessment Patient Stranspo0rt Travel and Accommodation Subsidies Diabetes Referrals

just 30 minutes a day provides a variety of heart health benefits. For more information about joining or starting a local walking group visit http://walking. Hydrotherapy is a series of gentle

movements performed in a heated pool. It may be beneficial for people who suffer from injuries or conditions affecting their muscle and bones. Some hospitals in the Mid North Coast offer hydrotherapy programs for little or no cost. For more information on classes in your area, please contact your local hospital. For what’s happening in your local area or register your exercise program visit https://

From page 15

yoga teachers, providing teacher training specifically geared to seniors and older grown ups. She is also conducting evidence-based research on the effectiveness of her yoga classes for improved balance and falls prevention among her clients. Find out more here: and



Fresh hope for pain relief with new SCU joint venture


ewly signed agreements have paved the way for a flourishing North Coast industry built on the medicinal value of cannabis. The agreements between Southern Cross University and Solaris Nutraceuticals commit to the development of hemp and medicinal cannabis products in the Northern Rivers region that will enhance animal and human health. Vice-Chancellor Professor Adam Shoemaker said the agreement was a great step forward not just for the region, but also for consumers. "Universities have a vital role to play as catalysts for diversification and development – creating new opportunities through 21st century industries,” said Prof Shoemaker. “This agreement is a great example of Southern Cross University’s commitment to engaging with industry and the

Universities have a vital role to play as catalysts for diversification and development

Inspecting the SCU facilities. From left: Michael Horsfall, CEO Solaris Nutraceuticals; David Parry, director Solaris Nutraceuticals; Ashley Dowell, manager SCU’s Analytical Reseach Laboratory; Pro Vice Chancellor of Engagement Ben Roche, Vice Chancellor Prof Adam Shoemaker and Vaughan Macdonald, general manager of Richmond Valley Council.

community, so that we can create an environment for discovery and commercial development, driving changes in our backyard that can translate into benefits around the world." Prof Shoemaker signed the agreement with CEO of Solaris

Nutraceuticals, Michael Horsfall, committing to a new approach that brings together the University’s expertise in medicinal cannabis research with the corporate capabilities of Solaris Nutraceuticals. The University’s Lismore

Melanoma is in the eye of the beholder


niversity of Queensland researchers have found that freckles and moles appearing on the iris indicate a high risk of melanoma, particularly in people under 40. Associate Professor Rick Sturm of the University’s Dermatology Research Centre said the presence of pigmented lesions was an effective predictor of the risk of melanoma that complemented traditional factors. “We found the presence of three or more iris pigmented lesions was associated with a 45 percent increased risk of melanoma,” Dr Sturm said. “ “The presence of iris freckling and naevi provides additional information about an individual’s melanoma risk over and above factors like blue eyes, red hair, fair skin and the number of moles on the skin.” 30

Freckles and moles appearing on the iris indicate a high risk of melanoma

The study, involving Professor H. Peter Soyer and Dr Antonia Laino, involved 1117 participants of European background living in south-east Queensland. Dr Laino said the results showed that participants with pigmented lesions were 1.45 times more likely to develop melanoma. “This association was particu-

larly strong in people under 40, suggesting a genetic susceptibility. “These lesions should be used as markers for melanoma risk in younger patients,” she added. The UQ Diamantina Institute study was published in the British Journal of Dermatology. doi/10.1111/bjd.16323/abstract

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campus is equipped with highsecurity research laboratories where researchers work with the world’s most diverse collection of cannabis seed and has already established an international reputation for botanical research. The decision of Solaris to establish a new medicinal cannabis plant in Casino, just a halfhour drive from Lismore, has underscored the potential of this collaboration to yield substantial outcomes.


Motorbikes and quads most dangerous for kids An Australian Institute for Health and Welfare report shows that nearly 22,000 Australians were hospitalised from 2010/11 to 2014/15 as a result of an injury on a farm, with 77% being men. Just over 71% of people hospitalised as a result of farm-related injury resided in Inner Regional and Outer regional zones. Injuries involving motorcycles and quad bikes accounted for 42% of hospitalisations in children aged 0–14 and 21% of hospitalisations in people aged 15 and over. Injuries involving horses accounted for 16% of hospitalisations in children up to 14 years of age 80% of which involved girls. Most of those injured had been bitten or crushed by a horse.

healthspeak April 2018

Where to for Private Health Insurance?


