HealthSpeak December 2018

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$ $ $


issue 23 • december 2018



Commissioning: Strong partnerships delivering quality care 4

Ulong's community clinic


Too Much Medicine


Transformers III


15 education for GPs

Commissioning explained 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: Northern Rivers 2A Carrington Street Lismore 2480 Ph: 6627 3300 Email: Tweed Valley 145 Wharf St, Tweed Heads 2486 Phone: 07 5589 0500 Email:

editor Janet Grist


n this final issue of HealthSpeak for 2018, our feature sets out to explain to our valued health partners how we work with our commissioned providers once the NCPHN contract is in place. I know many health professionals are curious to know more about the PHN’s new commissioning role and how it operates and I hope this feature

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


well-known medical educator Dr Hilton Koppe talks about how he began working in dementia education for GPs and how he’d like this health condition to become part of the regular GP landscape. And on page 4 there's a heart-warming story about how a communitiy champion, NCPHN and TAFE NSW joined forces to bring a nurseled clinic to a sleepy town of 131 people. A win-win for all. I'd like to take this opportunity to wish you all a relaxing and healthy holiday and look forward to speaking to you again next year. All the best for 2019.

Building on solid foundations

Health Speak Contacts Editor: Janet Grist Ph: 6618 5400 Email: Clinical Editor: Andrew Binns Email: Design and illustrations: Graphiti Design Studio Email:

article clears up a lot of questions. To help explain how we build relationships with our commissioned providers, I interviewed contract manager Michael McGowan. His approach is one of collaboration and encouragement, being alert to the challenges of the providers and having the flexibility to vary contracts when unexpected health needs arise. Working in this way ensures constant vigilance about the health landscape in our various communities and enables appropriate responses in a timely way. Also on page 15 of this issue

ceo Julie Sturgess


’m pleased to be writing my first column for the final edition of HealthSpeak for 2019. The past four months have been a whirlwind of meeting health professionals and stakeholders and getting around our footprint, but it’s all been great. In my travels, what’s become obvious to me are the great relationships that have been forged between the Local Health Districts, general practice and the PHN. We have a really solid foundation to build upon. And it’s good to recognise that in the federal government sphere there’s a real bipartisan commitment to the significance of the role of PHNs as the regional connectors and coordinators of health care. We can be confident that what we are building together with our health partners, NGOs and community organisations the will have time to grow and mature. The other thing that’s really

struck me since I started here is the impressive capacity and dedication of the people who work at NCPHN. Our staff are equipped with amazingly broad and highly developed skills. I’m excited about what we can achieve with such great people. As we move forward we’ll be able to make good use of all those skills and experience and that puts NCPHN in a really firm position.

We can be confident that what we are building together will have time to grow and mature Likewise, the maturity shown in fostering the well-established relations staff have created with stakeholders will hold us in great stead. Of course we’re never standing still. We're always looking at ways to improve what we do. And in conducting this

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year’s Needs Assessment we’ve incorporated a lot more feedback from members of our Clinical Councils, allied health professonals, service providers and our Aboriginal Medical Services into that body of work. NCPHN relies on the knowledge and insights of our region's health professionals working in both mainstream and Aboriginal health to guide our work and advance health outcomes for all. Looking ahead, our immediate focus is on improving the way we commission programs and projects. We are constantly learning in this relatively new space. Through our process of commissioning we are monitoring and evaluating the work of our commissioned partners and the effectiveness of what we at the PHN are doing. We look forward to making use of our experts’ knowledge of health across the North Coast to help us drive the health outcomes we need. May I take this opportunity to wish you and your families a safe and happy Christmas/Summer break. I look forward to meeting more of you in the New Year. healthspeak December 2018

Social determinants of Aboriginal health addressed through commissioning clinical editor Andrew Binns

Artworks created at recent community workshops at Tabulam.


boriginal and Torres Strait Islander health is inextricably linked to the social, emotional, spiritual and cultural wellbeing of the whole community. Since colonisation, Aboriginal health has been adversely impacted by systematic attempts to eradicate or undermine their culture. In the first half of the 20th century, right up to the 1960s, the Australian Government sought to create a single, uniform white Australian culture. This was pursued though assimilation policies which destroyed Aboriginal identity and culture and justified the removal of children from their parents. Against such adversity, cultural continuity and self-determination have been protective factors for Aboriginal and Torres Strait Islander peoples’ health. Connection to Country, including spiritual and physical connection to the land and waterways is key to cultural knowledge, kinship and identity. In his Closing the Gap address on 10th February 2016, the then Prime Minister Malcolm Turnbull called for government to “do things with Aboriginal people, not do things to them.” He cited December 2018 healthspeak

four key factors for improving the quality of life and achieving health equity across all aspects of the social determinants of health. 1 Connection to culture 2 Allowing Aboriginal and Torres Strait Islander people to determine and implement solutions 3 Improving cultural awareness and respect across the wider Australian population 4 Effective partnerships – Aboriginal and Torres Strait Islander health is everybody’s business Addressing these four factors requires creative solutions. An innovative project called Art on Bundjalung Country that addresses better health and wellbeing for Aboriginal and Torres Strait Islanders in Northern NSW through connection with cultural arts, was initiated by the North Coast Primary Health Network (NCPHN) in 2016. This project was commissioned to Arts Northern Rivers in early 2018. The 2018 Art on Bundjalung Country project has the following objectives: 1 To improve connection to Aboriginal culture through

community art activities. 2 To increase social inclusion and cohesion through community art activities. 3 To develop business acumen and links to economic sustainability through community art activities. 4 To develop knowledge and skills in the practice of art. The project delivered with fund-

Participants have already expressed their delight in seeing their memories and stories translated onto canvasses ing partner NCPHN, and cultural partner Lismore Regional Gallery is being managed by Arts Northern Rivers’ Indigenous Project Officers Sarah Bolt and Mark Cora. They are building on the past workshops and exhibition of artworks at the Lismore Regional Gallery in 2017. This has opened up professional skills opportunities for Aboriginal art-

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ists on Bundjalung Country. Further funding has come to the project with Arts Northern Rivers being awarded a $45,000 grant for the Art on Bundjalung Country project. This was from the Department for Communication and the Arts, Indigenous Languages and Arts Program. The Federal member for Page Kevin Hogan, when congratulating Arts Northern Rivers on the project, acknowledged the important partnerships between NCPHN and the Lismore Regional Gallery. In addition to the industry and employment opportunities provided through this project, there is therapeutic benefit derived from all forms of arts practice. For those who have suffered significant trauma, art can provide some solace from a turbulent life and this is important for healing the emotional wounds of the past. Through this project there will be opportunities to purchase works of art for your workplace or home. As well as a large Aboriginal art market event in April next year there will be opportunities to buy work online. Connecting to our Aboriginal culture is enriching for us all. Here’s a report from Sarah Bolt, Project Manager for the Art on Bundjalung Country. She is pleased to share that the workshop program in Jubullum has commenced and is already delivering some great outcomes. The Jubullum workshop activities commenced in August 2018, focusing on painting and dancing. More than 20 participants attended the first workshops. In fact, the response has been so positive we have decided to extend the workshop program

Continued page 10 3

Nurse-led clinic a testament to community partnerships


CPHN is excited to share the news that the small town of Ulong near Coffs Harbour will have a refurbished clinical space opening in 2019 with free, monthly nurse-led clinics re-starting in 2019 staffed by nursing students from TAFE NSW. Since July 2018 Diploma of Nursing students from Coffs Harbour TAFE, under the guidance of Lisa Taffe, Head Teacher, Aged Care, Health & Nursing, have been working in a makeshift clinical space in the community hall as part of their practical work placement hours. It’s hoped the refurbished space will attract a GP to visit regularly. The consulting room is now complete in the renovated community hall through an NCPHN grant of $10,000 and local donations. Ulong lies nearly an hour inland from Coffs Harbour, along winding mountain roads. NCPHN prioritised Ulong as a town to support through its Community Voices program. The Diploma of Nursing students have been providing the town’s population of 131 with a free, professional nursing service offering many benefits including chronic disease management and prevention and health education. NCPHN’s Community Engagement Coordinator AnneMaree Parry said Ulong was recognised as an activated community ready for change. “Sadly, they’d experienced a number of suicides, heart attacks and car accidents, and other conditions needing hospitalisation and follow up care. We were keen to see how we could improve health outcomes in this vulnerable, isolated community.” Ulong’s community champion is the energetic and dedicated Carol Cleary from Ulong General Store. Carol told Health4

We were keen to see how we could improve health outcomes in this vulnerable, isolated community.

From left: TAFE NSW nursing students at Ulong. From left, Michelle Brown, Erin Hogbin, Jessica Connolly, Erica Davis.

Student Erin Hogbin with a community member.

Speak that she was motivated to improve health care for Ulong as she had been working part-time as a “counsellor” and part-time flipping burgers. “I’d be making burgers and advising customers to get some mental health support or visit a GP,” she said. “Now I’ll be working to get Outreach services out here such as a dietitian, mental health, women’s health and im-

munisation,” Carol added. Anne-Maree said that through Community Voices and Lisa and Carol’s commitment and efforts, community members are now receiving care that they wouldn’t otherwise have received. Through Community Voices Ulong has also received first aid training so that residents feel equipped to respond in the event of an injury or accident.

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By working with NSW Ambulance, community members have been trained as first responders. Ulong’s clinical space is a great example of how with trust and community champions, positive change to improve health can happen in the smallest of places. The partnership between TAFE NSW and the Ulong community affords students the opportunity to increase their practical hours while providing the community with a free, professional nursing service offering health education and prevention of complications with chronic disease. In fact, the students have been instrumental in the early detection of potentially life-threatening conditions that had gone undiagnosed and untreated. “These moments really have an impact on all involved,” said Lisa. “Our students practice their skills such as communication, team work, working with people from diverse and challenging circumstances, and problem solving.” With the completion of the clinic and the possibility of a GP on the horizon, the future is exciting for the community and students alike. Lisa is pleased that students might soon have an opportunity to work alongside medical practitioners, allied and specialist services, which will further enhance their professional development. healthspeak December 2018

Winter Strategy 2017 Report Improved care and professional satisfaction

was for better access to primary care clinicians. Clinicians reported improved patient care and higher professional satisfaction. Almost all said they’d recommend the program again.


n February 2017 a joint project between the Northern New South Wales Local Health District and NCPHN was conceived to develop a more integrated strategy to better respond to increased healthcare demands over the winter flu season. This included heightened care for at risk patients. The Winter Strategy 2017 aims and strategies were developed through a co-design process with managers, clinicians and patients.


A pre-post patient experience survey was completed by 20.7% (paired data) and showed a net pattern of slightly improved scores, with most patients remaining the same. The survey showed very high

patient engagement and satisfaction at the program’s start, which probably reflects the patient selection process favouring patients already well engaged with their general practice. The strongest improvement result

This project demonstrated the feasibility and acceptability of this general practice initiative and its ability to foster collaboration between private and public sector health providers. There was widespread support for the Winter Strategy to continue with interest from other LHDs and PHNs to replicate or adapt the approach.


Self-selected practices were funded for up to 6.15 hrs of practice nursing time for each enrolled patient. This allowed nurses to proactively care for frail and vulnerable patients for the 17-week program. Mixed methods were used to evaluate the program. With no control group, the evaluation did not attempt to measure the impact on hospital admission rates.

2018 Winter Strategy feedback


There was strong interest from primary care teams with high completion rates (24 of 30 practices) and 664 of 709 enrolled patients (91%), including 18 who died. The average patient age was 73 years. Throughout the program 30% were admitted to hospital (308 admission, 10 for influenza), indicating that health professionals can select a high risk cohort. Paired pre-post PROMIS-10 scores were completed by 19% of enrolled patients showing no significant change in scores. [For non-clinicians, PROMIS (Patient Reported Outcomes Measurement Information System) is a set of measures that evaluates and monitors physical, mental and social health.] December 2018 healthspeak

Initial feedback has been really positive. Twenty-four general practices registered and completed the program with more than 800 enrolled patients. In an interview with NPCHN, practices gave valuable feedback. This included: “We developed a checklist of health assessments and divided it between the doctor and me and we used this to prepare for winter. It’s worked really well.” – Practice Nurse More than a third of practices said how much

patients liked being invited to do the Winter Strategy. A quarter said that their proactive care (making outreach phone calls) was already getting results. “I have picked up 3 people already from the phone calls and got them to come and see the doctor sooner than they would have to really good effect.” By the end of the program the following emerged: 1. In 2018 the NNSW LHD Chronic Disease Management (CDM) teams committed to

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communicating with practices about patients admitted to hospital. Team members also followed up patients after discharge. This work was very positively received. 2. Half the practices noticed a big impact on teamwork. 3. More than a third of practices said that Winter Strategy 2018 made them look more closely at their patient care. A third also said it gave them the time and a reason to follow patients up. 4. The final word comes from two GPs. “Because we do this the patient thinks ‘I am getting special attention’. This makes the patient think ‘oh, they must be worried about me’. This increases the patient’s awareness a little bit more so the patient presents a bit earlier and it’s therefore preventative.” “Winter Strategy builds on what we are already doing. It focusses our attention on getting it right.”


Community says psychiatrists and dentists among hardest to access


n June 2018, North Coast Primary Health Network (NCPHN) ran Speak Up, a community survey asking locals for their opinions and information about their recent experiences with local primary healthcare services. The survey contained demographic questions as well as health and services related questions, which focused on accessibility, health challenges, specific types of services that are hard to access and questions about the quality of service received. Over a three week period, 3,372 locals completed the survey either online or on paper. Some key findings across the North Coast were: General Practice

• 9% of respondents said that seeing a GP was ‘very difficult’ while 19% said it was ‘difficult’. • 76% of respondents said they had a regular GP. This fluctuated from a high of 86% of people in Port Macquarie to 64% from Kempsey. Only 60% of Aboriginal people reported having a regular GP. • Most difficult areas to access a GP were Kempsey (72%), followed by Nambucca (59%) and Kyogle (41%). Specialist doctors

• 13.8% of respondents said that seeing a specialist doctor was ‘very difficult’ while 23% said it was ‘difficult’. • In Kempsey 61% of respondents said it was ‘difficult’ or ‘very difficult’ to see a specialist. Other regions reporting difficulty included Kyogle (49%) and Nambucca (41%). • The most commonly reported hard to see specialists were: psychiatrists (24%); cardiologists (19%) 6

and general surgeons (14%). • Most commonly reported challenges around seeing a specialist were: a long wait (58%); cost (56%); distance of travel (44%) and a lack of specialist in my area (44%). Allied health

• 6% of respondents said that seeing an allied health professional was ‘very difficult’ while 15% said it was ‘difficult’. • Most commonly reported hard to see practitioners were: dentists (38%); psychologists (30%) and physiotherapists (21%). • Kempsey had the highest proportion of respondents saying it is “difficult” or “very difficult” to access an allied health professional (41%), followed by Kyogle (37%). • Most commonly reported challenges were: cost (60%); not covered/not covered enough by Medicare (46%) and long wait (37%). Mental health services

• 11% of respondents said that accessing services to get help with a mental health issue was ‘very difficult’ while 17% said it was

‘difficult’. • Most commonly reported hard to see services were: counselling (45%), a doctor with knowledge in mental health (38%) and NSW health community mental health (33%). • Kempsey was the region with the highest proportion of respondents saying it is “difficult” or “very difficult” to access mental health services (37%), followed by Lismore (35%) and Byron (33%). • Most commonly reported challenges were: cost (46%); a lack of services (43%); and having a poor past experience (29%). The findings of the 2018 Speak Up community survey were included in the NCPHN Needs Assessment report submitted to the Department of Health in November. Once approved, this report will be available on the NCPHN website: needs-assessment In addition, a video presenting key findings from the survey can be viewed here: https:// Further data will be available online early 2019 in topic and location specific fact sheets at:

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New bandage speeds up healing US engineers have developed a low-cost wound dressing that uses energy generated from a patient’s own body motions to apply gentle electrical pulses at an injury site. In rodent tests, the dressings reduced healing times to a mere three days compared to nearly two weeks for the normal healing process. Scientists at the University of WisconsinMadison also plan to test the devices on pig skin, which closely mimics human tissue. The new dressings consist of small electrodes for the injury site that are linked to a band holding energyharvesting units called nanogenerators, which are looped around a wearer's torso. The natural expansion and contraction of the wearer's ribcage during breathing powers the nanogenerators which deliver low-intensity electric pulses. And the low-power pulses won’t harm healthy tissue like traditional, high-power electrotherapy devices might. Researchers say the results of their studies represent an exciting new spin on electrical stimulations for many wound types, given the simple design. If the team is successful, the devices could help solve a major challenge for modern medicine. Researcher Xudong Wang said the cost would not be much more than a regular bandage. “The device itself is very simple and convenient to fabricate,” he said.

healthspeak December 2018

Community Conference looks at topic of Too Much Medicine

Four questions for your doctor Studies have shown that these questions can improve the quality of the information you get from your health professional. They are: • What are my options? • What are the possible benefits and harms of those options? • How likely are those benefits and harms to happen to me? • What happens if I do nothing? (Obviously depending on the severity of the case).


n late November NCPHN and the Northern NSW Local Health District co-hosted the 2018 Community Engagement Conference at Ballina. The theme was Improving Health: Everybody’s Business, Everyone’s Responsibility. The Chair of the Community Engagement Council Ms Anne O’Donoghue opened the gathering. Anne shared her reflections on receiving what she considered to be poorly managed health care surrounding a cancer diagnosis compared with another health crisis where her specialist listened empathically and gave her options. “It’s not easy, but it’s important to ask questions of your doctors. Don’t be too bolshy, but stand up for yourself and get all the information you need to make an informed health care choice,” she said. The conference’s keynote speaker was Dr Ray Moynihan, former journalist and now academic researcher with a global reputation. In 2017 Ray won a National Health and Medical Research Council Early Career Fellowship to investigate the problem of overdiagnosis. Speaking on the topic Too Much Medicine, which he described as too many pills, too many tests, too many diagnoses, Dr Moynihan addressed the over-medicalising of common human traits with a humorous presentation. He talked about the fictitious condition Motivational Deficiency Disorder – the symptoms of which are laziness, a family history of idleness, not wanting to leave the beach, not wanting to get out of bed on Mondays etc. Using this fictitious disorder, he was able to point out how over diagnosis and over treatment can happen. He said it’s not unusual in our health system that a healthy person is diagnosed December 2018 healthspeak

Dr Ray Moynihan at the 2018 Community Engagement Conference.

It’s not easy, but it’s important to ask questions of your doctors with a disease that won’t cause them any problems. “It’s an unnecessary diagnosis that causes more harm than good and leads to unnecessary treatment and wastes resources better spent on unmet need.” He gave the example of a thyroid cancer study published in the New England Journal of Medicine. “In this study researchers estimated that half a million people were being diagnosed with thyroid cancer unnecessarily. And the potential harms are the unnecessary anxiety of the cancer label, the unnecessary surgery which leads to lifelong medication and in rare cases damage to organs. “And the problem here is that rates of diagnosis of thyroid cancer are going through the roof. In Australia in the last 20 years we’ve had a threefold increase in the numbers being diagnosed

with thyroid cancer. The problem is that the tiny tumours in the neck are being picked up and treated and diagnosed as if they

were life-threatening tumours. “The problem is they are not. Many of them are totally benign and this is a real concern and the thyroid community is starting to address it,” he concluded.

A holistic, team-management approach to physical rehab. Dr Ulla Gerich-McGregor FAFRM is a Rehabilitation Specialist with a particular interest in: • Pain management with a multi-disciplinary approach, • Spasticity treatment, including botulinum toxin injections post-stroke, CP and TBI, • Post multi-trauma management, including TBI and SCI, • NDIS assessments and support. Clinics located at: Ballina, Bangalow & admitting rights to St Vincent’s, Lismore. Call 0439 469 191 or email to make an appointment.

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For our full list of services & more information please visit:


Are you making the most of your practice nurses? Scholarships available to upskill through Southern Cross University

Management of Chronic & Complex Health Conditions


ractice nurses are a valuable commodity in a busy general practice, but often they are not working to the full scope of their skills. With the permission and encouragement of GPs, the role of practice nurses can encompass patient carer, educator, quality controller, organiser, problem solver and mental and relationship builder within and outside the practice. To enhance the role of PNs, Southern Cross University is offering an online Graduate Certificate in Primary Health Care Nursing. North Coast Primary Health Network is offering a number of scholarships to eligible nurses covering 80% of tuition fees. This qualification will expand and extend a nurse’s clinical practice. The course runs over eight months part-time and

starts on 4 March 2019. Online delivery gives students the flexibility to study at a time that suits individual circumstances and commitments. The curriculum is studentcentred and makes the most of experiential learning by using online delivery and face-to-face learning through a practical intensive. This four-day intensive (for Clinical Reasoning & Assessment Skills) allows students to come together to work in groups and consolidate their learning in a supportive envi-

ronment where practical skills are assessed. The Graduate Certificate’s major areas of study are: Primary Health Care Practices & Philosophy

- Explores the way primary health care is delivered and how this aligns with the values of the World Health Organisation. Students will critically examine how health care practices impact on individuals, families and communities

- Builds on knowledge and skills to demonstrate sound clinical judgement and reasoning based on evidence-based nursing care. A systematic and comprehensive approach to health assessment and chronic health complaints will be explored.

- Focuses on an identified area for improvement in the work setting. A number of change management models will be explored.



Clinical Reasoning & Assessment Skills

Enhancing and Expanding Practice

New service supports people after they attempt suicide he launch of an innovative suicide prevention program, funded by North Coast Primary Health Network last month enabled around 30 mental health providers and health workers to get together in Lismore. The Federal Member for Page, Mr Kevin Hogan, officially launched The Way Back Support Service, a Beyond Blue program for Northern NSW that supports people in the critical weeks after they attempt suicide. The Way Back Support Service is receiving Commonwealth funding of $1 million from North Coast Primary Health Network

- Examines common chronic and complex conditions such as asthma, diabetes, COPD and CVD. Students focus on a patient centred model of care involving a team and will learn how to provide effective education and support so that patients can be involved in self-managing their conditions. Includes caring for conditions in Indigenous communities and other Culturally and Linguistically Diverse Communities.


Check the Southern Cross University website to see if you qualify for one of North Coast Primary Health Network scholarships. Go to: scholarhips Scholarship applications close on 15 February 2019. Apply for the course online Participants at the media launch in November took the opportunity to mingle and network.

(NCPHN) - part of the Federal Government’s National Suicide Prevention Trial.

Sadly, the rate of suicides is higher across Northern NSW Continued page 39

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Complete the application online at: For more information, contact Dr Louise Horstmanshof at louise.

healthspeak December 2018

Healthy Towns Community Events prove popular


CPHN’s Healthy Towns program is working to improve the health and wellbeing in six North Coast communities in 2018. Following the initial consultation stage, initiatives are being progressed to improve social connectedness, provide information and opportunities for better health, and address service gaps. To find out more about Healthy Towns, visit www.

Community Wellbeing Days Throughout October, Healthy Towns partnered with the Rural Adversity Mental Health Program to host community wellbeing events in Lake Cathie, South West Rocks, Woolgoolga and Maclean. Hundreds of locals attended each event to find out more about local services and activities. In Lake Cathie, community members came down to the foreshore for free health checks, and a range of fun activities. The Mid North Coast Local Health District (MNCLHD) brought along a smoothie bike, using pedal-power to blend banana smoothies. Members from the NSW Rural Fire Service went head-to-head in a healthy cooking competition. BBQ sliders, a ukulele band and face painting entertained locals over lunch. Woolgoolga runs Fluro Friday each week at the beach to raise awareness around mental health. Healthy Towns partnered with Fluro Friday and the early morning community event kicked off with an anti-bad vibe circle, December 2018 healthspeak

followed by yoga and a healthy pancake breakfast. Other activities included cooking demonstrations, face painting and nature mandala making. Alongside the Clarence River in Maclean, locals were able to find health information for all life stages. Community Health offered free blood pressure and balance tests. Maclean TAFE kept things interactive with virtual reality goggles to try. And n true Maclean spirit, Alistair Wallace entertained by playing bagpipes while the crowd enjoyed a BBQ lunch.

Locals were able to find health information for all life stages

Maclean event coordinator Carolyn Ardler said: “It was great to see the community enjoying the atmosphere. It was also fantastic to see service providers networking, and sharing information, to create strong links and referral pathways for the community.”

Parkruns Parkrun is now running in Casino and South West Rocks, in collaboration with Local Health Districts. Parkrun is a free, weekly, timed 5km walk or run open to all members of the community. In South West Rocks, Parkrun

Top and middle: Maclean fun day. Above: Bagpipe player, Alistair Wallace in Maclean

launched on Saturday 6th October. Despite a wet start, 144 parkrunners turned out to take part. The event starts at 7am each Saturday at Horseshoe Bay Reserve.

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In Casino, NCPHN and Northern NSW LHD are working with community to design the 5km route. The aim is to launch Parkrun in Casino in early 2019.


Orion communication tool linking up health teams


r Peter Silberberg, a GP at Jullums Aboriginal Medical Service in Lismore and Chair of NCPHN’s Northern Clinical Council, has signed up to trial the Orion Shared Care tool to enhance communication between teams of health care professionals. And he recommends other GPs take a look at it. The Orion Shared Care Tool is a collaboration between the Northern NSW Local Health District, North Coast Primary Health Network (NCPHN) and NSW Health’s eHealth. It is a shared care planning tool for patients with complex and chronic needs. It allows the GP and other team members to create and update a living care plan. It lets care team members add other information about the patient and makes it easier to securely share information between care team members. The tool integrates with Medical Director and Best Practice for GPs. Other clinicians access it via a web portal. The free to use system is external to My Health Record and Peter said he’s using it for

So far I’m impressed by this new electronic system even though I’m a slow up-taker of new systems

patients he sees who are linked to Community Mental Health. “Orion allows me to see their three-month psychiatric reviews and I can also have direct communication with their case workers. Orion allows me to share basic information such as past history, medications and allergies and I can easily download letters or health summaries. “So far I’m impressed by this new electronic system even though I’m a slow up-taker of new systems. I’m still not on Facebook!” Peter was trained by Northern

NSW Local Health District’s Orion team and he said they are easily contacted to obtain support. He is also giving the team useful feedback to make the system more user friendly and clinically useful. He said that while there was about five minutes involved to set up the care team for a patient, once that’s done it’s fairly quick to keep track of new messages as he receives an email notification when a new message is added. Peter is pleased to have the opportunity to be part of a new ehealth system that allows better communication with colleagues working for the Local Health District.

Solid Mob supports general practice patients

From left: Mook Harrington, Joe Gordon and Cassandra McKechnie


When HealthSpeak visited Bugalwena General Practice at South Tweed Heads last month, Solid Mob were set up in the reception area to support and advise patients wanting to quit cigarettes. Bugalwena Receptionist Kerry Lehmann said Solid Mob were visiting the practice once a fortnight to talk to patients thinking about giving up tobacco and to support others who had committed to give up.

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From page 3

from the original four and continue them through to the end of the year. A key workshops focus has been the exploration of story, and in particular personal stories around growing up in the Jubullum area in Northern NSW - childhood stories exploring family and connection to country. This process of recalling stories has ignited the imagination of participants who have been encouraged to use the workshops to find a way of expressing these memories and regional stories. Participants have already expressed their delight in seeing their memories and stories translated onto canvasses and other objects used in the workshops. Place, identity, survival and belonging are key emerging themes. The idea of using personal stories to lead the workshops came about through an art piece created by one of the women at the first workshop. The workshop facilitators sat down with one of the Elders of the community who had shared a story of the significance of the Tabulam Bridge and his connection with it – having been born alongside that bridge! Our Elder explained that with a new bridge under construction the current structure, which is the longest, singlespan wooden bridge in the Southern Hemisphere, would be lost. This would mark the end of an era for the village of Tabulam. This highlights the importance of using story to create art around important memories. To capture these often untold stories on canvas promotes a sense of pride, a sharing of cultural knowledge, a sense of wellbeing and brings the past into the present in a creative response. The painting will be a way to move forward, together.

healthspeak December 2018

Parkinson’s Disease – What you need to know


oes my patient have Parkinson’s disease? Apart from medications, what other support and management options can I offer may patient? If these questions have ever popped into your mind then the recently added Parkinson’s Disease HealthPathway could be a helpful resource for you and

your patient! The HealthPathway can help guide practitioners through the assessment, management and referral aspects of Parkinson’s disease. Parkinson’s is a progressive, degenerative neurological condition which results from the loss of cells in parts of the brain including the substantia nigra.

Cultural Awareness Training for Coffs’ GPs and allied health

It is the second most common neurological disease in Australia, with an estimated 80,000 Australians being affected. On average 32 people are diagnosed daily 20% of whom are under the age of 50. Whilst there is usually a combination of motor and non-motor symptoms, every affected person can vary in the symptoms they experience and the way that the symptoms progress. Because there is currently no cure for Parkinson’s, available treatments aim to manage symptoms and maintain quality of life. Keeping in mind that a person’s treatment regime is likely to change as symptoms and severity progress.