hen the Federal Government announced the latest rise in private health insurance premiums, it quite rightly pointed out that the percentage increase was the lowest in almost two decades. The rise of 3.95 per cent approved for 2018 was lower than the year before and well below the six per cent plus rises in 2014 and 2015. But as the critics have pointed out, it was still more than twice the rise in average wage rates for 2017 - and that premium rises have been well outpacing inflation for most of the last twenty years. This prompted the Federal Opposition to promise a two per cent cap on premium rises for two years and a Productivity Commission review of the industry. Simple maths tells us that if premiums continually outstrip income growth then health insurance will become unaffordable for all but the rich. So why are the rises in premiums so steep? Can anything be done? As we know, health care costs are rising everywhere because the population is ageing, many procedures are becoming better but more expensive and we expect more from the system. In short, as we become richer, we are spending more of our resources on health care because we want to. But how can this increase in demand be met in the most costeffective way? Like many developed countries, Australia has a mixed health care system where the costs are shared between governments, both state and federal, private health providers and consumers. Government picks up most of the cost of healthcare. In Australia 68 per cent of health care is provided by governments, financed through the tax system. Compared with other develApril 2018 healthspeak

finance David Tomlinson

oped countries (OECD) this is reasonably modest. We rank 26 out of 34 countries in terms of the contribution by government. Norway, Germany, Japan and Sweden are above 84 per cent and New Zealand is 80 per cent. The US is last at 49 per cent. There appears to be some room to move. But since the late 1990s, the then Coalition Government decided that falling private health insurance membership had to be addressed to take the pressure off the public system. Between 1997 and 2000 it introduced the health insurance rebate of 30 per cent as a carrot and, as sticks, the Medicare surcharge for those with no private insurance and Lifetime Health Cover to penalise young people who did not join up.

In Australia 68 per cent of health care is provided by governments, financed through the tax system This worked and the proportion of people with private coverage grew from around 30 per cent to 50 per cent. But the figures are now dropping again. When the rebate was introduced in 1999 it cost the Federal Government around $1.4 billion. Next year the cost is likely to be $6.7 billion and rising despite means testing the rebate and

changing the formula. So what will the Productivity Commission look at if it gets the chance? One solution is to reduce or eliminate the rebate.

Some studies have suggested that if you abolished or reduced the rebate many people would leave, putting additional pressure on the public system. Some would stay – those who could afford the higher premiums and those who dislike the waiting lists for “non-urgent� procedures. And if the Medicare surcharge and the Lifetime Health Cover rules stayed, there would be even more people who would stay private. The question for government is: Would the reductions in costs from reducing the rebate exceed the extra costs to fund the public system to cope with the extra demand? Some economists have suggested that cutting the rebate would be cash positive for the Federal Government even if the public hospitals were fully compensated. More research here would be required. Is the community rating principle the right way to go?

At present funds cannot discriminate between members based on health status, age or claims history. Just about everyone pays the same. This contrasts with other types of insurance where consumers are assessed by risk such as driving record, smoker status and age. This principle distorts the

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market even further. The young subsidise the old and the healthy subsidise the sick. Is this what we want? Perhaps this principle could be abandoned and we should allow funds to charge what they like, offer what coverage they could sell and let the market work it out. Of course this would mean the public system would have to be a viable alternative for those who could not afford private health. Would a cap on premiums work?

The answer from economists is almost definitely no. The Howard Government froze premiums back in 2000 and 2001. After the freeze, premiums soared over the next four years to catch up. If the cap continued the result would have to be lower levels of coverage by the funds in the form of more exclusions and higher co-payments. People would be forced into the public system. Is there enough competition in the market? Vigorous competition tends to be better for consumers as it leads to higher efficiency and lower premiums. In Australia five companies dominate the market with more than an 80 per cent share. Most are very profitable. Can competition be increased? Are medical costs too high?

A tricky one to answer but over time medicines, types of procedures and technology change - and charges by health providers should reflect this. In some case charges have to fall and in others they will go up. These and many more questions need answers. But health care costs are going to continue to rise. We will be forced to change at some stage. 31

Why does Australia (and Northern NSW) have so much skin cancer? By Prof Terry Slevin Education and Research Director, Cancer Council WA; and Prof David Whiteman Group Leader at the Cancer Control Group, QIMR Berghofer Medical Research Institute


hite people are not made for Australia’s weather conditions. International comparisons highlight the extent to which we and our Kiwi friends are undisputed world champions in skin cancer. Unfortunately, we’ve long occupied gold and silver on the skin cancer Olympic podium. A conservative estimate of the cost of treating melanoma in Australia exceeds A$270 million annually. If we add nonmelanoma skin cancers (now called “keratinocyte cancers” after their cell of origin) and the bill is likely more than A$1billion a year. Why us?