A team-based biopsychosocial approach to management is recommended. The professionals within a team can also change with symptom progression. They will usually comprise of not only doctors and nurses but also potentially dietitians, occupational therapists, physiotherapies, speech pathologists and social workers to name a few. If you would like to know more about available support and management services then click through to the Parkinson’s Disease HealthPathway. Go to HealthPathways at: https://manc.healthpathways. User name: manchealth; password: conn3ct3d Search for Parkinson’s Disease. For further information on HealthPathways, please contact: or kkeyte@


Clark Webb

On Saturday the 10th November Clark Webb from Bularri Muurlay Nyanggan Aboriginal Corporation held a cultural tour at the beautiful Sealy lookout – known locally as “Niigi Niigi”, an important cultural site for the Gumbaynigirr people. This tour was provided by

Lismore’s Southside Health and Hire Centre (in association with Southside Pharmacy) have a large range of quality BARIATRIC and standard equipment for hire or purchase including shower chairs, lifters, electric beds, wheelchairs, seating, walkers, commodes and more.

NCPHN and was for general practices, allied health professionals and staff from local services who work with the local Aboriginal and Torres Strait Islander community. The afternoon started off with a special lunch - modern catering with a traditional twist - followed by a Welcome to Countryand Dreamtime stories. Then it was time for a walk to Korora lookout where Clark spoke about the native plants and sites that are significant to the Gumbayngirr people. He also shared some traditional and contemporary Aboriginal history and other interesting cultural information.

SOUTHSIDE HEALTH & HIRE CENTRE Call us today on (02) 6621 4440 or come in and say hello at 5 Casino Street, South Lismore. Southside Health & Hire Centre Where your health is our total concern.

Nurse on Duty

December 2018 healthspeak

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8:30am - 5pm Mon - Fri 8:30am - 12:00pm Sat Closed Sunday


TRANSFORMERS III – PLANNING & CONTRIBUTING TOGETHER Coast Primary Health Network, a partner of the Centre. “The Centre will be exploring SDoH in 2019 and in the lead up to this event we need to understand the role of alliances. Forming alliances with other providers is a maturity journey for all of us. Transformers III allowed us to discuss what others are doing and how we can contribute and collaborate effectively.”


In November, the Centre for Healthcare Knowledge & Innovation (the Centre) welcomed nine experts to the North Coast to discuss the role of alliances in health care. More than 130 service providers from primary health, social and community services, allied health and employment came together with university lecturers, students, local government and consumers to Transformers III. Held in Byron Bay and Coffs Harbour, this was the third Transformers Series hosted by the Centre, which was established in 2016.


“We know that medical care accounts for around 11 percent of a population’s health outcomes. The other 89% is what’s broadly called the Social Determinants of Health (SDoH)”, said Julie Sturgess, CEO of North


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Topics discussed at Transformers III included: • The growth and impact of alliances • Lessons from the construction industry and accountable care organisations • Managing alliances effectively and developing a ‘one team’ culture • Defining, measuring and rewarding value • The North Coast landscape and where we stand on shared investment Examples of successful alliances included: • Hunter New England Integrated Care Alliance (AUS) • Wollondilly Health Alliance (AUS) • Stockport Mental Health Alliance (UK) • Millom Alliance (UK) • Counties Manukau (NZ) • Oregon Health (USA) • Nuka Health System (USA) • Intermountain Healthcare (USA)

healthspeak December 2017


Groups were encouraged to discuss: • Services suitable for an alliance • What builds trust • Key challenges faced when accessing care • Strategies for bringing cross-sector parties together • The role of future workforce “Working in the local area in public mental health, alliances and working in a team are one of our core values,” says Trent Taylor, Northern NSW Local Health District. “By coming to events like Transformers we get to engage, get strategies and ideas and learn from overseas experience. More importantly we develop relationships that help us wrap services around those who need it.” Presentations, resources and learnings from Transformers III can be found at: www.

December 2017 healthspeak


The Centre for Healthcare Knowledge & Innovation is a consortium of ten North Coast service providers. It offers opportunities for general practice, allied health, pharmacy, specialist care, hospitals, education, social and community services, local government and social enterprise to upskill, network and learn from and with each other.

Universit y Centre for

RURAL HEALTH e du c a t ion • r e s ear c h • work for c e

Register for Centre events at www. Keep up-to-date with events and news at Visit the Centre’s Knowledge Library at

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Alternative to Hospital Project supports wellbeing at home for older patients


n June last year North Coast Primary Health Network (NCPHN) and the Northern NSW Local Health District (NNSW LHD) jointly funded and set up a pilot project under the Integrated Care Program to help older people living in the community avoid hospital stays. The project involves an aged care Nurse Practitioner being collocated within a general practice and seeing older patients with complex needs referred by the clinics’ GPs. The aim is to support older patients to remain safe and well at home and avoid unplanned hospitalisations. Aged care Nurse Practitioner Lisa Garland, normally based at Tweed and Murwillumbah hospitals, coordinated the project and 10 general practices are taking part. She explained how the project began and how it operates. “There was a fair bit of consultation with local GPs to garner interest and I started seeing patients in early July last year. The GPs talk to the patients and get their consent to be referred to me for an hour and a half long consultation. “Having this time means I can delve into a lot more areas than can be reached in a GP consultation. I don’t just take a medical focus, it’s more holistic, looking at cognition, mood, their living environment and supports. Those sorts of factors that impact on their safety and wellbeing at home.”

Positive patient feedback The high number of referrals Lisa received demonstrates a significant level of support for this type of intervention. An evaluation report of the project shows that from 1 July 2017 to 31st July 2018, 497 referrals were made to Lisa. She completed 604 face to face consulta14

Good clinician support

Aged care Nurse Practitioner Lisa Garland

Lisa considers it a privilege to have such a generous amount of time with patients tions, 439 phone follow up calls and 94 case conferences. A patient satisfaction survey

CASE STUDY Mrs MD is grail aged with history of paranoid delusions and cognitive decline. She had a fall at home and fractured her arm. She needed to have her arm in a sling for at least six weeks. Mrs MD was determined to leave hospital and discharged herself with COMPACS six-week service. She was living alone at home and services to support her were not

of 36 participants found an overall high level of satisfaction with the service. Eighty-five per cent of respondents said the service helped the client to stay safe and well at home and 97 per cent reported it was beneficial to have their consultation at their GP surgery. Eighty-eight per cent were very satisfied that the nurse practitioner helped them to access services and supports to maintain safety and wellness at home.

sufficient to support her current care needs. The Nurse Practitioner Aged Care offered Mrs MD the option of Emergency Respite in RACF rather than returning to hospital. Admitted to BUPA Pottsville for Emergency Respite for 3.5 weeks to allow time for fracture to heal and enable sufficient care and support during this period. Mrs MD returned home with support services three times a week.

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All 12 clinicians surveyed about the pilot indicated further support for the program to continue. All agreed that the project improved person-centred, proactive, holistic care and reduced unplanned hospital admissions. Lisa considers it a privilege to have such a generous amount of time with patients, to make referrals for them to other supports and services, and to help them maintain their independence at home. As well as helping people avoid hospital, due to her solid connections with local aged care facilities, Lisa is able to organise important support such as urgent respite when required. “I’ve been able to organise urgent residential respite when a carer’s either been very stressed or when things aren’t good at home, not safe for the person. Rather than the patient having to come to hospital for support, I’m able to get things happening earlier from the general practice,” she said.

Overall summary The aim of the project to provide proactive holistic, personcentred care for older patients in the primary care setting to maintain wellness and support in the community to avoid unnecessary hospitalisations was achieved. The project exceeded expectations with the recruitment of 10 general practices participating. The LHD and NCPHN are working together to come up with a sustainable model for this important area of health care. For more information contact Lisa Garland at lisa.garland@ or 0408 647 987.

healthspeak December 2018

Education: enabling GPs and PNs to diagnose and manage dementia

By Dr Hilton Koppe

How I got involved


bout four years ago I was at a GP education event with concurrent sessions. One on learning about how to teach on the topic of dementia and one next door involving ukulele playing and some other fun stuff. I went to the dementia session. There were four of us in that session and the room next door was full. But through attending that session I saw that a bunch of people from Tasmania are doing great work on dementia and GP training. And they offered us an opportunity to go down and visit them, watch how they deliver their workshop and then take a master class with their expert resource person. So Lennox Head colleague Dr Peter Silberberg and another Brisbane GP and I went down there and experienced three days of the best education sessions I’ve ever attended. It was just fantastic. And after this Peter and I worked with one of the Tasmanian team to deliver their workshop for North Coast GP Training a couple of times. Fast forward, and about two December 2018 healthspeak

years ago I was sitting at the Tweed Gallery having a coffee. The phone rings, and it’s Dr Marita Long from the University of from Tasmania, asking me if I’d be interested in working with their team to develop their education resources. They are keen to bring my medical education experience into their work. And that’s how I got involved in their dementia education program. The University of Tasmania houses the Wicking Dementia Research and Education Centre, the organisation I work most closely with - that and Dementia Training Australia (DTA) who provide the funding. This partnership between the Wicking Centre and DTA works to roll out education for GPs and nurses on the topic of dementia. What I’ve learnt from doing this work is that there are a lot of barriers to GPs diagnosing dementia, mainly a lack of confidence in their ability to do it. Dementia is more common than realised. It’s estimated that around 50% of people with the condition aren’t recognised as having dementia. And there are inadequate specialist resources to deal with it. The waiting time to see a

geriatrician on the North Coast is a year, and so if we’re waiting that length of time for people to see a geriatrician to get their dementia diagnosis and management there’s a window of opportunity for general practice to intervene. The goal of the work we’re doing is to increase the confidence and ability of GPs to be able to recognise, diagnose and manage dementia as much as possible. If you think about

It’s estimated that around 50% of people with the condition aren’t recognised as having dementia how back in the day diabetes was managed by endocrinologists, but now it’s a chronic disease managed in general practice, well we’re trying to create the same pathway for dementia as well. We’re now running workshops for registrars, supervisors and whoever else is interested. We’re targeting those groups because

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of ease of access to them. But early next year, we’ll be offering this training to Primary Health Networks across Australia. We’ll be offering a whole of practice approach, not just for GPs but practice nurses too, and the community as well. It needs to be a coordinated approach to raise the thinking and the confidence in people’s ability to deal with dementia in general practice. The topic of dementia is big and complicated and we’ve broken it down into small, easy to think about chunks of information that cover the majority of people with dementia. Of course there will always be cases that are more complex needing specialist support, as there is with diabetes, but most cases can be managed fairly well in general practice given adequate training. We’ve already delivered workshops to about 500 GPs, both registrars and GP supervisors. Alongside these workshops has been a research project following the participants. Researchers assess their knowledge and confidence around diagnosing and managing dementia before the workshop and afterwards. Interestingly, the knowledge and confidence of GP registrars and experienced GPs has proven to be fairly equal prior to the workshop. This research on the training is about to be published and it shows a big improvement in both knowledge and confidence after GPs attend the workshops. In the last months of this year we’ll get in touch with all the PHNs around Australia offering dementia training workshops next year. While there are competing demands for educational opportunities, we’re confident there will be significant interest. 15

The new PHN landscape Building health care capability & sustainability In July 2016 Primary Health Networks began the transition to become commissioning organisations. As you'd be aware, for the 12 to 18 months after July 2016, NCPHN staff worked successfully to transition a range of medical services to the management of other health and community organisations.

Now through our strong commissioning process we partner with local organisations to ensure that North Coast communities have quality care when and where they need it. Indeed, following our organisational transition, up to 30 June 2018 NCPHN achieved a great deal, working hard to secure more

How commissioning works TH E N E W PH N L A N DS C A PE

Commissioning is a new way of the health and community sectors working together with the community to design services that best meet specific local identified health needs. NCPHN has well-established and effective clinical and community councils across the region which guide our activities around commissioning, providing insights from both the clinical and community perspectives. Our commissioning work begins by gaining an understanding of the North Coast's health care needs. We conduct regular Needs Assessments involving our community, clinicians and service providers. The information gathered to inform our Needs Assessments comes from a community survey, ABS census data, hospitalisation data, mental health information and other health statistics sources.

Matching services to needs Having identified priority needs, NCPHN works to fill health care gaps and put in place local solutions that meet the needs of our particular communities. A great deal of work is done around strategic planning and design to identify needs and the best services to meet those needs. Following this, a tender process is carried out which provides opportunities for local service providers and organisations to add new programs and services through NCPHN funding 16



than 200 contracts with community organisations and individual health care providers to deliver health services. A list of the current portfolio of health care services and programs commissioned and

to those they already offer.

The benefits of commissioning This commissioning process is in stark contrast to the previous health care funding system which was centralised in Canberra. It failed to take into account local health care service information and locally identified needs. Because commissioning involves a tendering mechanism it does bring market forces to bear, but our commissioning process is not driven by costs. It's a process that works to match the best provider to deliver a specific health need for local communities. Recently NCPHN delivered Commonwealth funding worth $1.2m to six Aboriginal medical organisations across the North Coast to deliver suicide prevention programs. Each organisation is coming up with a tailored program to meet the particular needs of their clients. Commissioning allows us to meet local needs in innovative, effective ways. We’re not pushing ‘one size fits all’ models onto our health providers. We're about the best models to meet local needs.

Best hope for health reform A successful commissioning approach, such as NCPHN’s, focuses on three elements:

funded through NCPHN can be found as an insert in this edition of HealthSpeak. This portfolio addresses key priority areas such as Aboriginal health, mental health and alcohol and other drugs.

• Client outcomes - commissioning seeks to identify and prioritise outcomes. Of key importance is articulating what results the service will deliver for the client and the community. • Delivering better services. There is no one-size-fits all approach and the process should consider the best model of service delivery to achieve desired outcomes. Measurable service standards and performance objectives inform NCPHN and government about the quality of services delivered. • Providing greater value for money. Strategic commissioning is about improving efficiency and value for money. Selected service models should provide better service for less money or at the same value. One of Australia's most experienced primary health care players, Dr Claire Jackson, recently co-authored a paper titled Funds Pooling in Australia: could alliance contracting hold the key? Her fellow author was Professor Robin Gauld, Dean of New Zealand’s Otago Business School. The authors state that "A populationbased governance model, which unites diverse organisations and professional groups around a single patient-focussed vision for local health needs, is critically important to delivering the COAG reform agenda."

Building workforce capacity


W ithin the commissioning model opportunities exist for funding to be channelled into upskilling the workforces of our partners to better deliver local health care.

Health coaching

Transformers The theme for the Centre for Healthcare Knowledge & Innovation’s Transformers Series held in November was ‘Planning & Contributing Together’. Events were held in Byron Bay and Coffs Harbour. Health and social care professionals, together with local government agencies, NGOs, academics and entrepreneurs came together to explore new alliance trends.