Most Australians (and Kiwis) have the wrong type of skin for their environment. Basically, through migration, our two countries have been populated by many people with fair skin whose ancestors come from much less sunny climates. Lack of protective pigmentation leaves skin cells especially vulnerable to the DNAdamaging rays from the sun. During human evolution, our early hominid ancestors in Africa lost their covering of body hair and developed pigmented skins, presumably as protection against the harsh tropical sun. With subsequent migra-


tion out of Africa into Europe, the protective benefits of dark skin became less important for survival and were likely a hindrance to effective vitamin D production. There was selective pressure for less pigmented skin with more distance from the equator. In contrast, those who migrated out of Africa to Asia, Australia and the islands of Melanesia were constantly exposed to sunlight. So they retained their protective pigmentation. This explains why the recent European migrants to the Americas and Oceania arrived in the “new worlds” with skin types poorly suited to their new environments. This was in stark contrast to the welladapted skin of the indigenous inhabitants. While melanin provides protection against the damage caused by exposure to UV radiation, it’s not a “suit of armour”. Melanoma rates are far lower in people with pigmented skin such as Aboriginal people, but not non-existent. Melanin, which pigments the skin, protects against UV radia-

Most people think our rates of skin cancer are due to a ‘hole’ in the ozone layer, but this isn’t really the case

tion. This is why paler people will get more skin cancer. A major factor is geography – that is proximity to the equator. Generally speaking, the closer to the equator someone lives, the greater the amount and intensity of sun exposure they receive. That gradient is seen in a comparison of skin cancer rates across Australian states with Queensland reporting much higher rates than New South Wales, which is in turn higher than Victoria. Another is the earth’s elliptical orbit around the sun. The planet is about 1.7% closer to the sun in January, during the southern summer, and 1.7%

further away in July – northern summer. So that means when the sun is strongest the southern hemisphere is 3.4% closer to the sun than the north is during their summer. This increases UV by about 7%. Add to that the lower pollution levels and clearer air in the southern hemisphere – due largely to much lower population densities – resulting in UV levels about 7% higher than in the northern hemisphere. Taking all these factors together, southern hemisphere locations receive about 15% more UV radiation than the equivalent northern latitude location in any given year. What about the ozone hole?

Many believe the ozone hole – a naturally-occurring pool of ozone-depleted air arising over the poles – explains much of our excess skin cancer rates. Stratospheric ozone does reduce the amount of UV reaching the Earth’s surface. When the ozone layer was damaged by the release of CFCs and halon from refrigerants from the 1960s onwards, more UV reached ground level. So the depletion of the ozone layer caused legitimate concern and prompted the establishment of the “Montreal protocol” designed to eliminate ozone-damaging pollutants and repair the ozone hole. Most people think our rates of skin cancer are due to a ‘hole’ in the ozone layer, but this isn’t really the case. As the ozone hole over the South Pole breaks up in spring, pockets of ozone depleted air drift across Tasmania, Continued page 39

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healthspeak April 2018

Taking the fall


ithout warning I am falling through space, disconnected from the narrow path on which I had been walking. During my unplanned descent, time slowed and there seemed to be enough of it for lucid thought and reasoned discussion with the self. In the edge between life and death, this slowing of time is an instant activation of every brain cell. ‘Silly old git. Don’t you know the danger of elderly falls?’ I said to myself. I’d experienced this time delay phenomenon years before, during a car roll-over accident, from which I had luckily climbed out intact. The brown dog sitting next to me had passed slowly, upside down, through the space before my eyes. He was also unhurt. It was a gravel country road with no-one around. So we both had a pee. In a mad fugue I got back into the driver’s seat and tried to restart the very bent car. Eccentric guru Alan Watts once said ‘The most important thing to learn in life is when to stop.’ It was fortunate that the laws of physical reality ruled out a continuing of that journey as the front wheels were pointing in different directions. An old memory predominated - the great danger with falls in the elderly. At over 70, and a retired emergency doctor, I realised my immediate peril, but at the same time, in space, felt very peaceful, perhaps resigned, until the moment of bumpy impact. But wait - I’m still alive. This particular dirt-track is well-trod. Recent rain had made it a bit slippery. Even so, my own slip was completely unheralded. I have great faith in my Keens, the world’s most sure-footed sandal, but the left one could not do anything with no ground beneath it. As the embankment sloped to the left, my body rolled naturally down in this direction. First impacted was the back April 2018 healthspeak

of my left hand and shaft of forearm, positioned across my chest, hand covering the face. As I heard my sunglasses smashing and my hat flying off during the rapid rollovers I knew I was moving fast. Hips and knees were flexed so my body formed defensively into the shape of the unborn, back to the foetal position.

Hips and knees were flexed so my body formed defensively into the shape of the unborn, back to the foetal position Three times I rolled down this steep embankment until coming to a sudden stop, spreadeagled on my back, arms and legs flung out, the power of the mighty magnet clutching my body in an overwhelming sensation. Bushes and small saplings must have provided enough friction to slow the momentum. Willy, who was walking in

front, called out to me from above. ‘Are you all right?’ I didn’t want to move to find out the bad news so I just stayed still. Blissful. But her question brought me to my senses. I had to assess the damage, be my own doctor. Could I move my neck? Yes. Toes wiggling? Yes. Spinal cord intact. Move arms and legs, cautiously. Seems okay, nothing bent or torn, just bleeding from lacerations on hand and forearm. Once upon a time a doctor I knew fell off his verandah at home, making enough noise to attract his alarmed daughter from inside the house. ‘Are you all right Dad?’ ‘Just bring me a mirror,’ he answered. ‘What!’ asked the astonished girl. ‘When your mother gets home she will want me to see a doctor and I want to be able to tell her that I have.’ Doctors are a weird mob. Later, over a cold beer at the campsite, I reviewed my experiences in emergency departments - just how many serious injuries are seen from falls onto the outstretched hand, something I had avoided. They are all described similarly in the textbook. ‘Typically a fall on the outstretched hand is the precur-

a publication of North Coast Primary Health Network

light airs David Miller

sor to shoulder dislocationselbow injuries- various wrist fractures involving a complexity of vital moving parts, tendons, bones and ligaments.’ An idea formed. If a fall is inevitable, the back of the hand with a flexed elbow is a better impact buffer than the palm with a straight elbow. Back at the scene, I looked up at Willy from a height of about 3 metres. ‘I think I’m okay’, I said, climbing to my feet and pulling my body up with the support of the little saplings which had helped save my life. It could have been worse. I realised that this was another lucky day.


Thinking is Overrated Empty brain - happy brain Niels Birbaumer & Jorg Zittlau (Scribe 259 pp $27.99)


orget the smiley-face cover, reminiscent of the ‘free’ stickers handed out by plainclothes Hare Krishnas who, upon acceptance would seek a donation. Ditto the title, seemingly designed to make the book more popular. Although the title is a literal translation from the German, I can imagine the publishers agonising over whether it would work in English. Frankly, no, although emptiness upstairs is what this excellent work is about. The book follows Dr Birbaumer’s previous work, Your brain knows more than you think (Scribe 2017), which featured the psychologist/ neurobiologist’s exploration of neuroplasticity and his pioneering use oft brain-


Lismore Pain Clinic Referrals GPs are advised that physician Dr Frank Wagner is no longer working at the Lismore Pain Clinic. Referrals should now be made to Dr Tim Sholz until a


machine interface (BMI) technology in gauging “the virtually limitless capacity of the brain to remould itself ”. BMI, as he revisits here, creates a ‘neurofeedback’ loop from the brain to MRI signal reception, thence brain-image transfer and signal analysis by computer program, transfer of processed brain activity to the BMI software and finally, feedback of blood flow in the brain. Perhaps the complexity of the topic does require a smiley-face cover to address the diverse cast that populates the book. They include the Buddha, perhaps the prime example of ‘brain emptiness’, Schopenhauer, Heraclitus, Nietzsche, the Maharishi, researchers Donald Hebb and Peter Suedfeld, Zen monks, John Lennon and many more. Starting where the previous book left off, Birbaumer discusses the work his university has done with bedridden, paralysed patients, finding that a significant number appear to enjoy a good quality of life - “for some, even higher than that of healthy people!” He adds, “This despite the fact that they were no longer able to move a single muscle, and their brains showed mainly lowfrequency activity, described as typical of ‘running on empty’. “Or is the very reason for their happiness because their lives are filled with emptiness?” The reverse applies to healthy

replacement for Dr Wagner is appointed. Dr Wagner will continue to see patients in his private consulting rooms at 71 Uralba Street, Lismore; phone 6621 2151. Enquiries can be made to David Beveridge at the Pain Clinic on 6622 6966.