Participant comments: Working in public mental health, working in alliances and as a team is one of our core values. But let’s expand that team and work with GPs, NGO sector and Commonwealth and State funded services to wrap around the person. – Trent Taylor NNSWLHD If we can learn from each other, everyone is different with different ways of doing things. But if we can get together and share, five heads are better than one and we can create really innovative outcomes for people. - Ally Dench, Wollondilly Council and Wollondilly Allied Health Alliance.

HealthPathways A consortium for Health System Improvement has been established in partnership with the Local Health Districts. A key activity of the new body will be to foster the future development of the Mid and North Coast HealthPathways program. Work is underway to capture all commissioned health services on the HealthPathways portal for easy referrals.


One example of workforce upskilling is the exceptionally well received health coaching workshops held for practice nurses, GPs, LHD staff, ambulance and allied health providers across our footprint. Run earlier this year, more than 120 health professionals took part. Ninetyseven per cent of attendees rated the event as excellent with a pleasing 86 per cent of participants saying they would now implement changes to their work practices.

Strong partnerships foster success My Emergency Dr App NCPHN and the Mid North Coast Local Health District have partnered with telehealth provider My Emergency Dr (MED) to run a pilot program in South West Rocks to improve access to a doctor after hours. It was launched after Healthy Towns consultations with both community and GPs in South West Rocks highlighted a need for additional after hours medical support. The pilot aims to reduce the need to travel to the hospital emergency department when locals are unable to access their regular GP after hours. The MED app allows residents to call an Australian-qualified Emergency Specialist Doctor any time day or night, 365 days a year. The MED Doctors are able to diagnose illnesses, provide

From left: MNCLHD Integrated Care Project Officer Adam Ulrick, NCPHN Director, System and Service Integration, Steve Mann; CEO of MED, Dr Justin Bowra; and Seascape Medical Centre, South West Rocks General Practitioner Dr Akram Malak.

prescriptions, requests for pathology and medical imaging. They can even provide a discharge summary back to the patient’s GP. “Telehealth services such as My Emergency Dr have the potential to

improve health outcomes for regional and rural Australians. We’re excited to be bringing this pilot to the Mid North Coast.” Steve Mann, NCPHN’s Director of System and Service Integration, Mid North Coast said. H E ALT H S P E A K



Strong partnerships foster success Community partnerships bring nurse-led clinic In 2019 the small town of Ulong near Coffs Harbour will have a refurbished clinical space in its community hall with free, monthly nurse-led clinics staffed by nursing students from Coffs harbour TAFE NSW. It’s hoped the refurbished space will attract a GP to visit regularly. The consulting room is now complete in the renovated community hall through an NCPHN grant of $10,000 and local donations.

Cross sector team work really benefits patients


Taking part in the Winter Strategy this year has been a very satisfying experience for all involved at Bangalow Medical Centre. HealthSpeak spoke to the centre’s Winter Strategy team about how valuable it had been for them to have Louise Emery, Care Coordinator for the NNSWLHD's Tweed/Byron’s Chronic Disease Management Team at NNSWLHD working with them to look after their enrolled patients. With Louise visiting enrolled patients at Byron Central Hospital, she was able to identify communication gaps between the hospital and the general practice and improve the way things were done. “The doctors working at Byron Central Hospital didn’t know any of the patients from the practice and one of the RMOs made a great suggestion. He suggested that when the practice got the alert that one of their patients was in hospital that they send through recent medical information about tests, specialist appointments, medications etc, so the doctors were more informed. “They pointed out that without that information they were sometimes repeating tests that had already been done.” Louise also noticed that with a change in medical staff or shift, sometimes discharge summaries were being overlooked and not getting to the practice fast enough. She was able to chase up the Nurse Unit Manager or the doctor to get the discharge sum18



mary sent through so that she could do a follow-up visit with that patient within 48 hours and be aware of any change in medications. Practice Nurse Rhonda West said the connection forged between the practice staff and Louise during the Winter Strategy was ‘amazing’. She said because the staff had a face to face meeting with Louise before the Winter Strategy be-


Ulong lies nearly an hour inland from Coffs Harbour, along winding mountain roads. NCPHN prioritised Ulong as a town to support through its Community Voices program. Read more about how community members, TAFE NSW and NCPHN worked together to bring these health services to a town of just 131 people on page 4.

Lisa Taffe, Head Teacher, Aged Care, Health & Nursing, TAFE Coffs Harbour with a community member.

patients in a meaningful way and the feedback was very positive. “They feel valued and know that for us nothing is ever a problem. If they have chest pain and they’re at home I say ‘ring an ambulance’. Previously they might have hesitated to ring an ambulance but we give them permission to look after their needs,” said Sherrie. And Practice Manager Megan Savins From left: Sherrie Smith, PN, Bangalow Medical Centre; Rhonda West, PN, Bangalow Medical Centre; Louise Emery, Care Coordinator, NNSWLHD Chronic Disease Management team Tweed/Byron and Megan Savins, Practice Manager, Bangalow Medical Centre.

gan, communication with her via email was simple and effective. She recommends personally meeting members of the LHD’s Chronic Disease Management team and Practice Nurse Sherrie Smith goes further. “It’s important to also know all your local allied health practitioners personally. If you’ve met them you’re comfortable ringing them when you need to.” Working as a team, making regular phone calls to enrolled patients, the Bangalow Medical Centre nurses and practice manager were able to support

explained that having regular contact meant that staff picked up on who was isolated and lonely. “One lady didn’t have friends up here and our PNs encourage her to go to the bowling club and join the CWA. And a local gentleman was encouraged to join the Men’s Shed. Without regular phone contact we would never have picked up that these people were lonely,” she said. Find out more about the NNSWLHD’s CDM team:

Strong partnerships foster success Grateful Winter Strategy patient

“When you have chronic pain it’s really reassuring to know that you are not in this battle alone, there are others who care for you. I’ve received closer attention from my GP and nurses and this

How to refer The insert in this edition of HealthSpeak is a complete list of all our commissioned services and programs currently in place across the North Coast. Below are the commissioned services to which GPs and health professionals can refer patients and instructions on how to refer.

Mental health New Access - across North Coast A free mental health coaching service to help people manage day to day pressures. Face to face or phone sessions available. People can make an appointment on 1800 010 630. Healthy Minds Healthy Minds is for people experiencing mild to moderate mental health concerns and who are under financial stress or who have an Australian Government Healthcare Card. Referrals should be faxed to 1300 853 248 or emailed to: Family Therapy Services, Bowraville Durri ACMS offers family therapy services for

Aboriginal families living in Bowraville. Phone Durri on 6560 2300. AOD & mental health programs 360 Outreach– Coffs area, Nambucca & Bellingen Mission Australia provides group, one-on-one and one-off counselling for young people aged 13 to 18 with both mental health concerns and alcohol and other drug issues. Mental health workers attend participating schools and work in the broader community around Coffs Harbour, Nambucca and Bellingen. GPs can refer patients by emailing: Durri Aboriginal Corporation Medical Service Maayu Mali Outreach, Mid North Coast This Outreach Program

- a culturally-based drug and alcohol outreach program on the Mid North Coast - is for Aboriginal people aged 12 and over. Inquiries, phone Durri on 6560 2300. Namatjira Haven Drug & Alcohol Healing Centre - Ballina, Lismore, Byron Bay, Casino, Kyogle Namatjira offers a Withdrawal Management and Residential Rehab program for Aboriginal men with both alcohol and/or other drug issues and mental health problems. To refer phone 6626 1098. b.well Outreach Service - Northern NSW The Buttery runs this outreach program which supports people over 12

NCPHN’s Monika Wheeler with patient Rodney Johnson

has stopped me from having to go to hospital which is a bonus for everyone.”

who have problems with both their mental health and drug and/or alcohol misuse. Inquiries to join, phone 6687 1658. Community Withdrawal Management and Aftercare Service – Mid north Coast For people aged 16 and over who need help with alcohol and other drug misuse and mental health concerns. Phone MNCLHD on 1300 662 263. Nimbin Integrated Service For people 16 and over who need help with alcohol and other drug misuse and mental health issues. Phone 6689 1692. EACH – Kempsey, Port Macquarie and Wauchope Counselling and care for students 12 to 16 years attending participating schools and colleges needing help with alcohol


and other drugs misuse. Phone EACH on 1300 003 224.


Goonellabah Medical Centre patient Rodney Johnson has battled chronic pain and disease for years and has spoken publicly about the benefits of enrolling in the Winter Strategy 2017. This was a partnership with NCPHN and NNSWLHD to provide additional practice support for high risk patients over the winter flu season. “Before this program I’d visit my GP and leave with a prescription and that was it. But now I have a team of people, doctors and nurses and other professionals who all work together and I have that personal reassurance and confidence that they are there to help me,” Rodney said.

Young People Early Intervention program – Bellingen, Nambucca, Grafton, Yamba, Maclean For youth aged 12 to 24 needing help with alcohol and other drugs misuse. Also available to carers and friends. Phone The Buttery on 6687. 1039. Community Day Stay Rehab – Lismore, Byron Bay, Tweed Heads For people who cannot access residential rehab, eg sole parents of young children. Phone The Buttery on 6687 1039. INTRA Outreach programs – Tweed Heads, Evans Head, Casino, Kyogle, Nimbin For people aged 12 and over with problematic substance misuse. Family and carer support available. Phone The Buttery on 6687 1039.



Goori Grapevine RAP Plan making good progress


CPHN’s Reconciliation Action Plan (RAP) Working Group is pleased to announce that the draft RAP plan was approved by the organisation’s Board in late November. In order to involve the wider community with the RAP Plan, an artwork competition is underway for budding or estab-

lished artists of all ages to provide a piece of art to illustrate the published Plan. The RAP Plan Working Group, which was set up earlier this year, is made up of 12 members including Elders, community members, a Board member and NCPHN staff members from across the region.

A total of five meetings have been held this year in the central location of Grafton to work through the draft plan. Two RAP Plan meetings were held with NCPHN staff. NCPHN’s Acting Aboriginal Health Manager Kim Gussy said the meetings had been warm and welcoming with meaningful conversations. On request from Elders, the outcomes of each meeting were sent out in a newsletter which was distributed to the communities. And in exciting news, NCPHN has approved a new project to capture Elder Stories throughout our region. In order to involve the wider community with the RAP Plan, an artwork competition is underway for budding or established artists of all ages to pro-

Guiding a healthier renal future


irst Nations people will play a fundamental role in developing guidelines to improve Aboriginal kidney patient outcomes, with more than $300,000 in Government funding to Kidney Health Australia to support national consultations. Kidney Health Australia will hold 20 community consultations across the country to inform the Caring for Australasians with Renal Impairment Indigenous Guidelines. Renal failure disproportionately affects First Australians and we need to work together to improve and maintain the health of those who contract kidney disease. Recent research shows nearly one in five Aboriginal and Torres Strait Islander people aged over 18 have indicators of chronic kidney disease. 20

Aboriginal people face unique challenges in the management of this condition, including access to services and leaving country to receive treatment. The guidelines are being developed to address these and other challenges and to work towards delivering better treatment options and a healthier future. They will also help support chronic kidney disease education, prevention, early detection, management and workforce education. Grassroots consultation will allow Kidney Health Australia to ensure the guide-

lines are relevant and reflect what communities want and need. In addition, a panel of Aboriginal and Torres Strait Islander health clinicians, including community-based practitioners, will advise on the consultative process and the content of the guidelines. The guidelines will complement the national renal roadmap currently under development and the priority placed on First Nations kidney health by the Council of Australian Governments. The guidelines will also be a resource for Māori people, with Kidney Health Australia securing separate funding to hold community consultations in New Zealand. Completion of the community consultations is expected in late 2019.

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vide a piece of art to illustrate the published Plan. For more information on this competition, go to: https://bit. ly/2PBGEE2

NCPHN’s Rhiannon Mitchell completes her studies

At the end of 2017 Rhiannon Mitchell from NCPHN’s Coffs Harbour office was accepted into a Graduate Diploma of Indigenous Health Promotion at the University of Sydney. Over the past 12 months Rhiannon has been studying in block mode at the university where she has attended lectures at the university and submitted assignments and other course work. Over this period Rhiannon has learnt about community profiling; health promotion program planning; research and evaluation; the art, science and politics of prevention of chronic illness; global health; communication and health literacy. Congratulations to Rhiannon for completing her Grad Dip while working at NCPHN. We look forward to her graduating in April 2019.

healthspeak December 2018

Planning Day brings together all Aboriginal health partners


n November 14, NCPHN held a Planning Meeting in Ballina involving the CEOs and senior staff of all Aboriginal Medical Services in the PHN footprint. They are: Bulgarr Ngaru, Rekindling the Spirit, Bullinah, Werin Aboriginal Corporation Medical Centre, Durri Aboriginal Corporation Medical Service, Galambila Aboriginal Health Service and Bawrunga Coffs Harbour Super Clinic. NCPHN staff in attendance were CEO Julie Sturgess; Acting Deputy Director Aboriginal Health, Monika Wheeler; Acting Aboriginal Health Manager, Kim Gussy and Amy Tyrrell, Planning Coordinator. The day’s agenda focused on Integrated Team Care– setting priorities both short and

long-term for improving the management and delivery of the Program. A discussion paper on the program had been circulated before the meeting and provided the basis for discussion and decisionmaking on improving the Integrated Team Care Program. Each CEO Chaired a session of the Planning Day. Topics included Cultural Safety, Removing Barriers to Access and Consistency of Service Delivery. NCPHN’s Acting Aboriginal Manager Kim Gussy said the day was the first time in a long time that CEOs and senior staff from all Aboriginal Medical Services on the North Coast had come together to set planning priorities.

“It was a really important milestone in moving forward in a united way with our Integrated Team Care program. There was an opportunity to hear from everyone and productive discussion, resulting in a set of priorities to improve the delivery of the program and health outcomes,” she said.

Fresh new look for Bugalwena General Practice


ugalwena General Practice at Tweed Heads has a brand new look after an extensive refurbishment. An Aboriginal medical service, Bugalwena was run by NCPHN until it was transitioned in 2017 to the management of Bulgarr Ngaru Aboriginal Medical Corporation. The practice has had a total makeover with fresh new signage out the front, and inside it’s unrecognisable. Although Receptionist Kerry Lehmann said no walls had been knocked out within the building, the waiting area feels much larger, modern and very comfortable. The clinic’s facilities have been expanded greatly. Previously the practice had two consulting rooms and now it boasts seven consulting rooms – including one larger treatment room. Kerry explained that the landlord had very generously extended the space available to the practice to allow the inclusion of the extra rooms. While staff endured about four and a half months of building disruption, including lots of dust, the project really ramped December 2018 healthspeak

up when the practice closed for seven days over NAIDOC Week which gave the builders a chance to really make some progress. Kerry said staff worked within the community while the practice doors were closed, to ensure patients were looked after. Included in the refurbishment is a new staff kitchen and toilets with wheelchair access. Bugalwena staff are all clearly enjoying working in their new, more spacious environment and patients are happy too.