book review Robin Osborne Many preferred self-administered electric shocks to the ‘boredom’ of their own thoughts ‘subjects’ asked to participate in tests involving sensory deprivation, even for just 15 minutes: “Some nine out of ten subjects described experiencing mental unease during the test… They couldn’t control the merrygo-round of their thoughts’,” as the researcher put it. Many preferred selfadministered electric shocks to the ‘boredom’ of their own thoughts. Replicating the test at home the subjects found it even harder to bear than in the lab, constantly getting up to access their smartphone or iPod. “It seems clear that our ‘multi-option society’ plays an important part in this, constantly providing us with some means to keep us occupied. This is especially thanks to social media… In summary, the brain ‘wants’ effects. These are preferably effects that the brain has already evaluated as being positive, or which have counteracted a negative effect in the past.” Importantly he adds, “However, the yardsticks for measuring this become lost when the only alternative is emptiness.” However, flotation tanks are found to be beneficial. So is the silence sought by the Zen masters, and the effect of orgasm - “our consciousness becomes

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completely disconnected from everyday reality…” Fascinatingly, he links divine enlightenment with temporal-lobe epilepsy, citing visionaries such as Moses, Mohammad and St Paul, and examines the experiences of professional musicians: “Many of the activities that can lead to emptiness are connected with rhythmical movement.” Rather more concerning are the ‘diseases of emptiness’, including depression and psychopathy. “It is the search for new sources of stimulation that ultimately categorizes ADHD and psychopathy as disorders of emptiness, since what such patients fear most is monotony and boredom. “Their brains cannot stand it when nothing is happening… while it might be enough at first to hold a lighter to a cat’s tail, later the desired kick can only be had by throwing an entire hutch of rabbits on the bonfire. This escalation means in turn that day-to-day stimuli are perceived as increasingly boring.” Boring in no way describes this book, up to and including the final chapter on the calmness of death experiences, and the similarities of the brain waves of unborn babies and those of near-dying adults. “The capacity to achieve a state of emptiness is preprogrammed in us before we are born. And so it should surprise no one that we retain an affinity for it throughout our lives. “Indeed the more surprising fact is that we repeatedly fear emptiness…. and diseases like depression or borderline personality disorder, in which emptiness is seen as a threat.” By way of age-old advice, he again cites the Buddha: “The wise show no elation or depression when touched by happiness or sorrow.” Easy to understand, less so to follow. healthspeak April 2018

Is retirement a health hazard?


ith our baby boomer For some, particularly if living population bulge and alone, a concern is loneliness with longevity increasing, it is and social isolation which can inevitable the demands on our also lead to mental ill health health services will significantly and subsequent physical health increase. Baby boomers are problems. already entering their seventieth The primary health care years. needed for people who are Many will have already bored and/or lonely is more retired or are preparing to related to community supdo so. Some of those will port rather than pharmaBy Andrew be happy to be out of the ceutical solutions. The Binns workforce, while others challenge for GPs and the would have preferred to allied health professionwork on longer, but this opporals they work alongside is how tunity may not have been open to address these social issues. to them. This is even more difficult if the So what are the health impatient is more focused on their plications for retirement, and physical rather than psychologiwhat is the difference between cal symptoms. a healthy versus an unhealthy If there is one useful piece of life after work ceases? GPs who advice for a retired patient, it is listen to patients who have the need for social interaction. recently retired may have heard It doesn’t matter what type of a number of scenarios. social connection this is Some retirees but the lack of it can reveal it is a be a health risk. Without solutions Above: fantastic time Ideally social to reduce the Volunteers for of life and that connection unexpected lack of the Lismore they have should involve purpose in life, the Botanic interests. and ‘daimonia’ never been physical and anxiety and low Gardens at Retirement basically meaning mood can lead to busier. Others mental activiwork and rest other risk factors for does not need to be human flourishing will do a lot of ties. This could health hazardous to health and or spirit. To achieve travelling that be achieved by there are some strategies this type of wellbeing previously they joining a local that are vital for maintaining one needs to look at activities may not have had the Men’s Shed group, physical health and psychothat provide a sustained sense time to do. But some of this playing golf or perhaps joining logical wellbeing. Obviously of achievement like going to a group may find that after these a choir. Other possibilities lifestyle choices such as healthy course or learning a new skill. pleasurable trips, boredom sets would be to volunteer for a food and drink choices, regular Anything that leads to perin. This can happen to people needy community cause. physical activity, adequate sleep sonal growth, autonomy, self from all walks of life, including The issue for general practiand keeping the brain acacceptance, positive relationthose in previously busy profes- tioners maybe a lack tive are important. ships, development of one’s best sional occupations. of knowledge as to Having retired, potentials and a strong purpose It is well known that boredom what community If there is one the initial relaxin life will all lead to psychologican lead to loss of self-esteem group is availuseful piece of ation and fun cal wellbeing. or anxiety and depression able for people advice for a retired things like travel These goals are likely to be during this time of adjustment. to join. Neighpatient, it is the initially provide present in those who say that need for social Without solutions to reduce the bourhood or interaction shorter term hesince retirement there are not unexpected lack of purpose in community donic pleasure. How- enough hours in the day. With life, the anxiety and low mood centres are posever a more sustained our fastest growing age group can lead to other risk factors sible resources for wellbeing is obtained from now 65 years and over we need for health. Examples are weight such information and eudaimonic pleasures. to encourage a sustainable gain from poor diet, physical activities chosen obviously Eudaimonia comes from the healthy and fulfilling retirement inactivity, excessive consumpneed to be tailored to a patient’s Greek word ‘eu’ meaning good which could last for decades. tion of alcohol, smoking etc. abilities, past experience and April 2018 healthspeak

a publication of North Coast Primary Health Network



Warning, cyclist ahead I am a MAMIL (Middle Aged So why talk about cycling Male in Lycra), but please keep in a health magazine? Well, reading, as this article could be wherever you look you will about you as well. If you have find studies which point never cycled, but have ever to the health benefits of passed a cyclist on the cycling. A 50% reduction By Chris road, you are part of the in cardiovascular-related Ingall problem and part of the illness, obesity, cancer and solution! The problem? Cars early death is routinely found account for half the serious injuwith people who cycle regularly. ries to cyclists in NSW, and NSW Mental health benefits of exercise has the worst statistics for cycle generally are well-known and the injuries in Australia. And the somental health benefits of cycling lution? Well perhaps we can take probably surpass the general a page out of France’s book and effect, due to the camaraderie (it make cycling our national sport. takes a village to change a tyre), Motorists in France will often of people who ride in groups, drive in a manner to protect the and (in the Northern Rivers at cyclist, sometimes slowing traffic least) the opportunity to enjoy behind them if it is an unsafe nature, usually at the best time of roadway to pass. the day. More specifically, cycling While cycling in France I have groups are commonly the final even had a car behind me put on resting place for runners whose their hazard lights to alert knees and ankles have the drivers behind started complaining, to slow down. with not uncomFor me, cycling has brought lower The crazy thing mon substantial weight, lower is almost every improvement blood pressure, cyclist drives a in symptoms greater fitness and car, so it is not and function buoyant mental really about “us as a result of the health versus them” on low-impact nature the road, rather it is of the sport. Building about working together up the vasta medialis is of to ensure safety for everyone. I particular benefit to stabilisation have seen many car drivers act of the patella, and once a runner aggressively towards cyclists, and has moved across to cycling, they equally many cyclists who ride rarely look back. wider (two abreast is legal) than There is a lobby group who they need to, to slow the cars up want bicycle helmets banned, behind them. Both behaviours though on looking at available are maddening to me, as both can data, it is clear to me bicycle helfuel subsequent rage interactions. mets have significantly reduced


the ratio of head injury to axial to cycle, I feel significantly duller and limb injury, really the only both physically and mentally, data which should be examined. and this is borne out in a number This group talks about a 20% of studies both here and in the decrease in the number of people UK. In the main, people ride riding bicycles over the time pebikes to improve their fitness and riod between 2011 and 2017, and maintain their mood and mental despite their agenda these figures capacity. They do not go out are usually born out elsewhere. on the road to give grief to car This is a saddening statistic, as drivers and indeed most cyclists it may mean our roads ride when cars are not are just becoming on the road, in the too dangerous early hours of the Motorists in France for cyclists. In day. I would love will often drive in a the Northto be able to manner to protect ern Rivers, a commute to the cyclist, sometimes cyclist needs and from work, slowing traffic behind to negotiate though this is them if it is an unsafe potholes, other when there are roadway to pass vehicles (cycles maximum numand cars!) as well as bers of cars (even magpies in season, and in paradise) and I feel it so every person who climbs on would be too risky. a bicycle needs to be at the top of So spare a thought for the next their game, which is not always bicycle rider you pass; slow down the case. Being a little hung over a little, give him or her at least from the previous night’s glass or a metre clear and please don’t two of red, or just being overtired lean on your horn. The cyclist can be the difference between knows you are there and will have a sharp and a dull reflex, and of prepared for you to overtake by course the inexperienced cyclist coming over to the left as much may reach for his front brake as possible, even if you do not before his rear one, which spells think this has been the case. A catastrophe. little toot once you have passed For me, cycling has brought the cyclist is fine and lets the lower weight, lower blood prescyclist know you see them as a sure, greater fitness and buoyant person, and not a statistic. You mental health. I may only cycle may find quite a few cyclists 100 to 150 km a week, though wave back at you to acknowledge this is enough to slow down my your courtesy, and as Humphrey inexorable slide of total body Bogart’s character said at the end fitness through middle age. On of Casablanca “this could be the weeks when I have not been able start of a beautiful friendship”.