From left: Lea Clayden Practice Nurse; Dr Paul Davies, Carly o’Keefe, Receptionist and Kerry Lehmann, Receptionist.

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Congratulations to Coraki, winners of the 2018 NSW Healthy Town Challenge!


his year Coraki locals partnered with organisations including Northern NSW LHD Health Promotion Unit, PHN, Solid Mob, Richmond Valley Council, the Mid-Richmond Neighbourhood Centre and University Centre for Rural Health to take on the NSW Healthy Towns challenge. This involved a range of projects to encourage physical activity and healthy eating. In November Coraki was announced the state winner - the town to have achieved the most change towards supporting community members to become healthier. The projects in Coraki included an open day at the swimming pool and taste testing and cooking demonstrations at the Coraki SPAR supermarket.

The Coraki takeaway now offers more healthy food options.

The local take-away shop is now offering more healthy-food options, a regular walking group has been established, and there are ongoing open days at the local Golf Club. Free coaching sessions for kids were run at the tennis club,

and together with grants from Tennis Australia and the Coraki Quarry, tennis racquets have been bought and the toilet and lights fixed. A large number of children and adults are now using the tennis court regularly. In addition, a Yulunga

Traditional Indigenous Games workshop was held for teachers at the two primary schools, and Stepping On Falls Prevention course and Qi Gong classes were run for the community. More than 30 residents enrolled in the Get Healthy Information and Coaching Service and lost on average 3.3kg of body weight. Richmond Valley Council and the Aboriginal community will be working together to plant shade trees and a bush tucker garden. As part of the riverfront development, a walking track, water bubblers and an outdoor gym station will be installed, and the wetlands rehabilitation project has also been started. The Healthy Town Challenge, funded by the NSW Office of

Continued page 39

Annual Nell Riordan lecture focuses on technology and patient care By Professor Iain Graham Dean, School of Health and Human Sciences Southern Cross University


ctober marked the annual event by the School of Health & Human Sciences at Southern Cross University – the Higher Degree Symposium and the Annual Nell Riordan Lecture. The theme of the event was focused around technological development and its growing impact on patient care. More than 60 people attended the lecture the keynote address was given by Ms Jennene Buckley and Aunty Jackie McDonald welcomed us to Country. I am pleased to say that three members of Nell Riordan’s family were able to attend. The related HDR symposium hosted 70 people who heard


various presentations from the School’s Higher Degree students. All presentations were of an exceptionally high quality both in content and in presentation. However four prize winners were identified by their peers, which added to this exciting Symposium. I also would like to acknowledge the academic staff who supervise the work of the students. Ms Jennene Buckley, CEO of Feros Care, was invited to present the Nell Riordan lecture. Jennene, also a local woman, became the CEO of Feros Care 17 years ago; at the time a small nonprofit single locality, residential provider of 95 clients in Byron Bay. Today it is one of the fastest growing aged and community care services in Australia, supporting now over 50,000 people per year and spanning

six states and territories’ along the east coast of Australia. It leads the industry in digital service models, customer led design and creates innovative and energetic service cultures. Jennene was inducted into the Aged Care IT Hall of Fame in 2016 and the company has won many national and international awards for

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their innovation and digital transformation. Prof Dian Tjondronegoro, SCU Professor and IT Discipline Lead in the School of Business and Tourism, presented the keynote speech at the Symposium entitled “How digital technologies transform the future health sector”. This was a wonderful keynote highlighting. The review by participants both for the Symposium and the lecturer was extremely positive. We look forward to another enlightening event in 2019 aimed at stimulating discussion around the provision of health and healthcare, currently undergoing profound changes nationally and internationally. My thanks to Ann Mulder for providing a full report of these events.

healthspeak December 2018

Do probiotics help after a course of antibiotics? By Lito Papanicolas, Infectious diseases specialist, South Australian Health & Medical Research Institute and Geraint Rogers, Professor, Director, Microbiome Research, South Australian Health & Medical Research Institute


f you take antibiotics, there’s a good chance you’ll also get diarrhoea. Antibiotics kill harmful bacteria that cause disease. But they also cause collateral damage to the microbiome, the complex community of bacteria that live in our gut. This results in a profound, though usually temporary, depletion of the beneficial bacteria. One popular strategy to mitigate the disruption is to take a probiotic supplement containing live bacteria during, or following, a course of antibiotics. The logic is simple: beneficial bacterial in the gut are damaged by antibiotics. So why not replace them with the “beneficial” bacterial strains in probiotics to assist gut bacteria returning to a “balanced” state? But the answer is more complicated. There is currently some evidence that taking probiotics can prevent antibiotic-associated diarrhoea. This effect is relatively small, with 13 people needing to take probiotics for one episode of diarrhoea to be averted. But these studies have often neglected to evaluate potential harms of probiotic use and haven’t looked at their impact on the wider gut microbiome.

Pros and cons of probiotics The assumption that there is little downside to taking probiotics was challenged in a recent Israeli study. (Cell 2018 Sep 6;174(6):1406-1423.) The participants were given antibiotics and split into two groups: the first group was given an 11-strain probiotic preparaDecember 2018 healthspeak

We still don’t know what types of bacteria are truly beneficial

tion for four weeks; the second was given a placebo, or dummy pill. The researchers found the antibiotic damage to the gut bacteria of those in the first group allowed the probiotic strains to effectively colonise the gut. But this colonisation delayed the normal recovery of the microbiota, which remained perturbed for the entire six month study period. In contrast, the microbiota of the second group returned to normal within three weeks of finishing antibiotics. This research exposes a perhaps unexpected truth: we still don’t know what types of bacteria are truly beneficial or even what constitutes a healthy microbiome. The answer is unlikely to be that individual bacterial strains are particularly helpful. It’s more likely a diverse com-

munity of thousands of different types of microbes working together can provide health benefits. This microbial community is as individual as each one of us, meaning there is not just one configuration that will result in health or illness. So, it’s unlikely that the addition of one or even 11 strains of bacteria in a probiotic could somehow balance this complex system.

A more effective (but less palatable) alternative?

chemotherapy treatment. These patients are predictably at risk of serious complications, such as bloodstream infection, as a result of microbiome disruption. Research currently underway will help us understand whether microbiome restoration with autologous faecal transplantation will translate into tangible benefits for these patients. But such an approach would not be a realistic option for most people.

Feed the good bacteria

The Israeli study also explored an alternative approach to microbiome restoration. One group of participants had their own stool collected and frozen prior to antibiotic treatment. It was then re-instilled into their gut at the end of the antibiotic therapy. This treatment, known as autologous faecal transplantation, was able to restore the microbiome to original levels after just eight days. The other group took 21 days to recover. This approach has also been shown to effectively restore the gut microbiome following combined antibiotic and

A more practical strategy to aid recovery is to provide the good bacteria in your gut with their preferred source of nutrition: fibre. Fibrous compounds pass undigested through the small intestine and into the colon, where they act as fuel for bacterial fermentation. So if you’re taking antibiotics or have recently finished a course, make sure you eat plenty of vegetables, fruit and wholegrains. Your gut bacteria will thank you for it.

a publication of North Coast Primary Health Network


Published with kind permission from The Conversation (www.

Nobel Prize for breakthrough discovery of cancer immunotherapy


his year’s Nobel Prize in Physiology or Medicine was awarded to James P Allison and Tasuku Honjo for their discovery of cancer therapy by inhibition of negative immune regulation. In the August issue of HealthSpeak, Oncology North Coast medical oncologist Dr Adam Boyce brought readers up to date with the use of immunotherapy in treating cancer and looked at a range of currently used immunotherapy drugs. This promising field of cancer treatment could not have emerged without the work of Allison and Honjo. By stimulating the inherent ability of our immune system to attack tumour cells, this year’s Nobel Laureates established an entirely new principle for cancer therapy. James P. Allison studied a known protein that functions as a brake on the immune system. He realized the potential of releasing the brake and thereby unleashing our immune cells to attack tumors. He then developed this concept into a brand new approach for treating patients. In parallel, Tasuku Honjo discovered a protein on immune cells and, after careful exploration of its function, eventually revealed that it also operates as a brake, but with a different

Checkpoint therapy has fundamentally changed the way we view how cancer can be managed. mechanism of action. Therapies based on his discovery proved to be strikingly effective in the fight

against cancer. Allison and Honjo showed how different strategies for inhibiting the brakes on the immune system can be used in the treatment of cancer. These seminal discoveries by the two Laureates constitute a landmark in cancer treatment. Allison and Honjo have inspired efforts to combine different strategies to release the brakes on the immune system with the aim of eliminating tumour cells even more efficiently. A large number of checkpoint

National prescription monitoring moves ahead An Australian company has been appointed to develop a national realtime prescription monitoring system. The Fred IT Group will lead the new national system which aims to reduce the impact of prescription medicine overdoses. The company will build and deliver the software system for the National Data


Exchange component. A report by the Australian Institute of Health and Welfare found that in 2016 there were 1808 deaths in Australia as a result of prescription medicine overdoses. This system will allow collaboration between medical and pharmacy software vendors and jurisdictions, which should

give health professionals in different environments a consistent user experience. Fred IT has already developed SafeScript, a Victorian prescription monitoring system which began its rollout in October. The introduction of a national approach to realtime prescription monitoring will help prevent prescription medication misuse and save

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therapy trials are underway now against most types of cancer, and new checkpoint proteins are being tested as targets. For more than 100 years scientists attempted to engage the immune system in the fight against cancer. Until the seminal discoveries by the two Laureates, progress into clinical development was modest. Checkpoint therapy has now revolutionised cancer treatment and has fundamentally changed the way we view how cancer can be managed.

lives. It will provide health professionals with accurate and up-to-date clinical data about patient prescriptions, and give doctors and pharmacists a platform that identifies and supports patients at risk.

healthspeak December 2018

Overseeing the Contract


CPHN’s main objective after a contract is awarded is to support the achievement of the agreed health outcomes. The approach taken depends on factors including: • The novelty, complexity and/or risk profile of the service or project • The confidence and/or experience of the contractor • The size and/or duration of the service or project

Relationship building

avoid misunderstanding and ambiguity about roles, responsibilities and obligations. Each contract includes key performance indicators and mechanisms for performance management. While NCPHN takes these

performance indicators seriously, it is always more concerned with achieving the project’s health outcomes. We are also committed to supporting contractors to effectively evaluate the outcomes of their services and projects.


The most effective tool we have to support contract management is the building of a positive relationship with the contractor. By attaining mutual trust and understanding, contractors are more likely to work proactively with the PHN to identify and share ideas that present opportunities for improvement. They will also be more willing to share issues, barriers and risks as they arise. NCPHN is flexible in responding to such issues and challenges and works with contractors to ensure any changes are managed formally. Often this is done by varying a contract to

Meet Mike McGowan – NCPHN contract manager Mike is managing 14 NCPHN contracts and told HealthSpeak that the way he works is through cooperation, collaboration and flexibility. It’s all about helping the provider to deliver the contracted services, which ultimately means better outcomes for clients and patients.

“The more legal side of commissioning includes a procurement process leading to the awarding of a contract. Then there’s a process beyond the contract execution which allows us to monitor and evaluate each contract, get feedback from providers and track how they are performing. “Before contract execution there’s a negotiation phase and each contract comes with performance indicators, targets and outcomes. But in the real world, when a provider begins delivering a service there are often challenges that may or may not have been foreseen. “And that’s when we need to problem solve together rather than trying to shoe horn reality into a prescriptive document,” Mike explained.

population health needs. They can also be about working in a complementary fashion with organisations providing similar services in the same locale without duplicating those services. “At least three of my contractors have programs that overlap geographically, so I made sure I put each of them in touch with each other to avoid duplication or potential conflict between services.

Local connections

Contract challenges These might include unforeseen additional costs or identifying developing

“Encouraging these local connections has been going really, really well. In fact it enables providers to make the most appropriate referrals. The stepped care model used in Alcohol and Other Drug treatment services becomes more achievable and manageable because organisations are recognising the skills and particular benefits that each of them brings. “And if a client’s needs would be better served by talking to a different local professional, they can refer them on,” he said. Continued next page




Trust in the provider and the PHN Relationship building is essential to successful contracting. “When we first put a program in place there’s a significant period of implementation and we’re coming to realise that in that period there are a lot of structural things to organise, but there’s also the issue of trust. We need to ensure the local communities have confidence in the provider to deliver a service. “I’ve been told it can take a school student three weeks to feel safe and to trust a counsellor before they open up about the issues they are facing.” And of course, it also takes time to build trust between the PHN and the provider.

A nurturing relationship


“The key words for me are cooperation, collaboration and working together. I see the work they do and I so highly value it. For me the relationship needs to be a nurturing one, not clinical and detached. Because unless you have a level of passion and understanding for what these people are delivering, then you won’t get the best out of your providers.” Mike is open about the fact that becoming a commissioning organisation is relatively new for NCPHN and that everyone is on a considerable learning curve. He says there is much to learn from day to day contract management that will better inform NCPHN’s future work. “But we still have the professional understanding that this is a contract and there are deliverables and we do need to make sure the contractors are delivering the best possible services. And our mission is always to improve the health of North Coast communities and that’s what we’re working towards in the way we manage contracts.”

Monitoring & Evaluation When it comes to the role of monitoring and evaluation, Mike’s focus is on ensuring the delivery of high quality services and better health outcomes for North Coast residents. “It’s all about helping the service provider meet their contractual obligations. And of course we have checks and balances in place. So if I see an area of concern in the quarterly or six-monthly reporting I sit down with them to work it through. It might be that they are having 26



trouble finding a qualified health worker as stipulated in their contract. We talk it through and look for a solution that benefits the service.” NCPHN has the capacity to vary service contracts – to make them more suitable for local needs or to increase or change the scope of funding. This is something that may only become apparent over time.

Mission Australia’s contract variation 360 Outreach, a school-based Alcohol and Other Drugs (AOD) Outreach program on the Mid North Coast was expanded in June 2018 to include treatment for co-occurring severe and complex mental health issues. The expansion was based on evidence from counsellors

IT’S ALL ABOUT HELPING THE SERVICE PROVIDER MEET THEIR CONTRACTUAL OBLIGATIONS. that increasingly, young people with substance misuse issues are presenting with co-occurring mental illness. Mike recognised an opportunity to vary the contract and expand the service when he sat down with Mission Australia Program Coordinator Sarah Sherlock. “It became apparent that the counsellors in delivering AOD treatment services were encountering a high percentage of young people who were talking to them about substance misuse, were also identified as having mental health issues. “So with the NCPHN Executive’s guidance and support, we decided to broaden the scope of the contract. It’s a great outcome. By being flexible in our approach we have managed to more effectively meet the needs of the community involved,” said Mike.