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healthspeak April 2018


New online tool predicts melanoma risk A ustralians over the age of categories: very much below 40 can now calculate their average, below average, average, risk of developing melanoma above average, and very much with a new online test. The above average. risk predictor tool esti“This online risk predicmates a person’s melator will help identify By Phoebe noma risk over the next those with the highest Roth 3.5 years based on seven likelihood of developing risk factors. It can be found at: melanoma so that they and https://publications.qimtheir doctors can decide on how to best manage their risk,” QSkinMelanomaRisk Professor Whiteman said. Melanoma is the third most After completing the short common cancer in Australia and test, users will be offered advice, the most dangerous form of skin such as whether they should see cancer. their doctor. A reading of “above The seven risk factors the tool average” or “very much above uses are age, sex, ability to tan, average” will recommend a visit number of moles at age 21, num- to the doctor to explore possible ber of skin lesions treated, hair options for managing their melacolour and sunscreen use. noma risk. The tool was developed by But Professor Whiteman cauresearchers at the QIMR Bergtions that people with a below hofer Medical Research Institute. average risk shouldn’t become Lead researcher Professor David complacent. Whiteman explained he and his “Even if you are at below averteam determined the seven risk age risk, it doesn’t mean you are factors by following more than at low risk – just lower than the 40,000 Queenslanders since average Australian,” he said. 2010, and analysing their data. An estimated one in 17 The seven risk factors are each Australians will be diagnosed weighted differently. The tool’s with melanoma by their 85th algorithm uses these to assign birthday. a person into one of five risk The test is targeted for people

aged 40 and above as this was the 98% for patients diagnosed at the age range of the cohort studied. very early stages. However, melanoma remains the “At the end of the day, everymost common cancer in Austrathing that raises awareness for lians under 40. melanomas and for skin cancer is Professor Whiteman said beneficial,” Professor Soyer said. that the test may be useful for Dr Hassan Vally, a senior those under 40, but it may not lecturer in epidemiology at La be as accurate, as that wasn’t the Trobe University, said the way demographic it was based on. risk is often communicated is But he added complete accuhard for people to grasp. But he racy couldn’t be guaranteed even said this model would provide for the target demopeople with a tangible graphic. measure of their risk “I don’t think of disease, and At the end of the it’s possible that point them today, everything that raises we’ll ever get to wards what they awareness for 100%. I think may be able to melanomas and that’s a holy grail do to reduce it. for skin cancer is that we aspire to, “Everything beneficial but in reality, cancomes back to how cers are very complex people perceive their diseases and their causalrisk, and how can they ity includes many, many, factors, make sense of it. including unfortunately some "If it makes people more aware random factors.” of their risks of disease that’s a The prognosis for melanoma good thing, and if that awareness patients is significantly better leads to people taking action and when it is detected earlier. The improving their health then that’s University of Queensland’s Progreat.” fessor of Dermatology H. Peter Soyer explained that the five-year This article is reprinted with survival rate for melanoma is kind permission from The 90%. But this figure jumps to Conversation

The seven risk factors the tool uses are age, sex, ability to tan, number of moles at age 21, number of skin lesions treated, hair colour and sunscreen use

April 2018 healthspeak

a publication of North Coast Primary Health Network



Mullum Women’s Shed strikes a chord


lthough Mullumbimby prides itself on its strong sense of community, tolerance and inclusion, there are a number of women who feel socially and emotionally isolated, lonely and disconnected. Many women in the region have expressed the desire to engage and collaborate with other like-minded women in a spirit of community and friendship. According to Mullumbimby Women’s Shed committee members, many women long for emotional and social engagement but feel blocked due to fear or because they don't know how to proceed. Some battle a sense of isolation due to losing a partner or a close confidante. Others may be lonely because they live in a remote area or with a disability. Empty nesters, single mothers and those new to the area can also crave connection. Such social isolation can be both a cause and a symptom of other issues such as depression, helplessness, social anxiety or agoraphobia. Loneliness can also hit those with a refugee background or those from the Indigenous and other communities. HealthSpeak visited Mul38

lumbimby Women’s Shed for its 2017 and it began in a small official opening in early March warehouse space, which quickly and spoke to committee member became too small for all those Julie Beesley. women wanting to come along. She explained that it was when Now Mullumbimby Women’s she was working at Southern Shed Facebook page has more Cross University on a video than 600 friends and it project that involved continues to grow. the Sudanese The concept It's a friendly, refugee comof the Mulsoulful sanctuary munity in lumbimby where women can Lismore that Women's encourage and learn the idea of Shed shaped from each other in a getting refuby the comsupportive environment gee women mittee is that underpinned by a together it presents an spirit of generosity and to connect opportunity inclusiveness. through art and for all women to craft came into connect through Julie’s mind. art. “And at the same time I heard It's a not-for-profit hub where someone talking about the women can come together to exMullumbimby Women’s Shed. I plore their creativity and develop went along to the first meeting artistic skills. It's a space where and found myself on the comwomen will feel welcome, supmittee. My ethos matched theirs. ported and inspired to develop, Since that time two women learn and share new skills in a who started it have had pressing range of arts and crafts such as commitments and handed the painting; weaving; pottery; tapreins onto me. And I connected estry; jewellery-making; sewing with Melanie Gunn, Christina and much more. Covington and Caterina Boschin It's a friendly, soulful sanctuand things went from there.” ary where women can encourage The first meeting about the and learn from each other in a Shed was held in September supportive environment undera publication of North Coast Primary Health Network

pinned by a spirit of generosity and inclusiveness. There is also an ethos of being environmentally conscious and sustainable with a focus on the use of recycled materials. Mullumbimby Women’s Shed comes to life each Thursday from 10am to 2pm and is managed under the auspices of the Mullumbimby Neighbourhood Centre. The address is 91 Main Arm Road, Mullumbimby (part of Wildspace). “It’s a dream come true for all of women and we are astounded at how many women are interested in becoming involved and how it’s resonated locally. “Now that we have this bigger home we’ll set up pockets of space with popular arts and crafts and women can get involved in projects they can do over time. They can up skill and share and we might hold some master classes as well,” said Julie. HealthSpeak congratulates all those involved in getting the Shed off the ground and established in its new venue. It’s a model that could be emulated in other North Coast towns. On Facebook, connect at Mullumbimby Women’s Shed. healthspeak April 2018

from page 32

southern Victoria and the southern part of New Zealand’s south island. The effects are minor and transient, and are being closely monitored by NASA and other agencies. In reality, ozone depletion has made no appreciable difference to skin cancer rates in Australia and New Zealand. The quantum of additional UV exposure was modest – and at a time of year when most skin was covered so as to stay warm. Happily, the Montreal Protocol has proven successful in facilitating ozone repair. Are we making any headway?

Melanoma rates in the under 40s age group (those who grew up with “Slip Slop Slap”) are coming down. This makes sense given the timing of the programs and the decadeslong lag between protecting our skin and the benefits of “avoided” skin cancers. But rates in the 60+ age group are still going up and as a result so are the overall rates. We anticipate and hope those will fall over the next decade. Comparisons with NZ suggest they have a lot to learn from our skin cancer messaging campaigns. But we both still have a long way to go to decrease the burden of skin cancer. Reprinted with kind permission from The Conversation –

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April 2018 healthspeak


Adhesive patch takes BSL Scientists have created a noninvasive, adhesive patch, which promises the measurement of glucose levels through the skin without a fingerprick blood The patch can be test, potentially attached to the removing the wrist to measure need for millions blood glucose of diabetics to without piercing frequently carry the skin. out the painful and unpopular tests. The patch does not pierce the skin, instead it draws glucose out from fluid between cells across hair follicles, which are individually accessed via an array of miniature sensors using a small electric current. The glucose collects in tiny reservoirs and is measured. Readings can be taken every 10 to 15 minutes over several hours. In a study published in Nature Nanotechnology, the research team from the University of Bath hopes that it can eventually become a low-cost, wearable sensor that sends regular, clinically relevant glucose measurements to the wearer's phone or smartwatch wirelessly, alerting them when they may need to take action.

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Profile for North Coast Primary Health Network

Healthspeak April 2018  

North Coast Primary Health Network is a not for profit organisation established to respond effectively to local health care needs. Focussed...

Healthspeak April 2018  

North Coast Primary Health Network is a not for profit organisation established to respond effectively to local health care needs. Focussed...

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