Submitting Unsolicited Proposals NCPHN encourages unsolicited proposals for innovative service delivery solutions, where the proposal is uniquely placed to provide a value-for-money solution. Proposals may be submitted to NCPHN at any time but will only be reviewed and assessed twice a year as part of our planning process. If you have any questions, email: To submit a proposal, go to: and click on Have you Got a Great Idea?

Medical rehabilitation specialist offering extended services on the Northern Rivers


fter more than six years as Clinical Director, Rehabilitation Services NNSW Health, Dr Ulla GerichMcGregor has now moved into private practice full time. “I set up my private practice – Rehab Balance – about five years ago to consult part-time out of Bangalow. I’ve now expanded this to full-time with the addition of consulting rooms at Ballina and admitting rights at St Vincent’s Hospital, Lismore. I’ve also started to offer in-house consultations to nursing home patients, targeting pain and spasticity management,“ Dr GerichMcGregor told HealthSpeak. Ulla originally qualified as an Orthopaedic Surgeon in Europe and later came to Australia in 2002 as a Hand Surgeon Fellow at the Royal North Shore Hospital in Sydney. Immediately prior to arriving in the Northern

Rivers she also worked as a consultant at the Metro South Persistent Pain Clinic in Brisbane. This training and experience adds much to inform her work as a Rehabilitation Specialist. She is a Fellow of the Australasian Faculty of Rehabilitation Medicine, which is part of the RACP. “I’ve long held a dream of

NSW pharmacies’ immunisation boost From 1 January 2019 pharmacists will be able to administer a range of vaccinations to people aged 16 years and older. As well as flu vaccinations, pharmacists will be able to administer privately funded diphtheria, tetanus and pertussis vaccines, as well as the measles-mumps-rubella vaccine. The move was announced in October by NSW Deputy Premier John Barilaro and Health Minister Brad Hazzard. Mr Barilaro said expanding pharmacy vaccinations gives people more choice. “We are told that access to a GP can be difficult at times when you live in the

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city, country or on the coast, so expanding pharmacy vaccinations gives people more choice”. However doctors have opposed the move, with Australian Medical Association NSW President Kean Sean Lim saying it would further fragment healthcare. David Heffernan, President of the NSW Branch of the Pharmacy Guild, hailed the “sensible” move, saying the inclusion of the whooping cough vaccine was especially beneficial for grandparents, carers of young children and partners of pregnant women, ahead of having contact with newborn infants.

gathering together a top team of rehabilitation specialists and practitioners – including physios, OTs, speech pathologists, psychologists, surgeons, massage therapists

– the whole deal. If you like, a ‘one stop shop’ for rehab. This dream is now a reality, with The Rehab Team offering the people of the Northern Rivers comprehensive, world-class rehabilitation services. It’s a great team, with members chosen to work in a patientfocussed, holistic approach, in collaboration with GPs, specialists and other allied health professionals.” You can contact Dr Ulla Gerich-McGregor for information or referrals on mobile 0439 469 191 or fax (02) 5631 8000. More information at www. and www.

On track to eliminating HIV


n 2018-19, NSW Health is investing $21.9 million in services to strengthen HIV testing, treatment and prevention. Northern NSW Local Health District Manager HIV and Related Programs, Jenny Heslop said NSW is on track to achieving its goal of virtually eliminating HIV transmission by 2020, with a 23 per cent drop in the number of new diagnoses in NSW. “We want to see this downward trend continue and urge anyone at risk of HIV to ensure they are regularly tested,” Ms Heslop said. “Once a person is diagnosed, they can start treatment early, improve their health and prevent the virus from being passed on to others.” From January to September 2018, 191 NSW residents presented with a newly diagnosed HIV infection compared with 249 during the same periods in 2013-2017, according to the NSW HIV Data Report.

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“This reduction is due to more people seeking early testing and treatment, as well as the introduction of pre-exposure prophylaxis for HIV (PrEP),” Ms Heslop added. The highly successful NSW Health EPIC-NSW trial made PrEP available to 9,414 people at risk of HIV from 1 March 2016 to 30 April 2018. The data also shows from January to September 2018 there were 42 per cent fewer Australian-born men having sex with men diagnosed with early stage HIV infection, compared to the same period over the past five years. “HIV in overseas-born men who have sex with men as well as heterosexual men, is often diagnosed late, which can lead to avoidable HIV-related illness,” explained Ms Heslop. For information on HIV testing, visit: hiv-tes


If only he’d had a My Health Record: Peter’s story Often health professionals don’t witness the benefits for patients in having a digital health record. Here’s the story of one couple’s experience and how having a My Health Record could have made a real difference in final stages of health care. This story was told to Emma Dykes, North Coast Primary Health Network’s Community Engagement and Communications Officer, My Health Record.


s Aaron sits with a cup of coffee in his hand, he stares at the table. He tells of the ups and downs in the journey through the health system during his partner’s liver failure. Aaron says after hearing about My Health Record and how it is used now to coordinate better patient care, he wants to explain what happened to him. He encourages people to consider the ‘what ifs’ before they are faced with a complex medical situation. Aaron sees the benefits of having a My Health Record - a central point of key health information accessible to health professionals. At 70 years of age, Aaron’s partner Peter had retired and planned on spending the rest of his years travelling. Peter had not heard of, or thought about a digital My Health Record, and neither had Aaron. Unfortunately, Peter’s health took a turn for the worse. Over two years, Peter underwent a number of operations under multiple doctors and specialists and visited both private and public hospitals. As Peter’s health deteriorated, Aaron was 28

A photo of Peter when he was appearing in Kiss Me Kate.

left to battle the health system alone. Because of the complexity of Peter’s health history, Aaron wishes they had known about My Health Record. If so they could have had Peter’s health summary in one place - medications, diagnoses, allergies and test results to show new medical professionals taking over care. Aaron says that Peter had a Plan of Care with his specialist and they had talked about the declining state of his health. Peter and Aaron both knew that Peter had only months to live and they made a plan to deal with this. Unfortunately, this was not documented where Aaron or Peter could access it, and when moved to the private hospital Peter was placed under a new physician and his care plans were changed. Looking back, Aaron is most

Aaron believes having a My Health Record would have really made a difference to the coordination of Peter’s care upset about the confusion and limited transfer of information when moving between doctors. He feels that if there had been a My Health Record in place, it would have allowed him to communicate Peter’s history and wishes with the new doctors more clearly. They would have been able to access lists of Peter’s medications, health

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history, blood tests and health wishes without relying on Aaron’s memory. Aaron recalls that Peter’s wish was to die at home. He was left to advocate for Peter’s wishes, but to no avail. Aaron says that it was stressful and there was a lot of pressure on him to communicate the facts with the health professionals. Instead of the original plan, Peter was denied palliative care and continued on treatments to prolong his life. The fight continued until Peter passed away in hospital after a traumatic decline in his condition. Now, several months after Peter’s death, Aaron fights the battle of wonder. He wonders what if? What if there had been better communication? What if the doctors had been able to consider Aaron’s views? What if Peter had had a My Health Record in place that contained his Advance Care Plan, previous history, medications and test results? Would the outcome have been different? Aaron believes having a My Health Record would have really made a difference to the coordination of Peter’s care. He believes that a central information source, controlled by himself and Peter, could have made the end of life journey a smoother, more pleasant experience. Aaron now has a My Health Record of his own and has asked his health care providers to upload his information. He has also learnt how to enter his own information into the record through his MyGov account. Aaron wants to encourage everyone to consider the benefits of My Health Record. For more information visit: www. or call 1800 723 471.

healthspeak December 2018

Improving transition of care on the Mid North Coast


program to improve the flow of crucial patient information between GPs, hospitals and other care providers on the Mid North Coast is seeing more timely and better quality discharge summaries. Coffs Harbour GP, Dr Adrian Gilliland, is a key driver of a program to improve the transition of care and transfer of crucial patient information among health providers on the Mid North Coast. Adrian recently spoke with the joint Mid North Coast Local Health District/North Coast Primary Health Network (NCPHN) Project Manager, Isabel Butron, about the program’s impacts on patients and providers. Adrian is Chair of NCPHN’s Mid North Coast Clinical Council and Board member of the Mid North Coast Division of General Practice. Isabel: Patients outside of urban centres often have to wait longer or travel more to see a GP or access emergency care. When they do see a GP or attend a hospital, they often assume their care-related information flows seamlessly between GPs and hospital doctors. From our experience, what sorts of challenges surround care transfers and are there any specific issues in regional and rural settings? Adrian: Emergency Department (ED) doctors and health professionals often need to share electronic summaries that community-based GPs and nurses need to pick up and continue. In rural and remote Australia, where there are limited services and greater workforce pressures, it is even more important that GPs get timely messages about what happened to their patient in hospital or in ED and vice versa. In our project we’ve seen many examples where transfer or discharge summaries were sent but not received, and where hospitals see the same patients December 2018 healthspeak

Supporting health professionals working in rural and remote areas to communicate effectively is vital

Dr Adrian Gilliland

return due to missed opportunities in the community. Time is spent running around to get the information, while we should be focusing on our patient’s needs. Some of our patients travel a substantial distance to see us. Not knowing that the patient has been in hospital is a very serious concern. Both general practice and the hospital sector often struggle to fix these issues alone. Isabel: How did the project get input from clinicians about the challenges around shared electronic communications, and what kind of areas did it focus on? Adrian: Clinicians raised the issues and concerns in a number of forums. We heard that the timeliness and quality of the discharge summaries were inconsistent. We just didn’t know what the barriers were, nor how to go about trying to rectify the problem. Therefore, in collaboration with the PHN an our LHD, we sought to identify the barriers

and develop recommendations for improving the timeliness nad quality of discharge summaries. It seems clear that the timeliness and quality of this information is extremely critical for the safety and high standard of care our rural and regional patients receive. Supporting health professionals working in rural and remote areas to communicate effectively is vital. Isabel: What do you think has been unique in this project and have you seen benefits from this project in your own practice? Adrian: This project has had some big impacts to the Mid North Coast. We have seen stronger relationships formed between each of the hospitals and between the PHN and hospitals. Shared planning and shared solutions are contributing to better outcomes. Within my own practice we have seen an increase in the timeliness of discharge summaries coming in. We now have a concise discharge notification from our hospital Emergency

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Department. We have seen an increase in the receipt of Mental Health discharge summaries. Isabel: Finally, what is your message to our regional areas? Adrian: Safe Transition of Care is a big piece of work and we have only begun. In the future we will need to focus on primary care changes and improvements. We want to improve continuously and ensure our patients’ safety. Dr Grant Rogers, Rural eMeds Chief Medical Officer/ Clinical Lead, NSW Minister of Health Rural eHealth Program said: “With the coming implementation of the eMeds electronic medication management system to 112 public hospitals across the rural local health districts in NSW, we hope this will contribute to the quality of discharge summaries and enhance the Transition of Care efforts to date. Integrating care between Local Health Districts, Primary Health Networks, GPs and community health services is vital in improving the patient’s journey.” The Safe Transition of Care Program is continuing to set priorities locally and to look at further communication improvements between hospitals and GPs. For more information on the program, contact Isabel. This article was published with kind permission from The Pulse newsletter. 29

Hospital stays for hip fractures declining D

Hip fractures are a common result of falls, mostly at home and are associated with other conditions.

ata from the National Hospital Morbidity Database for 2015/16 shows that during this period hip fractures were managed in 50,900 episodes of hospital care across Australia. The data was compiled in a report published by the Australian Institute of Health and Welfare. During 2015/16 there were an estimated 18,700 new hip fractures among Australians 45 years and over, around 199 fractures per 100,000 population. Between 2006/2007 and 2015/16 the rate of hospitalisations for new hip fractures fell by 9.5%. in 2015/16 most (58%) were neck

of femur fractures, 38% were pertrochanteric fractures and 5.8% were subtrochanteric fractures. Just under 95% of new hip fracture hospitalisations included at least one new diagnosis. The most common were • Fluid disorders – electrolyte and acid-base balance (20%) • Anaemias (20%) • Delirium (20%) • Type 2 diabetes (19%) The 2015/16 figures show that women were 1.7 times more likely to fracture a hip than men and Indigenous Australians had a 5% higher incidence of hip fracture than other Australians.

Occupational therapy graduates making a difference every day By Lee Adendorff

Children are complex beings. We take a holistic view of every child


outhern Cross graduate and occupational therapist Emma Hoare. Photo by Regi Varghese. Learning to ride a bike is a rite of passage for most children. But not for all. For one small boy, the bicycle had become a two-wheeled torture device, a source of frustration and anxiety instead of joy. It took six months of therapy and intervention with Southern Cross University graduate and occupational therapist Emma Hoare before he could even look at it, let alone get on it. It took even longer before he learnt the underlying skills he needed to feel empowered and to control his feelings so he could make those first wobbly metres on his own. Now, thanks to Emma, he is riding to school with his siblings, just like any other boy on his street. Emma works for Empowered Kids, a Gold Coastbased consultancy owned by fellow Southern Cross University 30

Southern Cross graduate and occupational therapist Emma Hoare. Photo by Regi Varghese.

alumna Kristy Harris. The consultancy specialises in providing paediatric occupational therapy services. Emma's typical work day can include helping children to confront their food phobias or overcome a fear of failure for a task as simple as riding a bike or even to learn how to interact with others at kindergarten by ‘thinking with their eyes’ and responding to emotional cues. “There is no such thing as a typical intervention. Children are complex beings. We take

a holistic view of every child because every child is going to be different,” she said. After finishing high school on the Gold Coast, Emma worked in real estate for a year before switching to studies in nutrition. Although she enjoyed working in health, she was searching for something more. With girlfriends studying occupational therapy, Emma was encouraged to try the course at Southern Cross. “In the OT course I felt like everything we did had a point

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and a purpose which is perfect for me because I need to know why I am doing something.” As she moved through the course, paediatrics became her clear calling. “When I was at uni, if we could choose a case study I would always choose the paediatric one, even for my Honours project. There was so much that spoke to me – the Nurtured Heart approach that reinforces positive behaviours for example. “Now I’m specialising in food therapy, developing school skills, building a growth mindset and self-confidence, and developing strategies to support sensory processing challenges. No two days are the same – it’s exhausting sometimes but deeply, deeply satisfying work.” healthspeak December 2018

Should Globalisation be saved?


he Washington consensus is collapsing and under threat. This consensus - which manifests as globalisation, neoliberalism, economic rationalism and free market economics - advocates free international trade, smaller governments, less “red tape”, no subsidies, privatisation, lower taxes and a free labour market. But post GFC we now see a reaction to globalism led by President Trump. Trump told the UN in September that he rejected globalisation in favour of patriotism. We assume he means the nation state. And it’s not just words. Trump has started a trade war with China, imposed tariffs on its closest allies, withdrawn from the Paris Climate Agreement, upended the free trade agreement with Mexico and Canada, withdrawn from the Trans Pacific Partnership, threatened to leave the World Trade Organisation, threatened to abandon NATO and the nuclear disarmament treaty with Russia and to build a wall on the US-Mexican border. He has promised this will return jobs to the US, raise wages and living standards and make the US more independent to pursue its own course. This outcome is unlikely but looking around the world at Brexit, the rise of left wing and right wing populists in Europe, Asia and South America, we can see many agree with him. But should we ditch globalisation and return to nationalism? Globalism has fundamentally changed the world as we know it, with millions of people in less developed countries having been brought out of poverty. Health care has dramatically improved, people are living longer, education is becoming the norm and December 2018 healthspeak

life is much better for most. This is no mean feat and was accomplished in 30 years or less. As the middle classes in less developed countries have expanded, so too has their appetite for tourism, different foods, education and better health care. But as we know now, globalisation has its downsides. Developed countries saw their

But abandoning globalism has a huge downside. Living standards in the west would decline and we would become more insular

manufacturing industries decimated as they closed down and moved offshore. Income and wealth inequality grew dramatically in the west, in some cases obscenely so. Even today in the US the average worker has not seen a real wage increase for decades despite strong economic growth. Even displaced workers who

managed to find other jobs, have to deal with lower paid, insecure and less fulfilling work. This is mirrored, more or less, in countries including Australia. In addition most of this rapid growth has come at the cost of the environment. Climate change in particular will affect our lives in unpredictable ways. If unchecked it will be disastrous. Dealing with climate change is just one of the many areas where free markets have failed – and always will. The decision to open borders for trade and investment has seen capitalism explode. Corporations have become gigantic, tax avoidance is rampant and there is now a race to the lowest corporate tax rates. Global supply chains mean corporations can cherry pick where they source their inputs, often exploiting workers in horrific conditions. Greed is encouraged with many corporations now paying little heed to what was once considered a social responsibility to do the best by their customers and their societies. The Banking Royal Commission is evidence of that, but so are the tobacco companies and the fossil fuel corporations which put profits before human welfare and long-term survival. Those people in the West left

a publication of North Coast Primary Health Network

finance David Tomlinson behind by globalisation have legitimate grievances. Unfortunately their anger has been mixed with ugly elements of racism and xenophobia. This has to be addressed and countered. But abandoning globalism has a huge downside. Living standards in the west would decline and we would become more insular. Some are happy for this to happen. They want a return to a village lifestyle where we primarily buy local and live more modestly. But one of the biggest drawbacks is that anti-globalism has become confused with antiinternationalism. The latter is about ensuring cooperation between countries to solve global problems – such as global warming, global tax avoidance, preventing international wars and so on. The answers are not easy and going back to the nation state is probably unlikely. But we do need global co-operation to curb the excesses of globalisation. There are still many people in Africa and elsewhere living in poverty.


Institute leads the way in radiotherapy accreditation standards conformity with the standards rather than it being a voluntary undertaking. Major centres in Sydney have sought support from us on their own journey to demonstrating conformity with the standards, showing that big things do come from small packages. National implementation of the Radiation Oncology Practice Standards will benefit individual centres and the broader radiation oncology community to improve patient service.

By Stephen Manley Radiation Therapy Manager, North Coast Cancer Institute


orth Coast Cancer Institute’s Radiation Oncology services at Lismore, Coffs Harbour and Port Macquarie have been working collaboratively to meet the Radiotherapy Accreditation Standards. As an organisation, we have a high focus on quality so when the Radiation Oncology Practice Standards were published in 2011 we elected to demonstrate that we could achieve, conformity with the standards and maintain this high level within the normal business operations of a radiation oncology treatment centre. The Clinical Governance Units of Northern NSW and Mid North Coast Local Health Districts were engaged as our auditors and through their experience with accreditation they pushed us to provide evidence for the standards that demonstrated that our practices were at a level of excellence. Some of the hardest evidence to obtain required the engagement and cooperation of other hospital departments. We used an oncology electronic medical record (MOSAIQ) and the RANZCR peer review instrument to ensure that most

of the required clinical evidence was obtained through accessing routinely-collected data. To achieve conformity with the standards it was not simply a matter of ‘cutting and pasting’ as additional audits needed to be identified and performed. Despite our enthusiasm and existing systems, it took over two years to demonstrate conformity. Through the initial project of demonstrating voluntary conformity, we were able to strengthen our practices and regular auditing processes to improve our practice - the ultimate goal of any quality improvement undertaking. In 2017 we repeated the process and updated our evidence to maintain currency and relevance

to the standards. In 2018 we are working towards a system where our evidence is available and accessible “live” so that our conformity with the standards is always current and not linked to any audit cycle. This will also allow us to have various content experts conduct a “desktop review” and provide further opportunities to share our good practice and learn from others. Team members who have driven this work were invited to join a national committee and subsequently contributed to the standards being refreshed and republished in 2018. The national committee is now working on a process to ensure that all practices in Australia can demonstrate

New Guideline for assessment & diagnosis of autism The new diagnostic Guideline has been developed and published by Autism CRC with the support of the National Disability insurance Agency. The health community has been requesting a national, consistent guideline for autism assessment and diagnosis for many years and this Guideline is in response to that need. The Guideline aims to create greater consistency in diagnostic practices across


Australia to ensure individuals on the autism spectrum and their families receive the best clinical care available.

The publication also emphasises the importance of listening to individuals and their families about the impact of behaviours on family life. The Guideline’s recommendations have been approved by the National Health and Medical Research Council. To access the Guideline, go to: knowledge-centre/resource/ national-guideline

a publication of North Coast Primary Health Network


SCU’s new naturopathic medicine centre Marcus Blackmore AM has made a record $10 million personal donation to Southern Cross University. Vice Chancellor Professor Adam Shoemaker said the gift would be used to establish a National Centre for Naturopathic Medicine at Southern Cross University to engage in naturopathic medicine higher education, research, and engagement with the profession. “We aim to establish an internationally-recognised centre of excellence in naturopathic medicine education and associated research. We are proud to be the first Australian university to offer higher education qualifications in naturopathy. This will enable Southern Cross to provide distinctive career pathways and ongoing development for the profession, as well as increased research capability,” he said. Work begins immediately on the new centre with a planned opening in 2019.

healthspeak December 2018

Funky Vintage Ladder O

utside a bric-a-brac shop, among the stuff spilling onto the footpath, something caught my eye. ‘Funky vintage ladder $165.’ On closer look, yes, it was quite retro and a bit bent in the frame. It had a narrow base and narrow smooth steps. Was it being sold for climbing or just decoration? Everybody has stories of older people toppling from ladders, the resultant injuries sometimes severe, even fatal. One well known close call was Molly Meldrum at home, up a ladder hanging Christmas decorations. Toddlers tumble over all the time. It can look disastrous but more often than not they seem to bounce. I have a relative, very fit for her age who attends a seniors’ circuit training class at Sydney University gym. It’s run by Sparrow, an 80-year-old former Wallaby. He has great results improving health and fitness in his large group of retired academics, who have lived largely sedentary working lives. He has workout tee-shirts with points of guidance on the back: • Do your squats • Get set to lift • Don’t climb on ladders Sparrow is adamant on the last point as people become much more brittle with ageing and ladder climbing is a major cause of hospital admission. The figures are alarming: - In 2002, 3,374 Australian men over 60 were hospitalized for ladder falls. - In 2012 the number was 4,945 and 80% of these occurred at home. With the bulge in the boomer population, the figures are likely to get worse. It just takes one wrong step. ( au/5628-ladders-risky-forolder-men) Sparrow has a point, and December 2018 healthspeak

whether seniors should climb ladders at all is controversial. A fall from a ladder is high category risk, even from a metre off the ground, but having to consider it to be too dangerous at all puts some people in a quandary. Dr Atul Gawande in his book Being Mortal explores the issue of balance between safety and independence in residential care. Safety outranks independence, understandably. It would be reasonable to assume that most people in their 60s and

Whatever the answer, no-one could argue with Sparrow about one thing. You can never do too many squats.

70s who still use ladders are living at home. Gutters get full of leaves. A wall needs some paint. What to do? A tradesman’s visit takes a good slice out of the pension. My Sydney relative does not have a home ladder, so I asked her how she changes a light bulb. ‘Oh I just stand on a chair for that’. Right. A web search quickly found a ‘foldable

non-slip four step lightweight approved, one metre high stepladder with dual handrails’ for $70. This has to be better value than either the funky vintage or the wobbling on a chair that is not even designed for standing on. Handrails can change the game, taking us from our bipedal hominid to our evolutionary monkey form including quadruped prehensile stability. As George Orwell said in Animal Farm, ‘Two legs good, four legs better’. Closer to home, I asked a friend, a retired doctor, who admitted, yes he does climb but he is more careful and no longer climbs onto the roof, and he won’t at all if at home alone. A helper can hold the ladder and pass things. They can also call 000 if necessary. Any fall has three components, the initiating incident, the descent and the impact. Parachutists joke that descent is no problem. It’s the impact. The initiating incident may come from equipment or a health problem. Perhaps an unstable knee gives way. Descent is usually sudden and without warning and may be complicated by more than one impact en route. There is no law, so it’s up to each individual and family to future proof elders against injury from slipping, tripping or toppling. Cognition, strength, flexibility, proprioception, and

a publication of North Coast Primary Health Network

light airs David Miller

someone to steady the ladder all improve the chance of a safe landing. A history of fits, faints or funny turns is a worry and painting the ceiling is not good practice for anybody of advanced age. Vertebral artery compression could cause imbalance. Is the climber strong, flexible and balanced? Can he/ she stand on one leg? Whatever the answer, no-one could argue with Sparrow about one thing. You can never do too many squats.



Unnatural Causes The Life and Many Deaths of Britain’s Top Forensic Pathologist By Dr Richard Shepherd Penguin 392 pp $34.99


Surgery students lack stitching dexterity Roger Kneebone, professor of surgical education at Imperial College, London, says young people have so little experience of craft skills that they struggle with anything practical. "It is important and an increasingly urgent issue," said Prof Kneebone, who warns medical students might have


e long believed, in the words of early novelist E.W Hornung that dead men tell no tales. But that was before Patricia Cornwell novels started filling bookshops and series such as Silent Witness jagged the TV ratings. This beautifully penned memoir by one of the doyens of this seemingly bleak profession is a real life account of how, from the age of 13 Dr Shepherd became attracted to forensic medicine. Four years earlier his mother had died and his father, previously remote, admirably turned his hand to running their London household. One day after school a friend showed him a medical text, the third edition of Simpson’s Forensic Medicine. Many decades later, Shepherd would write the twelfth. It was “a small tatty book… full of pictures of dead people. In fact, mostly murdered people. They were strangled, electrocuted, hanged, knifed, shot, asphyxiated… no hideous fate could escape Professor Simpson.” The same would be said of Dr Shepherd, as his career progressed from investigative work on street and domestic crimes to some of the worst killings of the modern era. These included the Bali bombings, 7/7 in London and 9/11 in New York, the Clapham rail disaster and mass shootings. Early on he learned that “the high academic grades but cannot cut or sew. "It is a concern of mine and my scientific colleagues that whereas in the past you could make the assumption that students would leave school able to do certain practical things - cutting things out, making things - that is no longer the case," he added. The professor, who teaches surgery to medical students, says young people need to have a more rounded education, including creative and artistic subjects, where they learn to use their hands.

book review Robin Osborne

There was no lump of meat so like a human… than a joint of beef. forensic pathologist was called to any suspicious death at any time of the day or night…I fell in love with the way [Simpson] rushes to crime scenes, often by steam train, and then used his medical skills to help detectives reconstruct homicide, solve the unsolvable, exonerate the innocent, argue the case in court and bring to justice the perpetrator.” Meeting his own unflinching standard for anatomical dissection during medical studies, he is soon helping police solve violent crimes and giving evidence that will put culprits behind bars. Along the way he debunks various myths - “Rigor mortis is… an even less reliable basis than body temperature for estimating

A professor of surgery says students have spent so much time in front of screens and so little time using their hands that they have lost the dexterity for stitching or sewing up patients.

a publication of North Coast Primary Health Network

the time of death…” As he developed a penchant for investigating knife crime, Shepherd finds himself “stabbing the Sunday roast with a series of different knives from different angles while I waited for the oven to warm up …There was no lump of meat so like a human… than a joint of beef.” Asks his daughter “You mean Daddy that you pretended our lunch was a human person being killed?” His son adds, “My meat’s full of stab marks.” He muses that knives are very often a woman’s weapon of choice, not only because there’s one in every kitchen drawer but because no knowledge or great force is required, this being a reason why stabbers often say they didn’t think the victim would be badly injured. “The most common is the claim that ‘he ran onto the knife’…This is not always easy to prove or disprove.” While the mostly British cases he profiles are distressing, not least those involving children, he shows an admirable mix of compassion and professional detachment. His main lament is that the courts decreasingly call on detailed forensic analysis. In the new world of budget cuts, brief conclusions suffice. As he puts it, “expert opinion is marginalized by the system…. Forensic pathology was a service, but [is] no longer the intellectually rigorous world I had entered, with its scope for debate, study and social change.” Dr Shepherd examines himself as well, noting that after referral to a hospital psychiatric team he was diagnosed with severe PTSD. He believes this was not caused by any particular one of the 23,000 bodies on which he had performed post-mortems, nor a specific disaster, or all of them together. “It is caused, in its entirety, by a lifetime of bearing first-hand witness to, on behalf of everyone - courts, relatives, public, society - man’s inhumanity to man. For that, he and his ilk deserve our deepest gratitude. healthspeak December 2018

Simpler ways of managing complex trauma


he Royal Commisuse of prescribed medication sion into Institutional such as anxiolytics, antideResponses to Child Sexual pressants or other psychoacAbuse has now been followed tive drugs. by an apology from Prime The benefit of these is Minister Scott Morrison variable, with often on behalf of the nation disappointing efBy Andrew for failing and abanfectiveness. Then Binns doning the thousands there is help through of survivors of such abuse. counselling, mindfulGPs, and the allied health ness courses, yoga and other professionals they refer to, therapies, but the painful are likely to see the afterintrusive thoughts and turmath of this examination of bulent emotions are usually institutional failure. There unrelenting. will no doubt be an increasAdding meaning to life by ing number of legal cases, in volunteering, joining a club addition to the many already or taking part in any activity happening, seeking justice that brings people suffering and compensation. This will from trauma in contact with involve many victims reliving others can be helpful. But their horrific stories of abuse. one often overlooked therapy Such disclosure often leads - pet therapy or animal asto a stormy time emotionsisted therapy (AAT) - as it ally for those who have is often called can suffered from this complement complex trauma, other theraand this is pies. often among Unconditional love middle-aged develops between or older a pet and its owner people. The with significant challenge is to mutual benefit know what is helpful and what isn’t. Many would have led a life with chronic anxiety, depression and hypervigilance. This may in turn have resulted in excessive use of alcohol, cannabis or other illicit drugs. For some it may be regular

mental, physical and social Sometimes a sufferer of such trauma can identify with health benefits to their a rescue animal that may have owners. They can also be of benefit for those who are also suffered adverse experilonely, depressed or socially ence in their early developisolated. ment and this transferFor many ence of emotions anxious people can add to the there is noththerapeutic For many anxious ing more benefit. people there is calming Rannothing more than the domised calming than the purring controlled purring of a cat on of a cat on trials for their lap or walking their lap or AAT are not a dog walking a dog. performed The overactive like those by sympathetic nervous pharmaceutical system can thus be subdued companies for psychotrowith consequent lowering of phic drugs. However there is blood pressure and heart rate. plenty of anecdotal evidence Unconditional love that AAT is beneficial for any adverse event in life including develops between a pet and bereavement, veteran military its owner with significant mutual benefit. No drug, legal or injury, physical, emotional or illegal, can match this simpler sexual abuse. therapeutic intervention. Companion animals can lift the spirits and provide

Cat drawing by Jeni Binns

December 2018 healthspeak

a publication of North Coast Primary Health Network



Kids and food: advice from a paediatrician


hat should children eat? the plate and a balance of carbs, A vexing question in protein and fat for growth, body today’s dot com times. Billy Con- composition and neural developnolly summed it up nicely when ment. Again, as adults our bodies he said “I love children, but can withstand most of the I couldn’t eat a whole one”. dietary fads thrown at us, To eat an average child but children are serving By Chris Ingall today, the percentage of the god of growth, and fat would be unpalatable. need nature’s intelligence, So to discuss this, both quality not our limited version. and quantity need consideration. Trouble is, nature’s not selling. Yes we eat too much for the As an exception to prove the amount of exercise we do, and rule, the manufactured baby that is reflected in our BMIs, but foods for four-month-old babies the type of food is also can achieve a consistency critical. which is imposFat, sugar and sible in the kitchen Children are salt all sell well, (much to many serving the god as our taste buds a mother’s of growth, and accommodate chagrin). The need nature’s increasing levsilken texture intelligence, not els, so before we allows the baby our limited version realise it we need to easily protect more of them to their airway. This satisfy our palates. So means fewer false if we as adults are so easily starts for baby, and earlier sold down the river, imagine how dietary variety. easy it is for the fast food indusFrom about six months of try to sell to our children. age, babies are more able to take The modern fashion of parents a range of textures, though still sharing power with their children love the dairy-based yoghurts can provide kids with a bigger and custards, which are an easy window to make ill-informed way to give them the calcium decisions. And that is why you they need for their skeleton. Iron see so many advertisements for is the other essential at this age, foods containing added salt, and too much milk can cause a sugar and fat during kids’ primenet loss of iron from the body. time viewing. For babies from an allergic Children of all ages need plengene pool, especially those breast ty of variety, different colours on feeding, the introduction of the 36

‘big six’ food proteins - cow, soy, Adolescents, particularly boys fish, egg, nut and wheat between in their growth spurts, need 4 and 7 months of age will induce calories. It’s hard to go past meat tolerance to those proteins. and three vegies. Again, we adults And so to toddlerhood, where have the luxury of indulging ‘control’ is the watchword, with in fringe beliefs without too control of food amount and pace much damage, but growth needs best left to the child. The choice mainstream. This is why vegan of what is in front of the child is adolescents are often struggling up to the parent however, with to take in enough iron, B12 and swaps as necessary within the calories. In our part of the world parent’s list of foods. Food not certain postcodes have high rates eaten can be glad-wrapped and of (protein) allergies and (chemiput in the fridge and reheated cal) intolerances, often with poor when hunger returns, rather diagnostics, such that the cure than rewarding bad behaviour. may be worse than the disease. Cheaper too! The only over-indulged Thankfully, neurotypical substance may be water, espechildren allow a generous range cially designer, with loss of renal of foods, in comparison say to medullary gradient a possible young children with autism, who consequence. These adolescents may only allow a ‘white can then be more at risk foods’ diet, with on a hot day, esperesultant scurvy, cially if water is rickets and iron relatively scarce, Adolescents, deficiency as they cannot particularly boys in all possible concentrate their growth spurts, outcomes. their urine. need calories. It’s Primary Even with hard to go past meat school kids are water, Paraceland three vegies easier to feed sus was right; healthily now, with you can have too tuckshops focusing on much of something as foods packaged by nature. By adessential as water. olescence, we have smart phones In summary, kids need plenty and social media as platforms for of what nature has to offer, at all fast and fad foods, and of course ages, with as much variety of food a breeding ground for insecurity groups as possible, and as little of body shape, with rising rates of as possible of foods packaged by anorexia, especially in girls. humans. Good luck, parents!

a publication of North Coast Primary Health Network

healthspeak December 2018


Australia has eliminated rubella – but it can still come back T

he World Health Organisation has officially declared that Australia has eliminated rubella. Rubella (German measles) is a contagious viral disease. The symptoms in children are generally mild – fever, rash and sore throat – but infection during pregnancy can be devastating for unborn babies. Infection in the first trimester of pregnancy results in an 80% chance of miscarriage or birth defects (congenital rubella syndrome) in the developing foetus. Babies born with CRS can experience deafness, blindness, cataracts, intellectual disabilities and heart defects.

1990s there were still an average of 4,000 cases a year.

Achieving rubella elimination

Elimination is defined as “reduction to zero of the incidence An Australian of infection caused by a specific discovery agent in a defined geographical In the 1940s, Australian area”. This means there can be ophthalmologist Sir Norman no endemic circulation of the McAlister Gregg was the first virus in that area. to describe the connection Australia was verified as between rubella infection in having eliminated measles in mothers, and cataracts and 2014. We were able to “pigother birth defects in babies. gyback” our rubella eliminaThis led to development of tion efforts onto those for the rubella vaccine in the 1960s. measles by switching Before the rubella from the schoolgirl vaccination, large rubella program outbreaks were to a single-dose Even in some recorded with childhood countries with more than measles3,000 docuvaccination mumps-rumented cases programs, coverage bella vaccine in 1963-64. is so low that large (MMR) Our first outbreaks still vaccine for vaccination occur both 12-monthprogram, introold girls and boys duced in 1971, only in 1989. targeted schoolgirls, with From 1993, a second dose the aim of preventing infecwas added to capture those who tion during pregnancy and the missed the first or who weren’t subsequent risk of CRS. But befully protected. cause most infections occurred Australia made a concerted during childhood and males effort to boost MMR vaccine were not vaccinated, the rubella coverage by conducting a mass virus continued to circulate, school-based vaccination camcausing outbreaks. By the early paign in 1998. December 2018 healthspeak

Since then, coverage has continued to climb, with more than 94% of infants now vaccinated with MMR. A recent study estimated that about 92% of one to 49-year-olds were immune to rubella. The impact has been clear: in 2012-17 there were only four cases of CRS and fewer than 40 cases of rubella reported each year – a far cry from the thousands reported in the prevaccination era.

Rubella elimination status As was required for measles, Australia had to submit a detailed report to the World Health Organisation, providing evidence that rubella had been eliminated. This included proof that most of the population is immune to rubella and that vaccine coverage is high. Showing low numbers of rubella and CRS cases was also important. In the past three years, the cases of rubella identified were strains from overseas, rather than from a virus spreading within in Australia.

Elimination doesn’t mean eradication Eradication only occurs when all countries have achieved

a publication of North Coast Primary Health Network

By Associate Professor Heather Gidding, University of Sydney; Aditi Dey, Senior Lecturer, Paediatrics & Child Health, University of Sydney and Professor Kristine Macartney, Paediatrics & Child Health, University of Sydney

elimination of a disease. The only human disease to have been eradicated is smallpox in 1979. The Americas region, and five countries within our region, have been verified as eliminating rubella and CRS. But it remains prevalent in many countries. Not all countries have introduced rubella vaccination. As of December 2016, just 152 of 194 countries had introduced vaccination. Even in some countries with vaccination programs, coverage is so low that large outbreaks still occur. In Japan, more than 1,100 cases have been reported this year.

No room for complacency We need to maintain high coverage with our routine vaccination programs to ensure elimination is sustained, as rubella is still likely to be imported from other countries. Travellers should have had two MMR vaccinations before going overseas. And every effort must be made to ensure new arrivals in Australia are up to date with their vaccinations, especially women of childbearing age. Finally, to eradicate rubella we need to support other countries in our region, and globally, to strengthen their control efforts. Printed with kind permission from The Conversation – www.



What is art therapy?


f you’ve ever looked up at clouds and recognised shapes in them you would have been working your intuition and imagination by association. Images seen in random marks or shapes is one of the processes used in art therapy to tune in to the ‘true self ’, By Liz Dowling, a person’s truth. Art Therapist, Art therapy may Northern Rivers be broadly described as ‘counselling through art’ although it is primarily a non-verbal therapy in which the process of creating an artwork is more important than the end product. There is no special ability or disability required to participate in this process, no right or wrong, it is unique to the person Sometimes it may take time creating the image. Where an to understand their image so I art therapist may guide the usually suggest they keep it in process initially only the person view at home somewhere for a understands their reasons for their choices and any subsequent week in case it ‘speaks’ to them. The final part of the session responses which occur during is debriefing from the process. the artmaking. Whereas the freedom of The art therapist by necessity creativity may inspire joy, provides a safe and confidential it may also expose personal environment for clients, whether memories which need to be one on one or within a group understood and contained. This session. In demonstrating the is important as any deep issues individuality of perception may have surfaced and need to and encouraging a person’s be addressed to restore balance confidence in their selfwithin the person expression, each before leaving session becomes the therapeutic more and more The freedom of space. empowering creativity may Here the for that inspire joy, it may training and person. No also expose personal discipline in judgment memories which need or biased to be understood and psychotherapy thinking is contained and relevant imposed by the legal studies facilitator as the within the Masters person connects to course is invaluable. their emotions rather than Art therapists naturally have a their mental state. This aims to responsibility to ‘do no harm’ avoid any critical overload or and protect clients/participants overriding of their first responses with whom they are consulting. or ‘gut feeling’, inner guidance, Liz Dowling is a member of their truth. Northern Rivers Arts Health On completing their artwork, and Wellbeing. Its magazine participants are invited to style website is at: http:// discuss the process if they wish. 38 The website contains a directory of creative pursuits, profiles of art and mental health therapists and articles about arts, health and wellbeing. You can

also subscribe to the collective’s newsletter. To find an art therapist in your area, go to:

New book for patients about the medicines they’re taking If you have patients who want to know more about their medications, a new book called What Am I Taking? provides a reliable home medicines reference. The book gives medicine users, and their families or carers, essential information on drugs prescribed for them or those they’re already using. Edited by accredited consultant pharmacist Juliet Richards and peer-reviewed, it contains profiles of 100 of the most frequently prescribed drugs in Australia, representing around 75% of all PBS prescribing. Presented in clear layperson’s language, the profiles provide basic summaries of the drugs, including: • Brief explanations of

a publication of North Coast Primary Health Network

how they work • Warnings and precautions to observe • Significant drug interactions • Dosing information and instructions To purchase a copy of the book go to: https://www. products/what-am-i-taking

healthspeak December 2018

From page 22 From page 8

compared to the state average. In fact this region has the third highest rate of suicide in the state. Beyond Blue’s Deputy CEO Susan Anderson was MC for the event and explained how staff at the Tweed Hospital and the Lismore Base Hospital can now refer people to the service. The Way Back is being delivered by not-for-profit social enterprise New Horizons with support from Roses in the Ocean, a national lived experience of suicide organisation in Australia. A prior suicide attempt is the single biggest risk factor for suicide and those discharged from hospital following an attempt or suicidal crisis are 200 times more likely to end their lives. Research shows that the three months after an attempt is the most critical time for people at risk of suicide. The Way Back Support Service will provide crucial assistance during this period.

Ms Anderson said that after an attempt many people want support, but don’t have the confidence or the right information to access it. “The Way Back Support Service will ensure they are connected to the right services and support for their individual circumstances,” she said. Skilled New Horizons’ Support Coordinators will ensure that clients in a vulnerable state after attempting to take their own lives are linked up with all the care and support they need both in the health community and more broadly. The Roses in the Ocean peer CARE Companions, who have themselves a personal lived experience of suicide, offer another layer of support and understanding for the person. They are an integral part of the service. NCPHN looks forward to hearing more about the work of The Way Back Service further down the track.

Preventive Health and the NSW Heart Foundation, supports five rural towns each year to develop infrastructure and lifestyle programs for healthier living. The towns receive $15,000 funding each, with the winning town receiving an additional $5,000. Health Promotion Manager Jillian Adams said she was pleased with the outcomes for Coraki. “Much emphasis has been placed on the long-term sustainability, so residents can continue to benefit once the Healthy Town Challenge has finished.” “It is great that many of the projects are bringing the community together, which is good for mental health and social connectedness, “Ms Adams said. Following the success of the Healthy Town Challenge in Coraki, the team at Health Promotion is now considering applications for future Healthy Town Challenges.



Aboriginal health opportunities

Sharps containers Sutures, gloves, dressings etc Frequency-based or on call Servicing Far North Coast of NSW

TWEED HEADS From February 2019 long-term up to 12 months

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GP going on extended leave Phone: 6621 7431 or

Small, long-established, non-corporate private practice Wide range of local allied health & specialist support

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Gabrielle Boyce and Associates 581 Ballina Road, Goonellabah Phone (02) 6625 2888 Open extended hours

Trusted locally since 1992, at Physio Plus you’re in the right hands for: • Physiotherapy • Exercise Physiology • Occupational Therapy (Paeds) • Pain Management • Onsite gym & Pool Rehab • Custom Orthotics via Gaitscan technology • Waterproof casts/Braces/Splints • Manual Handling Training/Preemployment Screening Tony Morley, Emile du Plessis & Associates LISMORE – BALLINA – GOONELLABAH

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Physicians Rehabilitation Hydrotherapy Renal dialysis Respiratory Sleep studies

Are you making the most of your practice nurses? Scholarships available to upskill through Southern Cross University Practice nurses are a valuable commodity in a busy general practice, but often they are not working to the full scope of their skills. From March 2019, Southern Cross University is offering an online Graduate Certificate in Primary Health Care Nursing. North Coast Primary Health Network is offering a number of scholarships to eligible nurses covering 80% of tuition fees. Check the Southern Cross University website to see if you qualify for one of the North Coast Primary Health Network scholarships. Scholarship applications close on 15 February 2019. Go to: Apply online for the postgraduate Graduate Certificate in Primary Health Care Nursing here: