Project commissioned by the Department of
Health and Ageing
Evaluation of the Medical Specialist Outreach Assistance
Program and the Visiting Optometrists Scheme
Final report volume 2 –
Community case studies V0.2
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Revision History
Version
Date
Author
Modifications
0.1
26 September 2011
Jim Pearse, Deniza Mazevska,
Jesse Silverman
Initial version provided to DoHA for
review.
0.2
25 January 2012
Jim Pearse, Deniza Mazevska
Final version provided to DoHA after
editing.
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Title
Review / Signoff
Fiona Brooke
Director, Rural Outreach Services Section
Review
Kirsty Faichney
Assistant Secretary, Rural Health Services and Policy
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The following people have reviewed this document and approve its content at this point in time.
Name: Kirsty Faichney
Signature:
Title:
Date:
Assistant Secretary, Rural Health Services
and Policy Branch, Primary and Ambulatory
Care Division
Suggested citation:
Health Policy Analysis 2011, Evaluation of the Medical Specialist Outreach Assistance Program and
the Visiting Optometrists Scheme – Final report Volume 2 – Community Case Studies, Department of
Health and Ageing, Canberra.
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Table of contents
Appendix 2.a - Aurukun, Queensland .......................................................................................................................... 1
Appendix 2.b - Burnie and the north- west region of Tasmania ........................................................................ 11
Appendix 2.c - Crystal Brook, South Australia......................................................................................................... 18
Appendix 2.d - Dubbo, New South Wales ............................................................................................................... 24
Appendix 2.e - Karratha & Roebourne, Western Australia ................................................................................. 37
Appendix 2.f - Leongatha, Victoria ............................................................................................................................. 47
Appendix 2.g - Maningrida, Northern Territory ...................................................................................................... 55
Appendix 2.h – Tele-Derm, Australian College of Rural and Remote Medicine ............................................ 63
References ........................................................................................................................................................................ 69
MSOAP & VOS Evaluation | Final Report Volume 2
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Appendix 2.a - Aurukun, Queensland
Overview
Aurukun is a remote community located in Cape York, 800 kilometres by (largely unsealed) road
from Cairns, the nearest regional centre and 2,500 kilometres from the State capital, Brisbane.
The estimated population of Aurukun in the 2006 Census was 1,044, of whom 955 identified as
Aboriginal or Torres Strait Islander (Table 24). While there are a small number of outstations
around Aurukun, most people live in Aurukun itself. The ABS population estimates for 2010
show the Aurukun population at 1,216 residents (ABS 2011b). The accuracy of Census and
population estimates is an issue for remote communities like Aurukun. One of the issues
impacting estimates of the resident populations is its high mobility.
In the 2006 Census, 32.3% of the population usually residing in Aurukun were children aged
between 0-14 years, and 9.2% were people aged 55 years and over. There were 31 people aged
65 years and older. The median age in Aurukun (Aurukun Shire/Suburb) was 25 years, compared
with 37 years for people across all of Australia.
Township/ location
Aurukun Statistical
Local Area
Table 1 – Regional population statistics (2006)
Resident
ATSI
ARIA+
RemoteSEIFA
Population Population
(GISCA
ness Area
(ABS 2008)
(ABS
(ABS
2010)
2011a)
2011a)
RA5 Very
13.92
538
1,044
955
remote
% ATSI
91.4%
The nearest town to Aurukun is Weipa, which is 100 kilometres by unsealed road. For the 2006
Census, Weipa had an estimated population of 2,830, with 482 people who identified as
Aboriginal or Torres Strait Islander. The broader population of the Cape York region (which
excludes the Torres Strait) is 13,000 people, including the communities of Aurukun, Weipa,
Cooktown, Coen, Hopevale, Laura, Lockhart River, Kowanyama, Mapoon, Napranum,
Pormpuraaw and Wujal Wujal.
Freight is brought into Aurukun by road weekly during the dry season, and during the wet
season, it is brought in fortnightly by barge. During the wet season Aurukun is generally unable
to be reached by land, and supplies are either transported by ship or by air. Almost all
movements of staff and patients are by air. There is one regular daily commercial flight from
Cairns to Aurukun five days a week. The RFDS has a scheduled visit to Aurukun three times
each week, through which primary care staff are transported to and from the community.
Aurukun is a self-managed community situated on the western coast of Cape York. Founded as a
Presbyterian Mission in 1904, the Aurukun Community Council gained self-management status
in 1978 under the Local government (Aboriginal Lands) Act.
The local economy is dominated by government services. The main employers in the town are
the Community Council (which owns and manages all housing in the community), the school
Western Cape College - Aurukun Campus (P to year 10 school), the police, and an early
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childhood centre. There is also an arts centre and motel. There is a general store that sells
grocery items, meat, bread, milk and a range of fresh fruit and vegetables and is open seven days
a week. Many residents shop direct with major chains in Cairns utilising the regular freight
services for delivery.
A broader range of commercial services are located in Weipa. Several government services are
based in Weipa and provide outreach to Aurukun. Cairns is the major regional centre for Cape
York for commercial and many government services.
Since 2003, the Aurukun Alcohol Management Plan has been in effect and no alcohol is allowed
to be brought into the Shire.
Aurukun is one of four communities participating in the Cape York Welfare Reform Trial which
commenced on 1 July 2008. Work on an Aurukun Local Implementation Plan has progressed.
The Plan focuses on economic participation and health. It outlines business development actions
to increase employment opportunities for the local residents, including developing the Aurukun
Business precinct, the Three Rivers Tavern and progressing the creation of the Arts Precinct.
The Local Implementation Plan also includes the expansion the Wellbeing Centre to provide
counselling services to support people with issues such as drug and alcohol overuse, mental
health, gambling, family relationships and domestic violence issues.
Health service organisation
Aurukun is located in the Cape York Health Service (due to become the Local Health and
Hospital Network). The Network services a population of just over 13,000 people. Aboriginal
and Torres Strait Islander people make up more than half of the Network’s population (52.6%),
which is 4.5% of Queensland’s total Indigenous population.
The Network has no major referral hospital. However, there are strong linkages with the Cairns
and Hinterland health service. The Network operates two multi-purpose facilities at Cooktown
and Weipa, and 10 Primary Healthcare Centres at Aurukun, Coen, Hopevale, Laura, Lockhart
River, Kowanyama, Mapoon, Napranum, Pormpuraaw and Wujal Wujal.
The Weipa Hospital-Integrated Health Service has 12 acute beds and 10 aged care beds, as well
as an emergency department, primary health service, ambulance, allied health, and outreach and
preventative health services. In 2009-10, the facility had 522 same day and 584 overnight
admissions. The hospital is able to provide a facility in which minor procedures can be
undertaken by visiting specialist (e.g. cataract surgery, ENT and endoscopy procedures). Visiting
specialist services include ENT, dermatology, dental surgery, women’s health, ophthalmology,
paediatrics, endoscopy and mental health.
The Aboriginal health service for the Cape is Apunipima Cape York Health Council. Apunipima
has a similar geographic coverage to the Cape York heath service, but extends further south to
include Wujal Wujal and Mosman. Apunipima is a community controlled health organisation
governed by an Indigenous Board, representing the communities of Cape York. Through
Apunipima, Aurukun established the Aurukun Health Action Team in August 2008 with a
membership of 10 people. The Health Action team are also the ‘Advisory Group’ for the
Aurukun Well-Being Centre. The Centre is designed to improve the availability of health
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services. It provides a community-based approach to treating addiction and related mental
health issues, addressing family violence, reinforcing social norms and facilitating pathways out
of treatment to employment and education. The services offered include assessments,
counselling, support, case co-ordination and referrals to other services. The Centre is being
initiated under the auspices of the Royal Flying Doctor Services (RFDS) with the intention of
moving to community management over time.
The RFDS is also an important provider of primary care services in the Cape.
Aurukun is located within the Far North Queensland Division of General Practice. The Division
covers a wider area than Cape York, including the Torres Strait, the Cairns Hinterland and parts
of the Gulf of Carpentaria region (see Figure 1). It does not include Cairns. A new Far North
Medicare Local (Figure 3) will include Cairns and its hinterland, the Torres Strait, and Cape
York.
Figure 1 – Cape York Local Health and Hospital Network
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Figure 2 - Far North Queensland Rural
Division of General Practice
Figure 3 – Far North Medicare Local
Health services in Aurukun
Primary health care services for Cape York are complex. The Cape York health service plays a
key role in most communities through the two hospitals and community health clinics. These
clinics are generally the physical and organisational base through which the vast majority of
health services are delivered in these communities. Cape York employs community nurses,
including clinical nurse consultants (CNC), Aboriginal health workers, allied health staff and
other support staff.
In Aurukun, the health centre currently employs two clinical nurse consultants and three
registered nurses and one director of nursing (funded for five nurse positions), two Aboriginal
health workers (funded for nine positions1) and eight support staff (including drivers, security
and maintenance, funded for twelve positions).
One of the nurse CNC positions is specifically allocated to chronic disease issues. She has a
major role in coordinating referrals to specialists and following up patients. One of the nurses is
a school based nurse, funded through the Weipa outreach service as well as the Cape York
Aboriginal Academy.
The Aurukun Health Service is open seven days a week and provides an after-hours service.
Officially the service is identified as a public hospital, but it operates as a primary care clinic.
The MyHospitals web site shows the service had 43 same day admissions in 2009-10 and less than
Aboriginal health worker positions are for: senior Aboriginal health worker (1), sexual health (1), child health (1),
women’s health (1), general health workers (3) and trainees (2).
1
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10 overnight admissions. The service does not have ‘beds’, although patients requiring urgent
care are managed until they can be evacuated.
Patients can attend the clinic for primary care and acute medical issues or other chronic disease
issues. On attending the clinic they will be seen either by the visiting GP (four days a week) or a
nurse. Many patients attend the clinic to see visiting specialists (see below).
The Aurukun health clinic has many regular visiting staff. The RFDS has a significant role in
providing fly-in outreach primary care staff to Aurukun and other communities in Cape York.
In Aurukun, one GP flies into Aurukun on Monday and stays for two days, and a second GP
flies in on Wednesday and also stays two days. The RFDS manages chronic disease program,
funded by DoHA, which has increased general practice clinics and added new visiting allied
health services. Another initiative involving DoHA, Medicare Australia, Queensland Health, and
the RFDS involved increasing medical officer presence to five locations on Cape York Peninsula,
including Aurukun, through the implementation of the Rural and Remote Medical Benefits
Project. Through this initiative, Medical officers are able to stay overnight in the communities,
increasing the capacity to provide a more comprehensive primary medical service compared with
a fly-in fly-out service.
The RFDS also employs and flies in child health nurses. There are typically two nurses on the
ground in Aurukun and surrounding community for four days a week (there are three positions
with two nurses on the ground and one relieving). The child health nurses work with schools to
undertake child health checks. They receive referrals (from the checks and clinic) and they
follow up children and families.
The Well-Being Centre, which is managed by the RDFS in conjunctions with Apunipima, has
three positions (one vacant) related to community counselling and community development.
Visiting medical specialist services
Visiting specialist services are delivered through a combination of public hospital staff specialists,
largely based in Cairns, and some private practitioners.
Table 2 – Visiting health services – Aurukun
Specialty/Service
Number of
Number of
visits per
days in
year
community
per visit
RFDS – General Practitioners
52
4
RFDS - Rural Women's GP Service (GPs)
RFDS – Child Health Nurses
50
4
Mental Health Adult Psychiatrist (MSOAP supported)
4
4
Mental Health Clinical Nurse Consultant
Child & youth mental health and ATODS 2, CYMHS3), Health
workers (2)
Child & youth mental health clinician (MSOAP supported)
12
4
Dentist Team – Cairns
12
1
Dentist Team – Weipa
10
5
2
3
Estimated
number of
patients seen
per visit
Approx. 50
10
Approx. 40
25
10
10
3
20
Alcohol Tobacco and Other Drug Services
Queensland Health, Child & Youth Mental Health Service
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Specialty/Service
Number of
visits per
year
2
Number of
days in
community
per visit
1
Estimated
number of
patients seen
per visit
10
Australian Hearing (Audiologist)
ENT surgeon (also provides surgery services for Aurukun
residents in Weipa) (MSOAP supported)
Paediatrics (transitioning to Apunipima) (MSOAP supported)
General Medicine Outreach (MSOAP supported)
Frogs
Family health team CYHSD4 (CNC, Advanced Indigenous Health
Worker, an advanced School Youth Indigenous Health Worker)
Family health team CYHSD5 -Social worker/Child protection
liaison
Obstetrics and Gynaecology specialist
Women's Health Worker - Apunipima
Dermatology
Chest Clinic
Podiatrist (Apunipima - Healthy Lifestyle Program)
Diabetes Educator (Apunipima - Healthy Lifestyle Program)
Dietitian Educator
Endocrinologist (MSOAP supported)
Optometrist (VOS Supported)
Ophthalmologist (Plus visit to Weipa for eye surgeries)
HACC Assessment Clinical Nurse
Qld Health Occupational Therapist
Qld Education Occupational Therapist, Speech Pathology
8
1
30
8
8
6
1
1
1
15
20
50
2
12
2
20
6
1.5
10
2
2
1
4
3
1
2
2
13
11
20
20
3
Note: This table represents information collected through MSOAP national data and data collected during the site visit to Aurukun. It may not capture all visiting
services.
The specialist physician visits around eight times a year together with a physician registrar, a
paediatrician and post graduate medical students on an outreach rotation. The specialist
physician (Dr Clive Hadfield) and paediatrician (Dr Richard Haezlewood) have been regularly
visiting Aurukun for over 20 years. Both doctors are based at Cairns Hospital. Both visit a
range of communities across the Cape, Torres Strait and Cairns Hinterland. They initially
established the visiting service in response to needs identified in these communities and through
their clinical practice in Cairns. Dr Hadfield provides a visiting service for two days every
fortnight with an overnight stay. Every other fortnight he makes a day trip to Cooktown. Two
other general physicians in the Division of Medicine at Cairns Hospital also make outreach trips
from Cairns. Together, the three general physicians cover the communities of Aurukun,
Napranum, Weipa, Bamaga, Thursday Island, Hopevale, Wujal Wujal, Lockhart River, Cohen,
Pormpraaw, Kowanyama, Cooktown, Mapoon, Laura. Eight visits were scheduled for Aurukun
in 2011. Visits to all communities are scheduled approximately four months prior to the
commencement of the calendar year, and changes to the schedule are relatively rare. Clinic staff
commented about the reliability of the outreach service.
Dr Hadfield also holds a commercial pilot’s licence and has been the pilot for the visiting team
over this period of time. The flight to Aurukun is a charter flight and will typically take Dr
Hadfield, Dr Haezlewood, a registrar, post graduate medical students and other visiting services
4
5
Queensland Health Cape York Health Service District
Queensland Health Cape York Health Service District
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(e.g. allied health services). The team leaves Cairns around 7 am and gets into Aurukun around 9
am. The team then flies on to Weipa where they stay overnight, and typically will provide other
outreach services to Napranum (which is near Weipa), before returning to Cairns on the evening
of the second day.
As mentioned above, both Dr Hadfield and Dr Haezlewood have been visiting Aurukun for
more than 20 years. They are known by most members of the community. The continuity of
their involvement with the community was considered to be a key factor in their effectiveness in
working with people in the community.
The visit we attended was Dr Haezlewood’s last visit to the community supported through
MSOAP. In future, the outreach service for paediatrics will be provided by a Community
Paediatrician, who has recently been employed by Apunipima.
On the day we visited the community, an outreach eye team involving Dr Mark Loan (an
ophthalmologist) and Rowan Churchill (an optometrist) was also visiting. The team also
involved the Regional Eye Health Coordinator (Noel Rofe) who is employed by the Cairns based
Wuchopperen Health Service. The team has been operating since 1998, supported by
Wuchopperen Health Service, created following the recommendations of the Taylor report that
established Regional Eye Health programs with separately funded Eye Health Co-ordinator
positions. The outreach team is also supported through funding from Queensland Health, which
has a Memorandum of Understanding with Wuchopperen Health Service. The outreach service
built on a service originally developed in 1995 under the auspice of the Fred Hollows
Foundation (Brian 1997). The arrangements for the Cape for eye health services have been
described by Turner et al. (2011).
Dr Loane generally makes two visits to the Cape each year. The first visit, accompanied by the
optometrist, involves general eye examinations, providing laser treatment for patients with
diabetic retinopathy (using portable equipment), prescribing glasses, advising on basic eye care,
identifying and preparing patients requiring surgery, and undertaking other follow up. Aurukun
and several other communities are visited over the period of the week. The optometrist travels
with the Regional Eye Health Coordinator three times per year to each community to assess all
patients and to create a list of patients with pathology that need to see the ophthalmologist, who
travels with the team on one of these visits (the mid-year one). Surgery is performed after the
mid-year trip and at the end of the year, the optometrist trip serves as the surgical aftercare visit.
Through this system the patient only requires one trip away for cataract surgery and no trips for
most other procedures as they are treated in the community, unless they require acute care. The
system was worked out during the early stages with the Fred Hollows Foundation and remains
effective today. Generally, four days of optometry are required for every one day of
ophthalmology.
In a second visit to Weipa, cataract and other procedures will be undertaken, with patients from
Aurukun and other communities assisted to travel there. A charter flight will be arranged and
patients will be ferried to Weipa in groups of four to five on the morning of the surgery. They
will be admitted to Weipa hospital, have the surgery, and stay overnight prior to being
transported back the following day. Surgeries will be undertaken over a week at Weipa hospital,
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with around 70-80 surgeries performed in the period.6 A follow up outreach visit to Aurukun is
undertaken by the optometrist one to two months after the surgery week.
Both the visiting ophthalmologist and visiting optometrist bulk bill patients to Medicare, or if
details cannot be obtained, provide the service free of charge. They both work in private practice
and Medicare billing is the principal source of income for the outreach service along with the
dispensing of glasses, which is mainly through public funded spectacles scheme operated by
Queensland Health and also some private spectacles. The outreach ophthalmology service has
not been supported under MSOAP, except for assistance with equipment, which is provided
through IRIS. Support for travel is provided by Queensland Health. The outreach service
provided by the optometrist is supported under VOS, although under a specific arrangement.
The optometrist works exclusively through providing outreach services to localities in
Queensland remote regions, and does not have a base practice. He has been providing this
service to remote Queensland since the mid-1990s.
An endocrinologist has visited twice a year, but this recently increased to four times a year. For
the next clinic, this service will be provided as a telehealth arrangement. The specialist physician
who visits more regularly also provides consultations for many of the patients with diabetes.
An ENT surgeon visits Aurukun and provides minor surgery in Weipa. The clinic staff
coordinate a list of children requiring ENT surgery, liaising with parents and the school. The
clinic organises a charter flight with groups of patients (of about 10) to Weipa to receive the
required procedures and flies them back the same day.
Other visiting services supported under MSOAP include an obstetrician/gynaecologist (every
two months), an adult psychiatrist (every three months), a child psychiatrist (every six months)
who travels with a child mental health team and a dermatologist (every six months). Follow-up
surgical services are provided in Weipa, which avoids patients having to travel to Cairns. These
may also be supported under MSOAP.
Other visiting services
A diabetes team, including a podiatrist, a GP and a diabetes educator, visits two days per
fortnight from Weipa. The team is funded under the Healthy Lifestyle Program and is run by
Apunipima. The GP and podiatrist see a relatively large number of patients. However, the
service relies on the CNC to coordinate referrals and reminders.
Other visiting services include dentists from Weipa (one week every month) and Cairns (one day
every month). A family health team based in Weipa and Cairns visits regularly. The team
It is interesting to compare the current arrangements with those that applied prior to the outreach service as
described by Brian (1997 p 128): “The Queensland Trachoma and Eye Health Program (QTEHP) provided the bulk
of ophthalmic service to the Cape. Generally, this involved a community visit every second year, although some
communities were reportedly seen less frequently, Typically visits consisted of ocular examination and refraction for
spectacles. The latter formed the bulk of the work. Patients requiring cataract surgery and ocular laser for diabetic
retinopathy were added to southern, usually Townsville, public waiting lists. …Most of these patients required at
least three trips south, one for investigation and addition to the waiting list, one for surgery, and another for post
operation follow up. Travel required patient escorts. The approach was not meeting the caseload. It was not
uncommon for the QTEHP ophthalmologist to examine Cape patients who had been added to a southern waiting
list at a previous QTEHP visit.”
6
MSOAP & VOS Evaluation | Final Report Volume 2
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includes a CNC (a midwife), an advanced Indigenous Health Worker and a School Youth
Indigenous Health Worker. The visit to Aurukun from Weipa occurs two days a week. A social
worker/early intervention/child protection liaison officer visits Aurukun monthly. There is also
a visiting sexual health service from Weipa.
Organisational factors impacting on visiting specialist services
Specialist services are delivered through a combination of public hospital staff specialists, largely
based in Cairns, and private practitioners. Where possible patients are bulk billed under
Medicare, but this is often very difficult to achieve.
A white board in the clinic is used to record all visiting services. In addition, the RFDS
maintains an electronic calendar/database (http://www.rhsd.com.au/). This was not completely
up to date. As mentioned previously, some of the long standing visiting services (e.g. by Dr
Hadfield) are scheduled around four to five months prior to the beginning of the calendar year.
Other visiting services are usually scheduled in advance, but generally closer to the time of the
visit. The health service manager generally accommodates all requests, but at times there will be
significant pressures on available space. On some occasions visiting services arrive without prior
warning.
Within the community, accommodation options for visiting and local staff are very limited and
in high demand.
The clinic has six rooms for consultants, which are often under pressure when several outreach
services are visiting at the same time. For example, on the day Health Policy Analysis visited
there was an ophthalmologist, an optometrist, a paediatrician, a general physician, a physician
registrar, two medical students, the RFDS GP, an RFDS child nurse, an occupational therapist, a
rheumatic heart disease registered nurse undertaking an audit, three members of the family
health team from Weipa/Cairns and others. The local and visiting staff are generally flexible and
will ensure visiting specialists can be accommodated in some way.
Referrals to specialists are managed through both the Queensland Health electronic patient
management system (Ferret) and an appointment book through which patients identified for
follow-up or referral are recorded.
Prior to a visit, patient lists will be identified and sometimes discussed/communicated to the
visiting specialists. Paper invitations are prepared in the days prior to the visit, often by the
CNC. These are distributed on the morning of the visit, usually by the driver of the health
service. During the day a large number of patients will be transported to the clinic, particularly
where a visiting doctor, GP or nurse indicates it is important for someone to be seen.
Of the people identified on a patient list, typically around 50% will attend.
Effectiveness of visiting services
Local and visiting staff were asked about their views of the effectiveness of the visiting services.
Issues highlighted were:

That vast majority of visiting services are highly valued.
MSOAP & VOS Evaluation | Final Report Volume 2
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



The continuity of visiting staff has a very significant impact on the effectiveness of
service delivery. Visiting staff get to know the community and its challenges and
customs, the issues with particular patients, local staff, and the systems used by the local
primary care service. The community and patients are also able to develop a rapport
with the visiting service providers, which impacts on their willingness to change
behaviours and accept treatment. It was noted that often it is the specialist providing
continuity in service delivery, with a high turnover of other staff.
The continuity of remote area nurses was noted as an important issue for visiting
specialists. Remote area nurses who have been in the community for a longer period of
time were much more able to understand and work with the community and patients,
similar to the issues identified above. New staff often find working in remote
communities difficult and confronting. The visiting specialists believed that better
approaches were needed to attract and keep people in these roles.
Aboriginal health workers were seen as being extremely valuable in helping visiting
services working with patients and their families. In Aurukun there were only a small
number of Aboriginal health workers, although there are several vacancies.
Coordination of services on the ground remains a challenge. As mentioned above, on
some days there are many visiting services in the clinic. This puts pressure on the local
service, including the driver. Often clinical staff (such as the chronic disease CNCs) are
spending considerable time involved with coordinating matters prior to and after a visit.
Assessment of need and gaps in specialist services
Local staff commented on a number issues related to assessing needs for visiting services in
Aurukun. They did not believe they had been consulted on needs previously, and that input on
these issues had typically been handled by others in the health service. They were not aware of
and had not participated in a regional advisory forum for MSOAP.
Particular priorities identified included:



expansion of paediatrics and ENT.
extend GP coverage to five days a week.
more focus on chronic disease through extending relevant specialties.
It was commented that chronic illness prevalence seems to have increased in the community, but
only because issues are now being picked up. Previously they were not being diagnosed.
Local staff and the paediatrician commented that the clinical issues in child and adolescent health
were changing. Overall, health in children in the community had improved with the
introduction of alcohol management and the welfare reforms which had significantly improved
school attendance. However, a range of behavioural and mental health issues were beginning to
emerge. They felt there were gaps in the outreach child and adolescent mental health services
that needed to be considered.
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Appendix 2.b - Burnie and the northwest region of Tasmania
Overview
North-west Tasmania is a large and expansive region covering an area of 22,492 square kms,
which is approximately one third of the total area of Tasmania. It is renowned for its unique and
diverse environment, including rugged mountainous areas, extensive forests, old mining towns
and abundant farm lands. There are just over 100,000 people living in the North West region.
Figure 4 – Location of Burnie
Burnie is one of the more populated townships in north west Tasmania, and is 302 km to
Hobart by car. The Burnie-Somerset urban centre/locality recorded 19,160 people in the 2006
Census, of which 945 (4.9%) identified as Aboriginal and/or Torres Strait Islander (Table 3).
The north west of Tasmania is dispersed; it is comprised of pockets of townships with fair
distances between them. For example, there is a two hour drive between Burnie and
Queenstown. Most of the population lives along the coast. There are often single roads and no
public transport. Therefore, the populations within each of the townships are isolated in many
respects.
The north west region has the second highest ageing population in Australia. It has a low
socioeconomic status, and has high rates of obesity, diabetes, smoking, teenage pregnancies,
heart disease and chronic disease.
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Township/ location
Burnie (C) - Pt A
(Statistical Local Area)
Burnie (C) - Pt B
(Statistical Local Area)
Somerset
Table 3 – Regional population statistics (2006)
ARIA+
Remoteness Area
SEIFA
Resident
(GISCA
(ABS
Population
2010)
2008)
(ABS 2011a)
922
16,996
2.74
RA3-Outer regional
Waratah/Wynyard (M) Pt A (Statistical Local
Area)
ATSI
Population
(ABS 2011a)
814
%
ATSI
4.8
3.73
RA3-Outer regional
980
2,056
70
3.4
2.74
RA3-Outer regional
901
3,078
143
4.6
3.25
RA3-Outer regional
923
10,903
584
5.4
Health service organisation
There are two larger hospitals located in the north west region of Tasmania – North West
Regional Hospital and Mersey Community Hospital. North West Regional Hospital is the third
largest hospital in Tasmania Mersey is the fourth largest.
Table 4 – Profile of local hospitals
Township/location
Surgery?
No. of beds
Overnight
admits (0910)
5,964
ED?
Care types
100-200
Same day
admits (0910)
2,698
Burnie (North West
Regional Hospital)
Yes
Yes
Acute, rehab, sub and
non-acute
Latrobe (Mersey
Community Hospital)
Yes
50-100
4,295
4,200
Yes
Acute, rehab, sub and
non-acute
The catchment area for these hospitals includes Deloraine, Burnie, Wynyard, Smithton,
Rosebery, and Queenstown.
Other hospitals within the north west region are:




King Island District Hospital and Health Centre
Rosebery Community Hospital
Smithton District Hospital
West Coast District Hospital at Queenstown.
These are small community hospitals, generally staffed by GPs. In addition, a purpose-built GP
clinic has been developed, as well as a ‘health precinct’ in Sheffield, a township outside of
Devonport. It has been funded through Commonwealth funding (which was for the capital
component, to refurbish an old school). The health precinct will provide a variety of services in
addition to general practice, the most needed one (according to the community) being obstetrics
and gynaecology.
The nearest principal referral hospital to the north west is in Launceston, located approximately
148km by car from Burnie.
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Tasmanian Health Organisations (THOs) are the names being given to Local Hospital Networks
in Tasmania. North West Regional Hospital, Mersey Community Hospital and the other facilities
listed above are in the North West THO.
The division of general practice in which Burnie is located is the North Western Branch
Network of the Tasmania Medicare Local. There are 28 general practices within this Division,
with approximately 105 GPs. Within Burnie and surrounds (i.e. including Wynyard, Sommerset
and Penguin) there are approximately five to six practices with about 20-25 GPs.
Local staff reported a generally good relationship between the hospitals and GPs. For example,
the North West Regional Hospital and Acute Services employs a GP liaison officer. Also both
of North West Regional and Mersey Community Hospital work closely with GP North West.
Meetings are held regularly between the senior staff at the two hospitals and representatives from
GP North West.
Health services in north-west region
The two larger hospitals in the north west region provide a range of medical and surgical
services. They have been established to work together, with the Mersey Community hospital
being the elective, high volume, low complexity arm of the network. A profile of the services
delivered by the hospitals in 2009-10 is shown in the Table below.
Table 5 – North West Regional Hospital and Mersey Hospital admissions 2009-10
Service area
North West Regional Hospital
Mersey Community
Hospital
Childbirth
Medical (emergency)
Medical (other)
Surgical (emergency)
Surgical (other)
Same day
admissions
Overnight
admissions
Same day
admissions
Overnight
admissions
259
1,429
38
972
<10
2,414
1,644
518
1,388
10
266
2,689
22
1,308
420
1,492
1,634
121
533
* From MyHospitals website
The North West Regional Hospital has about 160 beds, of which 98 are inpatient beds. Others
are for day procedures and mental health. There are approximately 26,000 attendances to the
emergency department annually. This is about the same as Mersey. It has an intensive care unit,
and provides the more complex procedures for the region. Most of the region’s medical/
surgical workforce is in this hospital, and also provides services to the Mersey Hospital.
The Mersey Hospital has about 90 beds. It does not have an intensive care unit, only a high
dependency unit. As mentioned above, it has been streamlined to deliver less complex
procedures for the region, including endoscopy and gastroenterology (although these are also
provided at North West Regional Hospital), and ophthalmology and gynaecology. It mainly has
career medical officers (CMOs) (except for 0.5 FACEM).
Medical specialities offered within the region include:

general medicine
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


respiratory
endocrinology
cardiology (but only as a special interest area for a general physician).
Surgical specialties provided within region include:




orthopaedics
general surgery
obstetrics and gynaecology
gastroenterology.
The frequencies within which various clinics are conducted are in the Table below.
Table 6 – North West Regional Hospital frequency of specialist outpatient clinics
Specialty
Frequency of clinics
Diabetes Educator
Dermatology
Dietetics
Endocrinology (Paediatrics)
Endoscopy
Epilepsy
Genetics
Haematology
Medical
Neurosurgery
Oncology
Orthotics/Prosthetics
Pacemaker
Paediatrics
Paediatric Asthma Clinic
Paediatric Cardiology
Paediatric CF Clinic
Paediatric Diabetes Clinic
Paediatric EEG
Pain Management
Radiation Oncology
Respiratory
Speech Therapy
Stomal Therapy & Breast Care Nurse
General Surgery
Orthopaedic Surgery
Gynaecology
Jack Jumpers (Nurse Clinic)
Cardiology (Nurse Clinic)
Daily
Monthly
Twice Weekly
6 Monthly
Weekly
Monthly
4-monthly
Monthly
Weekly
Rotate on a monthly basis
Bi-weekly
Daily
Fortnightly
3 clinics per week
Monthly
3 Monthly
3 Monthly
Fortnightly
Weekly
Fortnightly
Bi-Monthly
Daily
Daily
Various – as frequent as weekly
Various – as frequent as twice weekly
Weekly
Weekly
Various, up to 4 times a week
There are waiting lists for many of these clinics.
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Visiting medical specialist services
Visiting medical specialist services to Burnie, supported under MSOAP in 2009-10 are shown in
Table 7 below.
Table 7 – Visiting health services – Burnie, 2009-10
Visits per
year7
No. of
patients8
ATSI
Patients
Dermatology
12
116
0
Physician - Endocrinology
12
0
0
Physician - Haematology
12
132
0
Physician - Neurology
12
75
0
Physician - Oncology
48
223
0
Physician - Palliative
26
249
0
Physician - Respiratory
12
128
0
Psychiatry - Forensic
15
8
0
Psychiatry - General
12
97
7
Psychiatry - General
12
62
0
Psychiatry - Geriatric
12
72
0
Specialty
Note: This table represents information collected through MSOAP national data and may not capture all visiting services
All these services visit at the North West Regional Hospital or at the private hospital (which is
subcontracted by DHHS to provide services to public patients for some specialities); none are to
Mersey Community Hospital at the moment. Visits to Mersey are from Launceston General
Hospital, and they include vascular surgery (once a month) and urology (weekly). MSOAP visits
to the local private hospital are for obstetrics and midwifery.
Visiting specialists mainly provide outpatient services, but also consult in relation to inpatients.
They also provide a consultation liaison role outside of their visits (e.g. the oncologist is accessed
regularly outside of their visit).
Most visiting specialists are from within Tasmania, but some also come in from elsewhere,
particularly Melbourne.
Organisation of accommodation and travel for some visiting specialists is done by the hospital,
and some by the specialists themselves. For example, specialists from Launceston and Hobart
tend to make their own arrangements, while arrangements are usually made locally for the others.
Visits for any year are mapped out at the beginning of the period.
North West Regional Hospital organises its own visits, and Mersey also does its own. For the
other district hospitals within the region, this is done by the clinic managers at each site.
North West Regional Hospital is trying to make better use of telemedicine. A paper is currently
being prepared around this to be presented at a regional level. There is currently poor use of
telemedicine for clinic to clinic services (i.e. patient sitting in a clinic on one end receiving a
service directly from a clinician at the other end).
7
8
Per annum (2009-10)
During the period from 1 January 2010 to 30 June 2010
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Telemedicine is currently used in a significant way for burns in the region. There are also plans to
use it for diagnostics on King Island, and also, for pre-admission for neurology.
In addition to visits to deliver services to patients, the region, through GP North West, has also
been successful in obtaining funding for visiting specialists to upskill local GPs. This was in the
areas of endocrinology and geriatrics. The geriatrician has worked with GPs as well as aged care
facilities. A comment was made that a targeted approach to upskilling such as this is important,
as it is unlikely to occur with specialists trying to deliver this alongside patient care. Also, GPs
cannot easily access specialists who deliver services in the hospitals for upskilling purposes.
Organisational factors impacting on visiting specialist services
Attracting medical specialists to work in the north west of Tasmania is an issue. The populations
in many places are small, and do not justify a full time person. Although the region is not remote,
the dispersion of the population means that there are rarely opportunities to keep specialists
occupied full time.
Another issue impacting on visiting specialists is flight times in and out of the region. Specialists
usually fly into Devonport, which is the closest airport to the region. The flights from
Melbourne do not get in until well into the morning, and leave in the late afternoon, which only
provides a short time for specialists flying in and out in the same day to be ‘on the ground’.
Clinic space is also an issue. North West Regional Hospital has 12 clinics from which visiting
specialists operate. There is a lot of pressure on rooms on Tuesdays to Thursdays, as many
specialists prefer not to come in on Mondays or Fridays.
Effectiveness of visiting services
MSOAP is vital for Burnie and the north west region because of sparse geography.
Patient numbers should not always be the justification for a service. In some instances, numbers
might be low due to a low population base, but the service is still needed.
In addition, flexibility is required for visiting services within the funding provided. That is, if one
service falls through, local health services should be able to use the funds for another needed
service.
Assessment of need and gaps in specialist services
Assessment of need is mainly done through examining the issues for which patients present to
emergency departments, and also through GP referrals. GPs in particular have expressed the
need for a geriatric specialist, mainly around dementia management.
Sometimes a community will raise the need for a particular speciality through their local MP.
Palliative care is one of the specialities for which need has been expressed in this way. Another is
endocrinology, specifically in relation to diabetes.
This need is then discussed locally, and raised with DHHS (as the fundholder) to develop
proposals for services.
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However, the approach to need was described as non-strategic, especially in relation to
competing needs. That is, it was felt that there was no overall strategic direction on how needs
are prioritised.
Palliative care is a need area in Burnie and surrounds, yet this specialty is struggling. This is due
to low patient numbers. The service is provided in people’s homes, and the time taken to do this
means that only very low numbers can be accommodated. Therefore, it is not attractive to
specialists financially. Usually there are two palliative care specialists providing services in the
area, but currently there is only one practicing.
Other gaps are:










neurology (particularly for stroke and degenerative disorders)
neurosurgery
ophthalmology (there is currently only one provider in the region, with very high waiting
times)
rehabilitation (particularly around people with strokes and degenerative disorders)
thoracic surgery
cardiothoracic surgery (although cardiothoracic/cardiology patients are able to be
followed up locally due to local general physician with cardiology skills)
geriatrics and psychogeriatrics
paediatric specialities, particularly ophthalmology and psychiatry/psychology (e.g.
behavioural issues in children is a big issue; there is a paediatrician locally with an interest
in this area, but the waiting list is high)
disability services for under 65s is an issue, for example, for people with Huntington’s
and other motor neuron diseases
pain management (this is only available in Hobart, and the largest difficulty is that some
pain management drugs are only available through a script by a pain specialist rather than
any other specialist, thereby limiting access to anyone who cannot see the specialist in
Hobart).
Eating disorders is a gap for the whole of Tasmania; patients have to travel to the mainland to
receive this service. Other services not available within Tasmania, which are not expected due to
the low population base, are high end treatments/surgery for cancer, heart problems and brain
injury or tumours. These are mostly available through Melbourne.
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Appendix 2.c - Crystal Brook, South
Australia
Overview
Crystal Brook is a small town of 1,185 people (according to the 2006 census) located in a region
with a well-developed agricultural industry. Including people living in the township and the
immediate vicinity, there were 1,549 people resident in 2006. The population in the local SLA
(Port Pirie Balance) was estimated as 3,532 in 2006.
Crystal Brook is located 199 kilometres north of Adelaide. There are several towns in the region
around Crystal Brook. Port Pirie is a small city with a resident population of 13,610 people,
which is located 29 kilometres from Crystal Brook. Other towns include Gladstone (population
764), Georgetown (population 119), Spalding (population 303), Jamestown (population 1,407)
which are all within 50 kilometres. Clare (population 3,063) is 77 kilometres away.
Of the estimated population of Crystal Brook in the 2006 census, 25 identified as being of
Aboriginal or Torres Strait Islander origin (Table 24).
Figure 5 – Location of Crystal Brook within South Australia
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Township/ location
Crystal Brook (state
suburb)
Port Pirie C Districts
(M) Balance SLA
Port Pirie C Districts
(M) - City
Port Pirie C Districts
(M) - City and Port
Pirie C Districts (M) Bal
Table 8 – Regional population statistics (2006)
ARIA+
Remoteness
SEIFA
Resident
(GISCA
Area
(ABS 2008)
Population
2010)
(ABS 2011a)
RA3 Outer
2.70
957
1,549
regional
RA3 Outer
970
3,532
regional
RA3 Outer
884
13,610
regional
2.72
RA3 Outer
regional
902
17,142
ATSI
Population
(ABS 2011a)
% ATSI
25
1.6%
46
1.3%
351
2.6%
396
2.3%
Health service organisation
Crystal Brook falls within the Country Health South Australia Local Health Network (LHN),
which covers all areas outside of Adelaide. The LHN services a very large geographic area,
operating through a network of 65 country hospitals and health centres. Crystal Brook is in the
mid north of country South Australia, for which the main health hub for the area is the Port
Pirie Regional Hospital and Health Service. In additional to Port Pirie, there are several small
hospitals/health services in towns in the near vicinity including:






Burra Hospital and Health Services
Clare Hospital and Health Services
Gladstone Health Centre
Jamestown Campus
Laura Campus
Port Broughton District Hospital and Health Service.
Geographically Port Augusta is the largest hospital near Crystal Brook (111 kilometres), all
referrals out of Crystal Brook are either to Port Pirie or Adelaide hospitals (principally Royal
Adelaide Hospital). Patients may be referred to Port Pirie to access visiting specialists that do
not visit locally, such as ENT.
The division of general practice in which Crystal Brook is located is the Mid North Division of
Rural Medicine. The Division’s geographical coverage extends from just north of Adelaide
through to the north east covering an area of approximately 62,000 square kilometres. It does
not include Port Augusta. There are two major population centres in the Division’s boundaries
Port Pirie and Clare. The region has a population of approximately 46,000, mainly distributed
sparsely across many small towns and 17 medical practices. GP coverage within the Division is
reported to be close to the average for Australia.
Crystal Brook will be part of the Country North Medicare Local, which include most of country
South Australia north and west of Adelaide.
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Health services in Crystal Brook
While the hospital in Crystal Brook generally services people from Crystal Brook and Red Hill,
the outpatient specialist services have a wider catchment area that includes Hawker, Orroroo and
Wallaroo.
Crystal Brook has one GP practice (Crystal Brook Medical Practice) with three FTE GPs.
Crystal Brook has a hospital with a small number of beds. Medical coverage for the hospital is
by the GP practice which is co-located with the hospital. There are about 500 separations per
year. It offers aged care, GP-type emergency services, obstetrics and outpatient services. The
hospital provided both day and overnight admissions, with about 20% of admissions being same
day. There is no surgery done at the hospital, except for simple procedures generally performed
by the local GPs. There is no mental health care available within the hospital. Most procedures
are performed at the hospital, and some, such as echocardiogram and electrocardiogram (ECG),
are also done in the medical practice.
A diabetes educator is employed in the hospital for two days a week (and works in other
surrounding areas for the remainder of the week). The hospital also has access to a
physiotherapist, a dietitian and a podiatrist, who all visit from Port Pirie.
Figure 6 – Crystal Brook Medical Practice
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Visiting medical specialist services
Visiting medical specialist services to Crystal Brook supported under MSOAP in 2009-10 are
shown in Table 9 below.
Table 9 – Visiting health services – Crystal Brook, 2009-10
Visits per
year
Patients
ATSI
Patients
Physician - Rheumatology
11
170
<10
Physician - Cardiology
11
393
<10
Physician - Endocrinology
16
324
<10
Psychiatry - Child and Adolescent
11
111
<10
6
37
<10
11
341
<10
3
<10
0
11
404
<10
Physician - Palliative
1
29
0
Physician - Palliative
0.4
0
0
Ophthalmology - General
11
360
0
Riverton
Physician - Palliative
0.4
<10
0
Spalding
Physician - Palliative
0.4
0
0
Auburn
Clare
Physician - Palliative
0.4
0
0
Physician - Palliative
0.4
0
0
Physician - Endocrinology
11
93
0
Psychiatry - Child and Adolescent
11
96
0
Psychiatry - Adult
11
101
<10
Town
Crystal Brook
Specialty
Psychiatry - Adult/Child and Adolescent
Physician - Gastroenterology
Physician - Rheumatology
Port Pirie
Dermatology
Jamestown
Note: This table represents information collected through MSOAP national data and may not capture all visiting services
Services which are not offered within the region for which patients travel to Adelaide include:




neurosurgery
spinal injury
general physician (for patients with multiple complex problems)
general surgery.
GPs in surrounding areas are informed about specialists visiting Crystal Brook either through
word of mouth, or through continuing professional development. The medical practice at
Crystal Brook is informed about visiting services in Port Pirie in particular in a similar way.
Some specialists require the medical practice to take their bookings, while others do this
themselves. In all instances, the medical practice provides reception services for patients turning
up for appointments.
Upskilling, in an informal sense, is a key feature of the way in which specialists operate when
they visit. However, the environment in the hospital (which is more ‘detached’) does not allow
this as easily when compared with the medical practice. An example is the GP asking the
endocrinologist about advice for their patients with endocrine disorders. The environment
facilitates ‘picking the brain’ of the specialists. Also, this informal approach was preferred to
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calling someone over the phone for advice, and is facilitated by building good relationships
between the visiting specialists and the local primary care providers.
Other ways in which upskilling occurs informally is through activities such as the visiting
cardiologist assisting with a stress test, or advice from the rheumatologist on joint inspections,
thereby building the skills of the GP to undertake this at other times.
There is also collaboration and follow up between specialists and primary care providers outside
of specialists’ visits. This is often in the form of a telephone call and/or email.
Formal upskilling occurs in the form of education sessions run by specialists at lunch time or in
the evenings. These are usually organised through the local division of general practice, and are
available to the wider region; not just to local practitioners.
The national Tele-Derm service is accessed by the GPs in Crystal Brook. They regard this is an
invaluable service, as there is no visiting dermatologist to Crystal Brook (only Port Pirie). It was
commented that apart from receiving the actual service, it is also educational for them.
There was also a trial of telehealth with dermatology. Funding for the trial was through
MSOAP, and it is now covered by Medicare.
There are no optometrists in Crystal Brook. However, the ‘Eyebus’9 visits and coverage is
generally good.
Organisational factors impacting on visiting specialist services
A major issue for Crystal Brook is space for visiting specialists. Although some specialist have
been able to increase the frequency of their visits in recent years, the room available does not
allow for any further expansion.
Another major issue is for patients needing to be seen in Adelaide. In most instances, people are
able to travel, but in other instances, people cannot easily make these appointments (e.g. elderly
and/or frail). Finance is also an issue for people, and the Patient Assistance Travel Scheme
(PATS) is accessed in these instances, and works well. However, another issue is appointment
times for people travelling from Crystal Brook. Often appointments are made early (e.g. 9 am),
not realising that it takes up to three hours for people to drive to Adelaide.
The Eyebus is a custom-built vehicle from which optometrist Jeremy Cutting operates a mobile optometric
practice in selected towns in rural and regional South Australia. The bus is fully equipped to provide complete
diagnostic eye examinations and carries a comprehensive range of frames, including those for veterans and
pensioners. The following checks are able to be done on the Eyebus:
9
Glaucoma field test
Diabetes eye checks
Macular degeneration assessment
Cataract testing
Digital retinal photography
Visual training
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Effectiveness of visiting services
The overall views on MSOAP in Crystal Brook are that it works well. Integration and
collaboration between primary care and specialists was cited as the main reason for this,
including enthusiasm from the individuals involved and networking between them. The
alternative model, which does not work well, is the sense that specialists are ‘plonked’ into a
region.
Therefore, outreach in the region is highly valued, and local practitioners are looking for ways in
which collaboration could be enhanced, as well as other opportunities to enhance services, such
as telehealth.
Assessment of need and gaps in specialist services
Local staff pointed out that there was not a strong sense of using need to shape health services
from a regional perspective. Need tended to be measured using waiting times for different
specialities.
It was also perceived that there needs to be a ‘marrying’ of what GPs regard as priorities for
health services for the region and what the community regards as priorities, because both groups
will have different perspectives.
No major gaps in visiting specialists were identified. Ophthalmology usually has a waiting time,
but there are two ophthalmologists in Port Pirie which patients can access.
The more significant issues are with increasing the frequency of some of the current visiting
specialists, but not having the room to do so. This is required for endocrinology in particular.
Telehealth was identified as a potential means to overcome this problem.
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Appendix 2.d - Dubbo, New South Wales
Region
Dubbo is a major inland city located 396km northwest of Sydney. In Table 24, regional
population statistics are presented, including for the catchment of Dubbo. The 2006 population
estimate by the ABS was 34,319 in the Dubbo Part A SLA and 3,525 in Dubbo Part B SLA. The
Aboriginal population was estimated at 3,812 within the Part A SLA and a further 97 in the Part
B SLA. However, the local AMS estimate is closer to 6,000.
Dubbo is a regional centre for the central Macquarie region and the broader North Western New
South Wales Statistical Division. The Central Macquarie Statistical Subdivision which has 50,166
residents in addition to the Dubbo population, and an additional 4,172 Aboriginal residents. It
includes towns such as Coonabarabran, Gilgandra, Wellington and Mudgee.
The North Western Statistical Division extends west and north to the Queensland border
including towns such as Bourke, Brewarrina, Cobar, Collarenebri, Coonamble, Goodooga,
Lightning Ridge, Nyngan and Walgett. In total (including Dubbo and the Central Macquarie
Statistical Sub Division there are 111,230 people living in the Statistical Division and 14,265
Aboriginal people.
Township/ location
Dubbo (C) Pt A (SLA)
Dubbo (C) Pt B (SLA)
Central Macquarie
Statistical Subdivision
excl. Dubbo
North Western Statistical
Division NSW
Table 10 – Regional population statistics (2006)
ARIA+
Remoteness
SEIFA
Resident
(GISCA
Area
(ABS 2008)
Population
2010)
(ABS 2011a)
RA2-Inner
1.95
957
34,319
regional
RA3-Outer
1052
2.94
3,525
regional
9.38
RA4-Remote
ATSI
Population
(ABS 2011a)
% ATSI
3,812
11%
97
3%
50,166
4,172
8%
111,230
14,265
13%
Dubbo serves as a major regional hub and has a substantial range of commercial services
available to the population, from entertainment to shopping to government services. In the
northwest region of New South Wales there are no other regional hubs with the services that
Dubbo offers, for this reason the town has a significant catchment area. Estimates of the
population that Dubbo serves exceed 120,000. As mentioned the estimated resident population
for the North Western New South Wales statistical division in 2006 was 110,000 people with an
estimated Aboriginal population of over 14,000.
Due to the role of Dubbo in the region, there is a significant amount of travel that occurs
between Dubbo and surrounding towns for commercial services. Transportation to Dubbo for
general purposes is mostly through private vehicles. The city is situated on the terminus of the
rail line from Sydney and there is no regular public transportation to more distant destinations.
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While Dubbo has good access from Sydney, highway is the only feasible option for onward
travel.
Figure 7 – Maps of Dubbo SLAs, Central Macquarie Statistic Sub Division and North Western New South
Wales Statistical Division, ASGC 2006
Dubbo (C) Pt A (SLA)
Dubbo (C) Pt B (SLA)
Central Macquarie Statistical Subdivision
North Western Statistical Division
Source: ABS 2011a
Dubbo is located 396km northwest of Sydney by road. It has a rail service to and from Sydney
and regular commercial flights to Sydney.
In the 2006 Census 23.7% of the population usually resident in Dubbo (Part A and B SLAs)
were children aged between 0-14 years, and 23.0% were people aged 55 years and over. The
median age in Dubbo was 35 years, compared with 37 years for people in Australia.
Health service organisation
Dubbo is located in the Western NSW Local Health District (LHD) within NSW Health system,
which includes the North Western Statistical Division NSW, and extends south to include
Orange and Bathurst. There are 40 hospital facilities within the LHD, many of which have been
converted to multipurpose services over the last 16 years. Orange, Dubbo and Bathurst
hospitals are the regional referral hospitals for the region, with Dubbo hospital the regional
referral hospital for the North Western Statistical Division areas of the LHD.
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Figure 8 – Western New South Wales LHD
Dubbo is serviced by the Dubbo Plains Division of General Practice, which has its main office
located in the city. The Division covers a region similar to the Central Macquarie Statistical
Subdivision. Currently there are 54 GPs in nine practices in the city of Dubbo, while the Dubbo
Plains Division has approximately 100 GPs in 36 practices.
A new Medicare Local will be called Western New South Wales, compromising the Dubbo
Plains Division together with the current Central West Division to the southeast and including
the major cities of Bathurst and Orange.
Specialist services
Specialist services are delivered through a combination of public (staff specialists) and private
practitioners. Many of these specialists visit from Sydney or other large centres as it is
challenging to recruit specialists to locate in rural communities. This has led to a situation where
the demand for a full-time specialist service is demonstrable but cannot be met from local
sources. Specialist services have tended to be ad hoc rather than driven by demand. Some private
services are carried out part-time without Commonwealth or state funding and consequently
depend on Medicare and patient revenue. Public services are funded through the operating
budget of Dubbo Base Hospital (DBH). The hospital would prefer full-time staff or VMO
services but have been unable to attract suitable applicants. The range of permanent specialist
services is presented in Table 25 (not comprehensive). Other specialist services are provided on a
part-time visiting basis.
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Specialty
Surgery
Nephrology
Anaesthetist
Cardiology
ENT
OB/GYN
Ophthalmic Practitioner
Paediatrics
Paediatrics/Neonatology
Psychiatry
Rehab Physician
Table 11 – Resident specialities in Dubbo
Number
Provides outreach to catchment (describe)
~6
Mudgee, Cobar, Walgett, Wellington
3
Bourke, Cobar
2
2
1
4
Visit Walgett, Bourke, Coonamble, Wellington, Coonabarabran,
Cobar
1
3
Bourke AMS, Nyngan
1
1
1
Hospital
The main hospital in Dubbo is Dubbo Base Hospital, which is in the category of hospitals
between 100 and 200 beds. It has an emergency department and provides acute, rehab and
subacute services. Admissions for the hospital are listed in Table 12. Lourdes hospital is also
located in Dubbo and is a third schedule facility that provides sub and non-acute services,
including rehab and palliative care.
Table 12 – Admissions to Dubbo Base Hospital 2009-10
Same day
Overnight
admissions
admissions
Childbirth
100
1,116
Medical (emergency)
632
5,060
Medical (other)
6,126
830
Specialist mental health
35
433
Surgical (emergency)
103
1,339
Surgical (other)
1,258
1,008
Total
8,254
9,786
Source: MyHospitals website
The specific services that are provided through Dubbo Base include:
 chemotherapy
 coronary care unit
 dialysis unit
 ear, nose and throat surgery
 eye surgery
 general surgery
 gynaecological surgery
 orthopaedic (bone) surgery
 urological surgery
 other elective surgery
 emergency department
 intensive care unit
 obstetrics
 oncology unit
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


outpatient services
paediatrics unit
psychiatric unit/ward.
Aboriginal Medical Services
Dubbo has one public AMS in the city, the Thubbo Aboriginal Medical Co-operative, which
provides services to the local community as well as to people from the wider catchment
(including from other AMSs). The Thubbo AMS has associations with the National Aboriginal
Community Controlled Health Organisations (NACCHO), Aboriginal Health Medical Research
Council of New South Wales (AH & MRC) and the Bila Muuji Aboriginal groups. The AMS
employs one full time and three part time general practitioners. Funding acquired through
Commonwealth support allows the clinic to stay open until 9pm, thereby enhancing public
convenience.
Thubbo is the largest AMS in the region as determined by the number of patient contacts, with
around 80 per cent identifying as Indigenous. Due to the role of Dubbo as the major hub for the
region, a larger population is served by Thubbo than a typical AMS. Many patients who come to
Thubbo live within the boundaries of other AMSs. For this reason, when patients from other
areas access services through Thubbo AMS, there is an attempt to inform the home AMS and
get transfer files over as appropriate.
Optometry
Dubbo itself is well served for optometry, with ten optometrists working in the town. Seven
provide outreach services.
Travelling into Dubbo
Dubbo is a major hub for the region and many people travel into the city from the catchment to
receive medical services. As an example, a visiting neurologist who worked for two and a half
days over a two month period had 26% of the patients travel in from outside of Dubbo. The
actual means of travel is generally through private transport although this may be funded by the
Isolated Patients Travel and Accommodation Assistance Scheme (IPTAAS) program. Some
Indigenous and elderly patients do use alternative forms of transport to get to Dubbo, including
buses (one arrival/departure per day) and other community transport. The Thubbo AMS does
provide some community transport within Dubbo as well as providing limited support to
patients travelling in from the catchment. In some special circumstances the AMS will cover
additional travel arrangements, including into Sydney.
It was pointed out that for many Aboriginal patients the main motivation for travel to Dubbo is
commercial (government services, banking, shopping) with medical attention regarded as
optional if time permits. Lower priority is given to medical appointments, even where an
appointment was pre-arranged. Some patients cannot or will not travel except in an emergency.
Dubbo may be up to six hours from a patient’s home. At those distances, travel is a major
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barrier, especially for older people and those living in difficult socio-economic circumstances.
Consequently, increasing access to medical services requires better transport links.
Travelling out of Dubbo
Patients have to travel out of Dubbo to receive a significant number of services that they need.
Medical services that patients have to travel for include many in-patient services, complex
outpatient diagnostics (e.g. PET-CT), thoracic surgery, spinal injuries, mental health and subspecialty services. (A full discussion of gaps is provided in the next section.) Traveling out of
Dubbo is however a significant challenge for much of the population. Barriers to travel include
time, local commitments, money and the desire to avoid the city. For example, if someone is
taking care of a sick or elderly family member, they cannot leave their home to travel to Sydney
to receive services. Other people will not attend a service to avoid the metropolitan areas.
Lourdes hospital staff brought our attention to the fact that the hospital is often responsible for
patient travel costs for patients that need transfer to services that the hospital does not provide.
This creates a significant, and at times unnecessary, expense for services that could be available
in Dubbo.
Visiting specialist services
Visiting specialists are common in Dubbo, funded both through MSOAP and through other
arrangements, including those employed in the public sector. As can be seen in Table 19, most of
the visiting MSOAP services are administered through private locations. The arrangements for
these services are mainly through the use of existing rooms at specialist medical centres in town.
Often the centre will arrange and manage patients, take care of paperwork and perform the other
administrative tasks needed for the specialist to provide services at the location. One interesting
case is that of a dermatologist, who after receiving MSOAP funding for many years purchased a
property and set up a secondary practice in Dubbo that he visits two days per week. While he
still receives MSOAP for his travel expenses, he is able to provide a more comprehensive and
integrated service to residents through his purchase of a local property.
Program
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
10
11
Table 13 – MSOAP services to Dubbo
Specialty
No of visits10
No
No of
patients
ATSI
11
patients6
Dermatology
48
2341
28
Physician - Cardiology
8
218
1
Physician - Cardiology
24
457
29
Physician - General
22
485
27
Physician - Neurology
24
115
11
Physician - Palliative
10
34
4
Physician - Rehabilitation
4
21
1
Physician - Respiratory
24
782
48
Physician - Rheumatology
22
437
21
Psychiatry - General
50
59
6
Psychiatry - Geriatric
24
12
0
Surgery - Gastroenterology
6
6
0
Where delivered
Private (Purchased)
Private
Private
Private
Private
Lourdes
Lourdes
Private
Private
Private
Lourdes (need provider)
Per anum (2009-2010)
During the period from 1 January 2010 to 30 June 2010
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Program
No of visits10
Specialty
No
patients
11
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP-ICD
MSOAP-ICD
Surgery - Neuro
Physician - Nephrology
Physician - Neurology
Surgery – Oral & MaxilloFacial
Chronic respiratory disease,
Respiratory physician
Cardiovascular Disease cardiology
6
2 (2010-11)
1 (2010-11)
73
No of
ATSI
patients6
0
Where delivered
Private (consultation only)
Hospital
Private (in the air)
Private
1(2010-11)
AMS
12(2010-11)
AMS
12(2010-11)
Numerous other specialists not covered by MSOAP visit Dubbo, many of which have a high
turnover. There are several different arrangements through which these specialists coming to
Dubbo. The first is specialists who have decided to provide services in Dubbo as a personal
choice, business reasons or both. In these cases the visits are not supported by any outside
source and the costs of providing the visiting services must be covered by payments from
patients. The second type is public visiting services that are supported by the state health
department. These services are provided at or through the public hospitals. The specialists
generally come from other public hospitals or private providers under contract to provide
services. Finally, it appears that there may be some specialists who visit and provide a
combination of public and private services to patients. A list of these other visiting services is in
Table 14.
Table 14 – Visiting services to Dubbo not supported by MSOAP
Type
Specialty
Number of visiting specialists
Public
Diabetes Specialist
2
Public
Anaesthetist
Up to 3
Private
Gastro
2
Private
Ophthalmology
4
Private
Cardiac
1
State/private (to hospital)
Oncologist
1
State/private (to hospital)
Haematologist
1
State/private (to hospital)
Radiation Oncologist
2
Mix
Cardiology
~7
Public
Clinical Genetics
2
Undetermined
Colorectal surgery
1
Private
Gastroenterology
2
Public
Haematology
5
Private
Neurology
2
Mix
Neuropsychology
2
Private
Nuclear Medicine Physician
1
Private
Oculoplastic Surgery
1
Private
Ophthalmic surgery
3
Private
Ophthalmology
1
Private
Oral and Maxillofacial Surgery
1
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Type
Specialty
Number of visiting specialists
Public
Orthopaedic
1
Private (small amount public)
Orthopaedic Surgery
11
Public
Paediatric Cardiology
2
Public
Paediatric Nephrologist
1
Mix
Paediatrician
2
Mix
Psychiatrist
8
Private
Reconstructive Cosmetic Surgeon
1
Private
Rehabilitation Physician
1
Private
Rheumatology
2
Private
Thoracic Physician
1
Private
Thoracic Physician/ Sleep Medicine
1
Private
Urology
2
Private
Vascular Surgery
1
Undetermined
Vitreoretinal Specialist
1
Services delivered outside Dubbo to the wider catchment population are provided through
MSOAP (Table 15), Dubbo Base Hospital specialist (Table 25) and specialists in private practice
(Table 16).
Program
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
Table 15 – MSOAP services to Dubbo catchment
Specialty
No
No of ATSI
No of visits12
patients6
patients13
Psychiatry
6
15
1
Psychiatry
6
26
0
Physician - Addiction
Medicine (Drug and
Alcohol)
8
8
8
Surgery - General
5
98
37
Physician - Addiction
Medicine (Drug and
Alcohol)
12
12
12
Physician - Cardiology
11
62
20
Physician - Respiratory
11
35
12
Physician - Sexual
Health
2
8
1
MSOAP-ICD
MSOAP-ICD
MSOAP-ICD
MSOAP-ICD
MSOAP-ICD
MSOAP-ICD
MSOAP-ICD
MSOAP-ICD
MSOAP-ICD
12
13
Diabetes team
Cardiovascular Disease
Diabetes
Cancer
Chronic Respiratory
Diabetes
Chronic respiratory
disease
Chronic respiratory
disease
Cardiovascular disease
4 (2010-11)
11(2010-11)
4(2010-11)
8(2010-11)
2(2010-11)
6 (2010-11)
Location
Warren
Nyngan
Bourke
Bourke
Walgett
Walgett
Walgett
Walgett
Lightning Ridge,
Goodooga
Bourke
Bourke
Bourke
Bourke
Wellington
Coonamble
6 (2010-11)
Wellington
6 (2010-11)
6 (2010-11)
Wellington
Per anum (2009-2010)
During the period from 1 January 2010 to 30 June 2010
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Program
MSOAP-ICD
MSOAP-ICD
MSOAP-ICD
MSOAP-ICD
MSOAP-ICD
MSOAP-ICD
Specialty
No of visits12
Cardiovascular disease
Chronic respiratory
disease
Chronic respiratory
disease
Chronic respiratory
disease
Cardiovascular
Cardiovascular
6 (2010-11)
No
patients13
No of ATSI
patients6
Location
Coonamble
Bourke
6 (2010-11)
Brewarrina
6 (2010-11)
Walgett
6 (2010-11)
5 (2010-11)
10-48 (2010-11)
Lightning Ridge
Walgett
Table 16 – Non-MSOAP specialists from Dubbo visiting Dubbo catchment
Specialty
Location
Number of
specialists
Cardiology
Mudgee
1
Dermatology
Mudgee
1
Gastroenterologist
Mudgee
1
Gynaecologist/Urogynaecologist Mudgee
1
Neurosurgery
Mudgee
1
Ophthalmic Surgeon
Mudgee
1
Ophthalmologist
Mudgee
1
Ophthalmologist
Gulgong
1
Orthopaedic Surgeon
Mudgee
2
Psychiatry
Mudgee
2
General Surgery
Mudgee
1
It is clear that there are different roles that visiting specialists play in the health service delivery
framework within Dubbo. The success of the services would appear to be related to the need
that the visiting service is responding to. However, in general, the view was expressed that the
visiting services were not meeting the needs of the community. However, this did not necessarily
reflect the quality or quantity of services being provided, rather, the significant need that exists in
Dubbo.
At Dubbo Base Hospital most of the visiting specialists were there to provide services that could
not be provided by resident staff. Some of these services are most likely best provided through
visiting services due to the level of demand for them. However, many of the visiting services that
are provided into Dubbo Base (mostly through the state) are there to make up for recruitment
shortages for full time staff. Significant workforce and recruitment issues exist at the hospital,
which leads to chronic understaffing (for specialists) that have to be supplemented with visiting
services. The issue is magnified in the catchment area where fewer services are available to begin
with. A compounding factor on the staff shortage at the hospital are acute cases from Dubbo
and the catchment that may have been prevented through better availability of primary and
secondary services. For these reasons, the hospital currently uses and views visiting services as
replacement services for staffing shortages.
The Lourdes hospital, which provides sub and non-acute services to mainly elderly patients, uses
visiting specialty services to supplement the clinical staff that they already have. While there are
also significant recruitment and staffing issues for specialists, the need is not as significant as at
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Base Hospital. When a visiting specialist comes to Lourdes they function mostly as a
consultation service, providing input on challenging cases, setting up medication or care plans
and providing education and upskilling services to the clinical staff. This role for visiting services
appears to be very successful as it is well integrated with the services that are provided by the full
time staff at the hospital.
Visiting specialty services in the general community play several roles: making up for services
that are not being provided by the market, providing services that would not normally be
available and the provision of high level services. The rates that a specialist can earn in the city
are equal to or greater than the rates in Dubbo, the support/education network is smaller and
the major cities are a more popular location of residence for specialists. To overcome the
marketplace barriers, specialists can receive extra funding (i.e. MSOAP) or make a personal
choice to provide a visiting service for non-tangible benefits.
A second type of service being provided in the community is a specialist service that does not
receive sufficient demand to support the service being permanently located in the town. In this
case the visiting service either receives additional funding or has to be sustained through the
payments received through the provision of services. Finally, a visiting service can provide
expertise and connections that could not exist in the town that the service is being provided in.
For example, if a cardiothoracic surgeon from a major hospital in Sydney provided consultations
in Dubbo, the specialist could bring expertise from their colleagues in Sydney as well as a
personal relationship with patients who needed to travel to Sydney receive further treatment.
Visiting services to the AMS are culturally sensitive, affordable and integrated with the other
resources at the AMS. The first aspect is critical in that many mainstream services are not
culturally sensitive to Indigenous communities and therefore members of these communities do
not feel comfortable accessing them. Many mainstream specialist services also usually have
significant costs associated with them. Services provided through AMSs bulk bill or have low
fees and therefore are more accessible. The importance of integration of specialist services with
an AMS is that Aboriginal Health Workers and GPs in the AMS can develop relationships with
the specialists. These relationships increase attendance rates and allow for better communication
between levels of care for the patient.
Gaps in specialist services
Significant gaps in specialist services exist in Dubbo. These are critical to service delivery for the
region as Dubbo is a major hub. Some of the major specialties identified as gaps include:
radiation oncology, rheumatology, endocrinology, respiratory, neurology, ophthalmology, ENT
surgery, angiography (coronary, cerebral, renal), orthopaedics, psychiatry, child psychiatry,
dentistry and dermatology. Indigenous gaps are greater as there is a lower level of access to
mainstream services from the Indigenous population. At the AMS, ear grommets for children
were identified as a major gap. In addition, many services, even if they are available in Dubbo
have significant waiting lists, are available only through private practices, or both. This means
that the gaps in services are greater for certain populations.
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Assessment of need
The assessment of need in Dubbo is led by the Dubbo Plains Division of General Practice,
acting as a sub-contractor to one of the fundholders in New South Wales - the Rural Doctors
Network. To manage the need in the area, the Division develops and manages MSOAP
proposals. The process that they pursue to develop new services includes feedback from GPs,
surveys of specialists, analysis of service and health data, and meeting with stakeholders who
want to have input. For the last few years, the Division has mostly continued existing services
and only with MSOAP-ICD were they able to add new services.
Many stakeholders in the region feel that they have not been fully engaged in the process of the
assessment of need and the development of visiting services. The relationship between the AMS
and the Division is somewhat divisive, where the Division does not feel the AMS can get
services up and running efficiently and the AMS does not feel fully engaged in developing new
services. The hospitals do not feel fully engaged in the assessment of need, where changes in
available services are not acknowledged, with continuing services being prioritised over new and
urgent needs.
There is no indication that services that are being provided are not needed. However, they are
not necessarily the highest priority services. There is significant evidence that there is not
comprehensive engagement of the various local stakeholders to develop a comprehensive needs
assessment and visiting services plan for Dubbo. All of the stakeholders do have an idea of their
need and want to be engaged. The services appear to be based as much on need as they are on
other logistical factors associated with setting up services. The challenge with this approach is
that the services are more ad hoc and are not able to most efficiently address the community
needs. One challenge that was raised to providing a more comprehensive assessment of need
was that the administrative cost in time to create a plan for visiting services is not provided for in
budgets.
The success of visiting services is dependent on patient access to the services and integration of
care between the visiting service and other service providers.
Referrals in Dubbo mostly occur through standard referral pathways as would occur in a major
city. The Division maintains a list of specialists, both visiting and permanent, that provide
services to Dubbo. The list is mostly up to date and does provide contacts for referrals, including
secure electronic communication. Many of the providers in Dubbo do appear to know the other
specialists in town or a person to contact if a referral is needed. There was some feedback that at
times it can be challenging to know which specialists are available and who is still visiting.
However, challenges in accessing specialist services has more to do with availability than lack of
knowledge.
Management of referrals and patients is done almost exclusively by the visiting specialist or by
the site hosting the specialist. At the AMS there are significant administrative efforts that go into
referrals and managing patient lists. Currently, they are in the process of developing case
management services for their patients, which they see as critical to improving access and
utilisation of services.
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Notifications for new visiting services are often provided through the Division. New services are
sent out through a weekly e-mail that goes to GPs, allied health professionals and nurses. In
addition, a specialist health directory is also released. Despite the efforts of the Division there
was still a sense that stakeholders (AMS and Dubbo Base in particular), were not fully aware of
all of the visiting specialist services.
Communication between visiting services was cited as a key aspect of successful visiting services
to Dubbo. Having specialists provide letters and records to local providers is seen as an
important part of the services that they provide. While there was some feeling that this process
could be improved, the main complaint, from Dubbo Base, was that the fragmentation of
services and communication due to visiting services.
The issue that Dubbo Base Hospital had was that visiting specialists were not part of the referral
pathway for their hospital. What this means is that patients that require inpatient services at
some point after receiving visiting specialist services would enter a separate pathway. The change
in pathway can significantly hinder communication between Dubbo Base, the specialist and the
hospital Dubbo sends patients to (RPA). This leaves a significant burden on Dubbo base to
manage acute patients who are seen by a specialist outside of their typical pathway.
MSOAP and VOS impacts
The impact of MSOAP was seen as positive by all service providers in Dubbo except for Dubbo
Base Hospital. Improvements due to MSOAP were harder to quantify because of loss of
permanent services within the community and the high level of unmet need.
Lourdes Hospital and Thubbo AMS had the opinion that services had increased access
significantly, where specialists provided through MSOAP were seen as providing services that
would not exist without the program. At Lourdes they particularly valued that MSOAP
specialists could provide education and expertise that would not otherwise be available. At the
AMS, they felt that the services that MSOAP provided both met a need and provided a service
that might not have been otherwise accessed.
The Division felt that MSOAP provided an invaluable service, but did not have a significant
impact because other services had decreased during the time that MSOAP has been in operation.
However, they were of the opinion that if the program was not in operation that services would
be significantly worse.
Benefits
The main benefit of MSOAP was seen as improved access to services in Dubbo and the
catchment area. The additional benefits are increased utilisation of services by patients and
money savings through reduced travel. Through the consultations it became clear that there are
significant barriers, emotional, social, psychological and economic that prevent people from
accessing services. When the services are easily available to them they are much more likely to
access them. This is seen as the kind of benefit that cannot be quantified because there is not an
alternative service that a visiting specialist can be compared to.
The Division felt MSOAP provided specialists with exposure to Dubbo, leading to the creation
of new and sustainable services. Multiple groups cited the expertise of specialists from MSOAP
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as being a major benefit, including the relationship that they bring with major hospitals in capital
cities.
Areas for improvement
The current program could be improved through a better process of assessing need and creating
service proposals. It was felt that more people need to be brought together to discuss need and
develop priorities for the community. The situation in Dubbo is constantly changing and
therefore the needs of the community are shifting through the course of a year. Services were
provided more on a polling basis than through creating a plan to address the need in Dubbo.
Flexibility was seen as a major issue for the Division, where the planning and budgets of service
plans were too rigid given the realities of service delivery on the ground. They felt that if funding
was more flexible and services were paid for on a fixed price basis, administration would be
simplified and more services could be provided in an efficient manner. A second aspect of
flexibility is an increase in the inclusion of teams in the delivery of service, including care
planning and other support for the specialist (similar to MSOAP-ICD). The efficiency of the
specialist could then be significantly improved through distribution of unnecessary work away
from the specialist.
The area that was seen as being the most critical area for improvement was the level of payments
for administrative support to the specialists. Currently, organisations involved or specialists are
coming out of pocket to provide the support that specialists need to deliver their services. This
includes taking appointments, following up with patients, dealing with patients on the day of
service, writing up and sending letters to GPs and other tasks such as sending lab results back to
the specialist. Everyone agreed that these services were critical to the success of the service, but
due to the level of administrative payments the support is not sustainable. A related issue that
was raised is that the payment and billing process was seen as overly burdensome to the
specialists and their staff. It is already a challenge to deliver visiting services, the extra work
creates stress and less incentive to participate.
There were some specific ideas raised for improving MSOAP:







create more connections with groups that can source doctors to fill need (i.e. specialist
colleges, large hospitals, health networks)
increase marketing and advertising
keep payment levels in line with inflation
encourage multiple day clinics over single day visits
provide higher payments to some specialties to encourage them to participate
get more registrars to participate (get relationships with training programs)
focus on sub specialty services.
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Appendix 2.e - Karratha & Roebourne,
Western Australia
Region
Karratha and Roebourne are located in the Pilbara region of Western Australia. The whole
Pilbara region is 507,869 square km (including offshore islands), and extends from the Indian
ocean across the Great Sandy Desert to the Northern Territory border. The estimated resident
population of the Pilbara was 47,528 in 2009 (2.1% of the Western Australia population).
There has been significant growth in the resident population in the Pilbara over the last decade
(2.4% per annum), which is accelerating. The Western Australia Planning Commission and
Department of Planning have projected the resident population will grow to 140,000 by 203514.
In addition to the resident population, the Pilbara also hosts a very significant non-residential
population principally made up of a fly-in fly-out workforce in mining and construction. This
workforce was estimated to be around 15,000 in 2010 and is projected to grow to around 34,000
by 2020.
As at the 2006 Census there were an estimated 5,632 Aboriginal people living in the Pilbara,
making up 24% of the Pilbara population and 10.5% of Western Australia’s Indigenous
population.
The main towns in the Pilbara are Port Hedland/South Hedland, Karratha, Roebourne,
Wickham, Dampier, Onslow, Pannawonica,Tom Price, Paraburdoo and Newman. Port
Hedland/ South Hedland form the largest population centre in the region (resident population
around 11,957 in 2006) followed by Karratha (resident population around 11,728 in 2006). In
the state government’s Pilbara Cities strategy, Port Hedland and Karratha are identified as being
developed into cities of 50,000 by 2035.
For health services, Port Hedland is identified as a regional resource centre for the Pilbara.
Karratha is 242 km from Port Hedland and 1,542 km by road from Perth. Karratha is well
services by regular commercial flights to Perth.
Karratha, Roebourne, Wickham and Dampier are located in Roebourne shire/SLA, the largest
shire in the Pilbara region. The estimated resident population of the SLA was 16,423 at the 2006
Census with 1,831 Aboriginal people (around 11% of the population (see Table 17). The
estimated resident population the SLA in 2010 has grown to 19,143 (ABS 2011b), growth of
around 2.5% per year.
Road distances from Karratha to other towns in the Roebourne SLA are 21 km for Dampier, 39
km for Roebourne and 50 km for Wickham. Towns in the Ashburton SLA are closer to
Western Australia Planning Commission and Department of Planning (2011). Pilbara Planning and Infrastructure
Framework.
14
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Karratha than Port Hedland so to some extent Karratha services these areas as well including
Onslow (311 km from Karratha) and Pannawonica (200 km).
Karratha is a catchment for the towns in the west Pilbara. However there are extremely limited
public transport options into Karratha from its catchment. Transport is usually by private means
or through a limited patient transport scheme (for health services).
Table 17 – Regional population statistics (2006)
ARIA+
Remoteness
SEIFA
Resident
(GISCA 2010)
Area
(ABS 2008)
Population
(ABS 2011a)
Township/ location
Karratha (Urban
Centre/Locality)
Roebourne (Urban
Centre/Locality)
Wickham (Urban
Centre/Locality)
Dampier (Urban
Centre/Locality)
Balance of Roebourne SLA
Total Roebourne SLA
Ashburton SLA
Port Hedland SLA
East Pilbara SLA
Total Pilbara region
ATSI
Population
(ABS 2011a)
% ATSI
9.000
RA4-Remote
846
11,728
742
6%
9.619
RA4-Remote
631
857
524
61%
1,825
288
16%
1,370
29
2%
643
16,423
6,078
11,957
6,543
41,001
248
1,831
585
1,785
1,429
5,632
39%
11%
10%
15%
22%
14%
1,033
Figure 9 – Pilbara and other regions of Western Australia
Source: Small Business Development Corporation 2011
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Figure 10 – Towns in the Pilbara region
Source: Google Maps
Both Karratha and Roebourne have relatively young populations, although for different reasons.
In the 2006 Census 26.4% of the population usually resident in Karratha15 were children aged
between 0-14 years, and 6.8% were people aged 55 years and over. The median age of people in
Karratha was 30 years, compared with 37 years for people in Australia. Aboriginal people make
up around 6% of the Karratha population.
In 2006, 25.0% of Roebourne’s resident population were children aged between 0-14 years, and
18.0% were people aged 55 years and over, with a median age of 32 years. Aboriginal people
make up 61% of the Roebourne population.
Health service organisation
State health services are provided in the Pilbara from the Pilbara regional office of Western
Australia Country Health Services (WACHS). The management of the health service is based in
Port Hedland. The main hospitals in the Pilbara are located in Port Hedland and Karratha
(Nichol Bay Hospital). Population health (community and allied health), mental health and
community-based aged care services also operate from these centres. Smaller hospitals are
located at Onslow, Newman, Tom Price, Paraburdoo and Roebourne. A former hospital at
Wickham has been converted into a health centre incorporating an accident and emergency
service.
There are remote area nursing posts in some of the smaller communities, including Marble Bar
and Nullagine. Public health services are based in Port Hedland. There is also a renal dialysis
satellite service in Port Hedland, although patients on home dialysis modalities are scattered
15
Urban Centre/Locality
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across the Pilbara. Dental services are predominantly publicly provided by private dentists
operating in Port Hedland, Karratha and Tom Price.
There are three main Aboriginal Community Controlled Aboriginal Health Services across the
region, including Mawarnkarra Health Service (Roebourne), Wirraka Maya Aboriginal Health
Service (which provides a service to the greater Port Hedland and South Hedland area and
communities at Strelley, Woodstock and Warralong) and the Puntukurnu AMS (which service
remote populations in the east of the Pilbara).
The Pilbara Health Network (PHN) (the Pilbara Division of General Practice) works with GPs
and other primary health care providers across the whole Pilbara region. In addition to support
to GPs, the PHN delivers primary health care services in its own right, including audiology,
podiatry, diabetes education, dietetics, primary mental health, chronic disease management and a
number of preventative health programs. The network supports 10 medical centres, six
hospitals, three AMSs and a number of outlying nursing posts. The PHN is planning to publish
on its web site a “Pilbara Outpatient Specialist List”, to provide a guide to the local community
and health care providers on visiting services.
The Medicare Local planned for the region will include both the Pilbara and Kimberly regions.
The Royal Flying Doctor Service provides service out of Port Hedland, including emergency
transfers to from Pilbara locations to the Hedland Health Campus, inter hospital transfers to
Perth, ‘RFDS On the Road’ clinics, health checks and health information and primary Health
clinics to some of the more remote Pilbara regions.
There are several residential and home based aged care providers in the region.
General Practice and primary care in Karratha and Roebourne
There are three private GP practices operating in Karratha, with 13 GPs (mostly part time).
There is a plan for a GP Super Clinic in Karratha. A community health service is available in
Karratha.
In Roebourne, Mawarnkarra Health Service offers a range of primary care services.
Mawarnkarra provides services for Aboriginal people living in Roebourne, Karratha and
Wickham. It is the only GP service available in Roebourne. It is staffed by four part time GPs,
who provide the service on a locum basis, and two GP registrars. The service has a range of
community nursing, Aboriginal health workers and other staff. The service has an Aboriginal ear
health coordinator but no eye health coordinator. A range of visiting specialist services are also
provided out of Mawarnkarra (see below).
There are some limited community health services provided out of the hospital at Roebourne.
Another private GP practice operates out of Wickham which is nearby. Accident and
emergency services are available in Karratha and Wickham.
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Figure 11 – Mawarnkarra Health Service
Hospital services
Nichol Bay hospital (Karratha) is a 41 bed facility which reports slightly over 3,000 hospital
admissions a year, of which 45% are same day admissions. The hospital has an emergency
department, provides emergency and elective surgery, midwifery and a range of allied health
services including physiotherapy, occupational therapy, social worker, mental health, speech
therapy, radiology and gynaecology. The hospital is staffed by doctors, but there are no
specialists permanently based at the hospital. Port Hedland has resident specialists on staff
(general physician, obstetrics and gynaecology, anaesthetist and paediatrician) who also regularly
visit Nichol Bay. Around 27 individual medical specialists visit the hospital regularly (see next
section). Nichol Bay can provide minor surgery, but major surgery is referred to Port Hedland or
Perth.
Roebourne is a much smaller hospital providing around 300 hospital admission a year of which
27% are same day. There are no doctors working at the hospital. Medical support is provided by
Nichol Bay hospital. Roebourne hospital provides a step down service related to Nichol Bay
hospital. There are no specialists doctors who visit the hospital.
Table 18 – Characteristics of Nichol Bay and Roebourne hospitals, 2009-10
Nichol Bay hospital
Roebourne hospital
Same day
Overnight
Same day
Overnight
admissions
admissions
admissions admissions
Admissions 2009-10:
Childbirth
<10
163
0
0
Medical (emergency)
493
1523
43
207
Medical (other)
391
71
20
26
Specialist mental health
0
0
0
0
Surgical (emergency)
16
70
0
<10
Surgical (other)
439
72
0
<10
Total
1,339
1,899
63
233
Services available:
Beds
41
<50
Elective Surgery:
Yes
No
Emergency Department
Yes
Yes
Obstetrics
Yes
No
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Paediatrics
Yes
No
Visiting services – Nichol Bay Hospital
A broad range of specialists visit Nichol Bay, supported by either WACHS or MSOAP (see
Table 19). A general physician, obstetrician and gynaecologist, anaesthetist and paediatrician visit
from Port Hedland, but other visiting specialists are from Perth. MSOAP-ICD is supporting a
range of visiting allied health services.
Program
Table 19 – MSOAP services to Karratha and Roebourne
Specialty
No of
No
visits16
patients
No of ATSI
patients6
17
Karratha
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP-ICD
MSOAP-ICD
MSOAP-ICD
MSOAP-ICD
WACHS
WACHS
WACHS
WACHS
WACHS
WACHS
WACHS
Roebourne
MSOAP
MSOAP
MSOAP
MSOAP-ICD
MSOAP-ICD
MSOAP-ICD
MSOAP-ICD
MSOAP-ICD
Ophthalmology – General
Paediatrics – General
Paediatrics – General
Physician – General
Physician – Nephrology
Physician – Palliative
Surgery – Orthopaedic (two separate surgeons)
Surgery – Urology
Physician – Endocrinology (Diab)
Allied Health – Diabetes Educator
Allied Health – Dietician
Allied Health – Podiatrist
Physician – Cardiologist
Paediatric Cardiologist + Echo Technician + Nurse
Physician – Respiratory
Physician – Gastroenterology
Dermatologist
Surgery – General Surgeon
Surgery – Plastic Surgeon
2
12
8
10
4
4
22
4
4
4
4
4
6
4
2
4
4
21
4
0
0
76
22
37
2
364
20
*
*
*
*
NA
NA
NA
NA
NA
NA
NA
0
0
18
2
12
0
14
2
*
*
*
*
NA
NA
NA
NA
NA
NA
NA
Ophthalmology – General
38
24
Paediatrics – General
36
14
Physician – Palliative
2
2
Allied Health – Cardiac Ultrasonographer
4
Nurse - Chronic Disease
2
Allied Health – Podiatrist
2
Physician – Cardiology
2
Administration – Service
10
Notes: This list is based on information provided during consultations and may not be complete or accurate
2
8
2
Where services are supported by WACHS the costs of travel and accommodation are paid for by
the Pilbara Regional Office of WACHS. Where the specialist is employed by WACHS (at Port
Hedland) the costs of salary will also be provided by the Pilbara Regional Office of WACHS.
For MSOAP visiting services the Pilbara Regional Office of WACHS is the organisation that is
the ‘sub-contractor’. Proposals are usually developed by the Pilbara Regional Office and
submitted to the WA fundholder (Rural Health West). The MSOAP contract is usually between
16
17
Per anum (2009-2010)
During the period from 1 January 2010 to 30 June 2010
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WACHS Pilbara Regional Office and Rural Health West. Pilbara Regional Office then makes
arrangements directly with visiting specialists and allied health staff.
The Medical Specialist Services Officer at the Pilbara Regional Office of WACHS (at Port
Hedland) coordinates all visiting services including those funded under MSOAP and WACHS.
Prior to the beginning of the calendar year, the Office coordinates dates with visiting specialists
for the region, putting these into a larger calendar. Details of visiting services and scheduled
dates are forwarded to hospitals, GPs, health centres across the Pilbara. The Officer books and
pays for airfares for all visiting services and other aspects of accommodation.
There is additional coordination that occurs at Karratha. A position at Nichol Bay Hospital is
responsible for organising accommodation and local transport. Typically a car is hired for
visiting specialists and is available when the specialist arrives. Otherwise transport needs to be
provided. Specialists may be accommodated in a property managed for this purpose or in
commercial accommodation. Commercial accommodation is undersupplied and booking are
required three to four months in advance. The Pilbara West section manages approximately 270
properties for local and visiting staff.
The hospital runs around 80 clinics a month with 2.5 outpatient clinic rooms. There is extremely
high demand on space and visiting specialists are demanding more room. Some visiting services
are inpatient based (e.g. cataract surgery). Some specialists will bring a nurse who will undertake
a range of processes related to the consultation. Some clinics require more than one room.
Some visiting services require surgical facilities and this will often have a significant impact on
the hospital.
For Karratha and its catchment areas, GP referrals are made to Nichol Bay hospital. There are
around three staff who manage outpatient clinics and appointments. When a referral is received
the patient will be triaged and assigned to a clinic appointment. In some instances the visiting
doctor will be consulted and the patients triaged. In others, hospital staff will triage the patient.
Patient details will be recorded in a spreadsheet used to manage the outpatient clinic
appointments (these are manually entered). Patients will be advised on when the clinic will occur
by letter. There is no additional reminder system. The nature of the community creates issues
(e.g. high mobility of the workforce and regular movements of address). A current project is
looking to create better systems (e.g. SMS reminders).
There are very limited public transport options for patients from the catchment to travel to
Karratha. The Pilbara Office of WACHS and Aboriginal health services will assist with these
issues. An example was given of Aboriginal patients needing to attend a clinic from Onslow.
The process involved admitting the patients to Onslow the night before the clinic, using a
transport truck to take the patients from Onslow at 4:00 am arriving at Karratha at 7:30 am,
undergoing the procedure/consultation, and then the truck taking patients back to Onslow in
the late afternoon/evening. Mawarnkarra Health Service offers a transport service to get patients
in the Roebourne, Wickham and Karratha areas to specialist clinics at Nichol Bay.
Prior to the clinic the staff will retrieve the medical records. As patients attend they will be
crossed off the spreadsheet list. Hospital staff make a note in the record about the visit and also
record this in the patient administration system. An occasion of service is recorded on the local
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patient administration system. Recording of the number of clinic ‘sessions’ is manual.
Indigenous status of patients is retrieved from the patient record. Statistics are reported by
hospital staff to the Medical Specialist Services Officer who consolidates these and reports them
to the Rural Health West.
Some doctors bring their own patient records. Some make notes and leave a copy at Nichol Bay,
some prepare a letter locally and a copy is placed directly on the patient charts, and some provide
letters after the visit.
For any one clinic there are large numbers of patients who do not attend (estimated at 50%).
The issues for Nichol Bay include unwillingness to take time off work (e.g. for people working in
the mining industry), high mobility of the local population with household members employed in
the mining industry (including regular trips out of the region and frequent changes of address),
and difficulties in getting to Karratha (for patients living in the west Pilbara).
No facility fees are charged for visiting specialists. Visiting specialists display a range of different
attitudes towards billing patients, and it was reported these attitudes are changing towards a more
commercial orientation. In one case, the specialist charges all patients a gap fee, which has
meant Aboriginal people are very unlikely to see the specialist, despite the specialty being in an
area of very high need. The administrative steps associated with billing are undertaken by the
specialist and administrative staff are not supposed to be involved. However, some specialists
want staff to provide assistance on billing issues.
There is a Patient Assisted Travel Scheme (PATS) officer at Nichol Bay Hospital. The scheme is
principally used to assist patients to travel out of the region (to Perth), rather than assist patients
within the Pilbara to get to Nichol Bay hospital.
Visiting services – Mawarnkarra Health Service
A range of visiting specialists provide services at Mawarnkarra Health Service (see Table 19)
including an obstetrician, cardiologist, paediatrician, and ophthalmologist. WACHS employs
dentists who also visit from Port Hedland. Visiting allied health services are from the Pilbara
Health Network (podiatrist, audiologist, dietitian and diabetes educator). An optometry service is
offered by an optometrist who provides outreach services to the Kimberly and Pilbara regions.
Referral to the visiting specialists are made by GPs. Referrals will be entered in to the electronic
system. GPs will be consulted in terms of triaging patients. Appointment cards are sent to
patients prior to visit, a transport service is provided on the day, and patients are chased up
where they don’t attend. There is a dedicated driver for Karratha.
It was reported that visiting specialists at Mawarnkarra Health Service get very high attendance
because of the efforts in coordinate the visiting services.
There are pressures on space in the facility, particularly when some teams are visiting. For
example, the cardiology team requires three rooms when they attend. There are plans to expand
the facility to address some of the space issues.
Mawarnkarra Health Service uses CommuniCare (an electronic medical record and patient
management system) . All matters are recorded electronically there are no paper medical records
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kept. All follow up letters from visiting specialists are scanned into CommuniCare. Some visiting
specialist enter notes directly into the system. CommuniCare records care plans and has a recall
system for identifying patients requiring follow-up.
Optometry
A number of private optometrists operate in Karratha. As mentioned above, an outreach
optometry service is offered.
Benefits of MSOAP services
All informants thought that almost all visiting services supported under MSOAP were needed,
and that the program was extremely important. It was generally considered unrealistic to have a
significant expansion of local specialist staff resident in Karratha, due to cost and other factors.
Existing visiting services into the Aboriginal health service were considered to be working very
well.
Outreach services into Nichol Bay hospital were all needed, but there were significant pressures
in the facility due to the numbers of visiting services, pressures on space in the facility and staff
supporting the services and accommodation for visiting service providers in the community.
Coordination issues are still a major challenge.
An example of the positive impact of visiting services was given in relation to ophthalmic
surgery. Previously procedures were only provided in Port Hedland. This entailed a three day
trip for patients from West Pilbara, which was logistically difficult and very expensive. The
recently established IRIS model for delivery of services in Karratha and Roebourne was
considered a vast improvement. The IRIS team does not charge patients, brings a team of staff
and their own equipment (although Nichol Bay is looking to acquire required equipment in the
future).
Upskilling of local GPs and health providers was considered an important benefit, but this varies
across the visiting specialists. There are more limited opportunities in Nichol Bay due to the
nature and location of the services relative to general practices in the town.
Assessment of need
Local informants felt that historically there had been limited opportunities for having input into
decision making on priorities for visiting services. Despite some specific issues, there was a
sense that this was changing, particularly with the implementation of MSOAP-ICD.
An important local development has been the establishment of a Regional Aboriginal health
forum for the Pilbara. The forum involves, from the Pilbara, the three Aboriginal health
services, the Pilbara Women’s Aboriginal Corporation, Pilbara Health Network, the Pilbara
Regional Office of WACHS and the local RFDS base, and from the state level: the Aboriginal
Health Council of Western Australia, OATSIH and WAHCS. The forum has been operational
for around three years and is supported by a statewide technical group.
The approach to the forum has been to consider all resources related to particular issues, identify
priorities, develop jointly supported proposals in terms of new services, and monitor the
effectiveness of new services.
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The forum should consider all proposals for MSOAP services. One concern was raised about a
particular outreach service that was proposed, but was not supported by the Regional Aboriginal
health forum. However, it appeared the proposal was still pursued.
One view was that a similar approach was required in relation to health services generally for all
people in the Pilbara, but this was not currently in place.
Priority areas for improved outreach services identified by informants included:







renal and associated specialties
cardiology
ENT
expanded diabetes education (there are two diabetes educators for the whole Pilbara)
other chronic disease
dentistry (whole communities haven’t seen a dentist for 12 months).
allied health.
Several informants suggested there were still significant gaps in visiting services with demand
exceeding supply in some key areas (e.g. ophthalmology).
Areas for improvement
It was recognised there was a need to organise clinics well in advance. One factor is that there is
a three to four month waiting time for accommodation for visiting staff. Over the last eight
months local coordination had improved with only a limited number of ‘stuff ups’. It was felt
there was a disconnect between the process through which funding was approved and the need
to plan services well in advance.
It was felt communication from the state level to operational level was not always good. In the
past decisions had been made without adequate consultation with the hospital; with the hospital
not being informed early enough about decisions. It was felt decisions were more supply driven
rather than need driven, with a relative ad hoc approach to planning.
All informants recognised the need for good local coordination, and the need for more support
of these roles. Coordination between visiting specialists can sometimes be poor from a patient’s
perspective. An example was given in which one patient was booked to see four separate visiting
specialists in one day.
The Aboriginal health service emphasised the need for visiting services to be closely linked into
the primary health care delivery team.
One informant emphasised the need to have joint plans of three years, but to build in evaluation
of what has been achieved. Sometimes what appears to be a good idea cannot be implemented in
practice and it is always important to test how well services or policies are working.
It was felt that the state MSOAP Advisory Forum needed to move more towards a group that
reflects the needs of communities/services receiving outreach services, rather than the outreach
services themselves. Program reporting was considered onerous and inefficient.
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Appendix 2.f - Leongatha, Victoria
Region
Leongatha is a town located in South Gippsland Shire, 135km south-east of Melbourne. The
ABS estimated the Statistical Local Area (SLA) to have 12,318 people, 4,818 of whom lived in
Leongatha. Leongatha serves as a centre point for education, health and commerce in the region,
which includes a population of approximately 25,000 people, coming mostly from the three
South Gippsland SLAs (Table 24). Located approximately 15km from Leongatha is Korumburra,
a smaller town that has some commercial and medical services available for people in the region.
Table 20 – Regional population statistics (2006)
ARIA18 Remoteness Area
SEIFA19,
Population21
Township/
location
SLA
Leongatha
(state
suburb)
SLA
South Gippsland Central
1.49
RA2 - Inner regional
996
4,818
20
South Gippsland –
Central
South Gippsland – East
1.92
RA2 - Inner regional
964
7,500
27
3.12
RA3 – Outer regional
945
5,637
50
South Gippsland –
West
1.42
RA2 - Inner regional
945
7,783
28
SLA
SLA
20
ATSI
Pop4
Shown principal town then balance of SLA related to that town where appropriate. SEIFA used is index of relative disadvantage.
Health service organisation
Leongatha is served by one hospital and one health centre and is located in the Department of
Health, Victoria Gippsland DHS region (Figure 12). The nearest major regional Hospital is
located in Traralgon, approximately 73km from Leongatha.
18
http://www.spatialonline.com.au/aria/default.aspx
19
http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&2033055001_%20seifa,%20statistical%20local
%20areas,%20data%20cube%20only,%202006.xls&2033.0.55.001&Data%20Cubes&408900B305C15961CA257417
001175EA&0&2006&26.03.2008&Latest
20
http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&2033.0.55.001%20seifa,%20state%20suburb%
20codes,%20data%20cube%20only,%202006.xls&2033.0.55.001&Data%20Cubes&379403E9EBEDF2A4CA25745
70017FBFA&0&2006&29.05.2008&Latest
21 Source: ABS census data
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Figure 12 – Gippsland DHS region
General practice
Leongatha is served by the GPA South Gippsland Division of General Practice and will be a part
of the Gippsland Medicare Local (Figure 13), which is made up of the GPA South Gippsland,
Central West Gippsland and the East Gippsland Primary Health Alliance Divisions of General
Practice.
The Leongatha catchment is served by two health centres, located in Leongatha and
Korumburra. The centre in Leongatha has approximately 10.5 FTE GPs and the centre in
Korumburra has 5.8 FTE GPs. Within the GPA South Gippsland Division there are 14 practices
and 72 FTE GPs.
Specialist services
Specialist services in Leongatha are provided by visiting doctors through the Leongatha or
Korumburra hospitals. A small amount of Psychiatry services are provided through the
Korumburra Community Mental Health Service operated by Latrobe Hospital, Traralgon.
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Figure 13 –Gippsland Medicare Local
Hospital
Gippsland Southern Health Service operates two hospitals, with the main campus in Leongatha
and a secondary location in Korumburra. Leongatha Hospital has fewer than 50 beds, with
approximately 3,000 admissions per year (Table 12) and Korumburra hospital has approximately
1,000 admissions per year. Over the next three years there is a planned renovation of Leongatha
Hospital, including the construction of all new and modern facilities.
Table 21 – Admissions to Leongatha Hospital
Same day admissions
Overnight admissions
Childbirth
<10
210
Medical (emergency)
85
750
Medical (other)
665
289
Specialist mental health
0
0
Surgical (emergency)
<10
17
Surgical (other)
792
255
Total
1,542
1,521
The specific services that are provided through Leongatha include:
 aged care
 chemotherapy
 outpatient services
 urgent care services.
Optometry
Leongatha is well served by optometrists, with two resident optometrists in town and one
additional practitioner located in Korumburra.
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Travelling into Leongatha
Leongatha is a service hub for people living in the region, serving an estimated population of
about 27,000 people. Travel time into Leongatha from the catchment is typically 15-30 minutes,
with some people traveling up to an hour. The key services that people are travelling into
Leongatha for include gynaecology, general surgery and ENT services. Patients are even traveling
into Leongatha from the outer suburbs of Melbourne because the waiting lists for some
specialties are shorter than at the metropolitan public hospitals. Transport into Leongatha is
primarily through private vehicles (up to 95%), with community transport making up the rest.
Options for travel by community and public transport are very limited and are not time efficient
when available.
Travelling out of Leongatha
Travelling out of Leongatha for health services is very common as the hospital only has the
capacity and capabilities to handle 45-50% of the workload for the region. There are two other
small hospitals in the region, Wonthaggi and Warragul, which receive a small number of cases
from the Leongatha area. Wonthaggi is around a 30 min drive from Leongatha and has a hospital
of a similar size. Patients would be referred to Wonthaggi for dermatology, ophthalmology and
cardiology if they lived nearby. Warragul is a one hour drive from Leongatha on a very
challenging road, so only a few paediatric patients get sent to the hospital there. Most patients are
sent to Latrobe Hospital in Traralgon, which at 73 km is the closest regional hospital to
Leongatha. Services at Latrobe are significantly greater than Leongatha, having over 200 beds
and upwards of 28,000 admissions in 2009-10. Most services are available at Latrobe and patients
will often be sent there for oncology and other specialty services that are not available in
Leongatha. The other main referral pathway out of Leongatha is to the Monash hospital system
in Melbourne, primarily the Dandenong campus. Melbourne is approximately a one and a half
hour drive from Leongatha.
Visiting specialist services
All specialist services available in Leongatha or Korumburra are provided on a visiting basis.
Visiting services are supported by the hospital through free or low cost use of consulting rooms
and operating theatres as well as MBS payments for services provided. The hospital is set up for
and dependent on visiting specialists to provide many of the services that it offers to the
community, from consultations to procedures. Much of the administration for specialist services
is handled by the hospital and visiting specialists are closely integrated with the operations of the
hospital.
MSOAP plays an important role in delivering specialist services to Leongatha Hospital (Table
19), providing payments for over half of the visiting specialists. The feedback we received during
the visit was that many of the visiting services that the hospital receives through MSOAP would
not be viable without the program.
The non-MSOAP specialties that visit Greater Southern Health Service (Leongatha and
Korumburra) are:

general surgeon/endoscopist
MSOAP & VOS Evaluation | Final Report Volume 2

ENT/head and neck surgeon
P a g e | 50







orthopaedic surgeon
surgical assistant
physician/endoscopist
endocrinologist
Program
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
ophthalmologist
physician/neurologist
sports physician.
Table 22 – MSOAP services to Leongatha
Specialty
No of visits22
No
No of ATSI
patients23
patients6
Dermatology
8
0
0
O&G - General
O&G - General
O&G - Gynaecology
Paediatrics - General
Paediatrics Haematology
Psychiatry - General
Surgery - General
Surgery - General
Surgery - Urology
Physician - General
12
18
4
36
20
75
119
0
204
244
1
0
0
0
0
22
12
20
24
81
66
133
426
0
0
0
0
Where delivered
Leongatha Hospital
(new provider to
resume services)
Leongatha Hospital
Leongatha Hospital
Leongatha Hospital
Leongatha Hospital
Leongatha Hospital
Leongatha Hospital
Leongatha Hospital
Leongatha Hospital
Leongatha Hospital
Leongatha Hospital
Services to catchment
MSOAP services to the catchment region are all located in Korumburra and are presented in
Table 23.
MSOAP
Table 23 – MSOAP services to Korumburra
Specialty
No of visits5
No
No of ATSI
patients6
patients6
Paediatrics - General
17
113
0
MSOAP
Surgery - Plastic
State
Psychiatry
Program
Location
Korumburra
Hospital
Korumburra
Hospital
Korumburra
Mental Health
Service
Role of visiting services
Visiting specialist services in Leongatha are integrated with the state health system,
supplementing available services and providing a greater variety of specialists at rural hospitals.
Services are seen locally as both valuable and efficient because they are experienced as well
integrated with their existing health care system. For example, patients are admitted to the
hospital by a local GP, who also serves as the anaesthetists for surgery for these patients. The
GPs therefore have responsibility for the patient before and after the specialist performs a
procedure. A secondary outcome of the GP support is that the local GPs get significant
exposure to the specialist, providing important time for upskilling and education.
22
23
Per annum (2009-2010)
During the period from 1 January 2010 to 30 June 2010
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Leongatha Hospital is currently exceeding all of its targets for activity, an achievement that is
dependent on services from MSOAP providers. The overall volume of services at Greater
Southern is estimated at 45-50% of the total demand within the catchment. The target for the
Health Service is around 60-70%, which is dependent on the pending facilities upgrade and
secondarily on recruiting additional specialists to provide services.
Gaps in specialist services
The primary service gap identified in Leongatha was a shortage of services available in the
region. Local providers see that the types of services that are available meet most of the major
health priorities of the region. However, some specialties in Leongatha have long waiting lists or
infrequent visits and are therefore unable to handle all of the need that exists in the community.
Gaps in surgery and diagnostics exist, but are not unreasonable given the size and scope of the
hospital. CT, ultrasound and pathology services are available locally, with some specialty CT
scans available one day per week. General surgery, endoscopies and basic orthopaedics are also
typically done locally with more complicated and higher risk procedures sent out of the area. The
common diagnostics that are referred out include MRIs, invasive diagnostics, stress testing and
nuclear medicine.
Despite this there was an overall sense that the services meet the major priorities of the
community, there are some additional specialties that are seen as missing or underserved in the
community:







neurology/neurosurgery
orthopaedics (especially major
fractures)
dermatology
ENT
psychiatry
breast surgery
paediatric surgery








cardiology (including cath. lab)
oncology
high risk paediatrics
high risk gynaecology
rheumatology
ophthalmology
gastroenterology
endocrinology
Assessment of need
No coordinated effort exists in Leongatha for assessing the need or setting priorities for visiting
specialist services. Most of the services that exist have been developed on an ad hoc or
opportunistic basis. The fundholder has not directly engaged the local health centres or the
Division to help in the preparation of a needs assessment. The hospital has been most involved
in developing new services, but they feel that it is not a coordinated effort and that they often
have to initiate the process. The hospital also felt that the recruitment process has not been
sufficient in identifying new providers to meet existing need.
The success of visiting services is dependent on patient access to the services and integration of
care between the visiting service and other service providers.
Referrals to the visiting specialist are usually handled through the specialist. The hospital handles
appointments and letter writing for several of the specialists who work from their facilities. In
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these cases the hospital does not charge for these services. Surgery at the hospital is also
managed by the specialist, who has the responsibility to schedule theatre time.
Leongatha Hospital manages the process of notifying local providers of the visiting specialists.
When a specialist begins a service, a ‘meet and greet’ is arranged for the local GPs to learn about
the specialist and to begin to form a relationship with them. Once a service is set up specialists
are encouraged to liaise with the local practices. The hospital provides information to GPs at
practice meetings, and a clinical liaison exists to inform of changes in visiting services.
In addition to the efforts of the Hospital, the Division also informs all GPs and registrars of
visiting services. A list is maintained at the Division that documents the visiting services and is
updated approximately every six months. The list is used both in the education process for GPs
and as a resource to assist people who contact the Division. Overall, most providers are aware of
the visiting services to the area and are able to contact the Division or the hospital if they need
more information.
MSOAP impacts
MSOAP has had a significant positive impact on Leongatha. Since MSOAP began some of the
previous services have stopped, but through MSOAP the number of specialist services has
increased and they have become more varied. Having visiting specialists has also meant that
people do not have to travel out of the area as often and that the local GPs have access to
specialists for advice or quick referrals. In some cases, patients get appointments with a visiting
specialist or surgeon earlier than if they had to travel to Melbourne. The relationships that GPs
are forming with specialists are also leading to opportunities for education and upskilling that
improve the overall level of service for patients whether or not a specialist is there.
The hospital has indicated that the level of service that they are able to provide the community is
dependent on MSOAP. They have found that it would be very difficult if not impossible to
recruit doctors if the doctors did not receive the additional payments from MSOAP. The
hospital also estimates that they are able to provide services more efficiently than in the
metropolitan areas due to lower overheads and higher overall efficiency. Therefore, when a
service can be provided at the regional hospital it is cheaper to operate and reduces the money
and time lost in patient travel.
Areas for improvement
Increasing the number of services provided through MSOAP was seen as the most important
improvement that could be made to the program. Improving recruitment and specialist
engagement was also consistently raised as an area that needed work. Providers have found that
once a specialist comes out they tend to stay; the challenge is getting them there in the first place.
To improve recruitment, stakeholders suggestions included:



Getting specialists involved early in their careers so they can make MSOAP part of their
practice.
Involving interns and registrars in the program to make them more aware of outreach
services.
Providing more funds for recruiting.
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



Development of a national formalised recruitment structure that has specific goals and
measureable outcomes.
Develop a needs assessment and then recruit specialists to fill that need.
Developing marketing and recruiting events that get specialists involved (i.e. dinners).
Pay for some specialists to be employed part time and use that time solely for visiting
services.
Upskilling was raised as one of the major benefits of the program, but the hospital thought that
the provision of upskilling by specialists could be improved through more structure and
increased funding. More specific outcomes and metrics around upskilling could improve the
services significantly through encouraging the specialists to provide this service to local
providers. Finally, when upskilling is scheduled it is important that a block of time is set aside to
encourage a more comprehensive service.
Some general points of improvement were also raised:



increase funding for MSOAP
make administration and room rental payments directly to the location rather than
through the specialist (when possible)
perform better gap analysis of services in the community.
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Appendix 2.g - Maningrida, Northern
Territory
Overview
Maningrida is a remote community located in west Arnhem Land, located approximately 520 km
east of Darwin, a six to seven hour drive. The road is sealed to Cahill’s crossing over the East
Alligator River (approximately 300 kilometres), the balance being well-formed but largely
unsealed. Access by road is typically limited to the dry season (June to November). Maningrida
is accessible by air, with lights for night landings. There are morning and evening commercial
flights from Darwin on weekdays with one flight on Saturdays and Sundays. A regular barge
transports freight from Darwin. For health services, almost all movement of staff and patients is
by air.
The Kunibidji people are the traditional owners of the Maningrida country. There are a range of
other tribal groups who live in the area including the Kunbarlang, Nakkara, Burarra, Gunnartpa,
Gurrgoni, Rembarrnga, Eastern Kunwinjku, Djinang, Wurlaki and Gupapuyngu people. Prior
to the establishment of a settlement at Maningrida, local Aboriginal people travelled around the
region with their clan members following the seasonal varieties of food, water supply and
ceremonial commitments.
Maningrida was established by the Native Welfare Branch of the Commonwealth government as
a trading post and rations depot in the late 1940s. A permanent settlement was established in
1958, and within a few years many people from the surrounding area moved to live in the
settlement.
The estimated population of Maningrida and its outstations in the 2006 Census was 2,437
people, of whom 2,260 (92%) identified as Aboriginal or Torres Strait Islander (ABS 2011a). In
Table 24, regional population statistics are presented along with the estimates for Maningrida.
The accuracy of Census estimates is considered problematic for remote communities like
Maningrida. People in the community believe that the population size is closer to 3,500.
One of the issues impacting estimates of the resident population is its high mobility. There are
now more than 12 outstation centres in a radius of around 70 km around Maningrida, where
clans have returned to live on their ancestral lands. There are frequent movements of people
between Maningrida and the homelands and outstations. In addition, many Maningrida residents
will often stay in Darwin.
Maningrida is located in the West Arnhem SLA, which had an estimated population of 3,333 in
the 2006 census, of whom 3,078 identified as Aboriginal or Torres Strait Islander. The most
recent population estimates for the West Arnhem Balance SLA (which has a slightly different set
of boundaries to the West Arnhem SLA used for the 2006 Census), shows the population
increasing from 5,074 on 30 June 2005 to 5,589 on 30 June 2010 (ABS 2011b).
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Township/ location
Maningrida (Urban
Centre/Locality)
Maningrida Outstation
(Indigenous Area)
Balance of West Arnhem
Statistical Local Area
Total of West Arnhem
Statistical Local Area
Table 24 – Regional population statistics (2006)
ARIA+
Remoteness
SEIFA
Resident
(GISCA 2010)
Area
(ABS 2008)
Population
(ABS 2011a)
RA5 Very
11.34
Na
2,068
remote
RA5 Very
369
Na
remote
RA5 Very
Na
896
remote
RA5 Very
12.84
480
3,333
remote
ATSI
Population
(ABS 2011a)
% ATSI
1,904
92%
356
96%
818
91%
3,078
92%
Maningrida is one of the two largest Aboriginal communities in the Northern Territory (the
other being Wadeye). While the economy is dominated by government services, Maningrida has
a relatively developed commercial sector compared with other remote Aboriginal communities in
the Northern Territory. Many of the local enterprises are associated with Bawinanga Aboriginal
Corporation (BAC), the Maningrida Progress Association (MPA) and the Maningrida Aboriginal
Enterprise Trust (MAET) (NT Government 2008). There are two community supermarkets
operated by MPA and BAC. These are reported to stock a good range of goods at reasonably
competitive prices, including fresh vegetables and fruit, milk, bread, delicatessen items and dry
goods, basic chemist supplies, household goods, clothing and white goods (NT Government
2008; interviews). A weekly ‘tucker run’ is provided by BAC to supply outstations with basic
foods, household goods and clothing. Other commercial activities in the community include an
ANZ Banking Agency and Traditional Credit Union, the MPA motel (10 rooms), two BAC arts
and crafts outlets (Indigenous arts; screen printing), the Arnhem Land Barra Fishing Lodge.
Employment in the community is also provided by a range of government agencies or
government supported NGOs, including the Maningrida Health Clinic, Malabam Health Board,
the School, the Shire Council, Centrelink, Batchelor Institute and JET (Jobs, Education and
Training) Centre, community housing construction and repairs and maintenance.
Since 1 July 2008, Maningrida has been included within the West Arnhem Shire, which is one of
eight new shire areas located in the Northern Territory. (It was previously under the Maningrida
Council Incorporated.) The West Arnhem Shire covers an area of around 50,000 km² and has a
population of 6,591. It includes the communities of Maningrida, Jabiru, Minjilang, Warruwi and
Gunbalanya. Expenditure by the shire in relation to the Maningrida community was reported as
$8.2 million in 2009-10 (West Arnhem Shire Council 2010, p.68).
Health service organisation
There are two health service organisations that operate in Maningrida. The Northern Territory
government run Maningrida Health Clinic and the independent Malabam Health Board
Aboriginal Corporation. There is currently a close working relationship between these services,
which is described in more detail below.
The Malabam Health Board Aboriginal Corporation is a community controlled local health
service affiliated with AMSANT (Australian Medical Services Alliances of the Northern
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Territory). The Board’s members are local residents of Maningrida and its surrounds. Malabam
operates an aged care facility (including residential and home based care) and a range of other
services, some of which are closely integrated with services provided by the Maningrida Health
Clinic. Malabam indirectly employs (through AMSANT) the resident and visiting GPs who
provide primary medical care in the clinic.
Malabam has been around for about 10 years. The organisation is funded to employ health staff.
However, it is not sufficiently established to directly recruit and manage staff. Therefore it
purchases services from DHS, which are provided in the Maningrida clinic. The clinic then
provides reports to Malabam on the services provided under this arrangement.
The Maningrida Health Clinic is a Northern Territory Government managed service. Within the
Department of Health, it is managed by Remote Health within the Darwin Rural Region (see
Figure 14).
Maningrida is located within the catchment boundaries of the Top End Hospital Network,
which includes the Royal Darwin, Katherine and Gove hospitals. Most specialist outreach
services are provided by specialists based at Royal Darwin Hospital. Organisationally, Darwin
Rural Region is a separate entity to the Top End Hospital Network.
Maningrida is also located within the boundaries of the General Practice Network NT (which
covered almost all the area of the Northern Territory and some parts of South Australia). The
proposed Northern Territory Medicare Local will include the whole of the Northern Territory.
Maningrida
Hospital
DH staffed facility
Non DH staffed facility
DH visiting/mobile service
Visiting non-DH service
Figure 14 - Health facilities in selected areas of the Northern Territory
Source: Northern Territory Department of Health and Families 2010
General practice and primary care
Primary health care services for Maningrida are delivered mostly in Maningrida Health Clinic by
2.6 FTE GPs, 12 FTE remote area nurses (with one currently away from clinical duties, acting as
the centre manager) and 3 FTE Aboriginal health workers (one female and two male). The clinic
also employs additional staff as Aboriginal community workers (there are two of these working
as drivers) and support staff (two admin currently, with another about to start). The clinic has a
full time manager.
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One FTE GP is currently residing in Maningrida. Another is employed on a 0.6 FTE basis and
flies into the community for around two days per week. Currently the other available GP
position is covered by locums.
The remote area nurses based at the clinical are either employed to provide a generalist clinical
service or a specialised role (full or part time). Specialised roles include chronic disease
management, women’s health, midwifery, and children’s health.
The chronic disease nurse positions play a role in identifying patients with chronic conditions,
developing chronic disease management plans, identifying patients requiring follow-up or
specialist consultations and ensuring relevant protocols are followed. There are large numbers of
people within the community with chronic conditions, including rheumatic heart disease, other
heart disease, diabetes, and chronic respiratory conditions. However, there is sometimes a
challenge in identifying them, as the major focus (due to the busyness of the staff at the clinic
and competing work priorities) is on acute issues. Once identified with a chronic condition,
patients are flagged as such on the electronic patient information system. This system can then
be used to identify them for follow-up. However, setting priorities in terms of patients requiring
specialist referral is a challenge. This is partly due to nurses having adequate time to undertake
prioritisation, and partly due to not having clear and consistent clinical guidelines for this. The
chronic disease nurse role needs to work closely with a range of visiting specialists, including
general physicians, cardiologists, endocrinologists and nephrologists. However, there is little to
no time for upskilling, which is much needed.
The women’s health role is a part time role. The nurse providing this role also works in a
generalist clinical role. A women’s health clinic is run once a week, although women can come
into the clinic at any time to seek advice or treatment. The women’s health nurse plays an
important role in ensuring women receive regular screening (both for Pap smears and vulva
cancer, which is common among Aboriginal women in the Arnhem regions), have access to birth
control, undergo breast checks, and address continence and a range of other issues. The nurse
works closely with the visiting gynaecologist, who has provided consistent outreach to the
community over the years. The gynaecologist brings her own equipment, and also provides a
nurse who assists with co-ordination between visits. The clinic provides a dedicated vehicle and
driver to assist local women in attending the clinic on the days of the gynaecologist’s visit,
although they are currently looking into recruiting a female driver to further increase attendances.
Nevertheless, attendances for gynaecological appointments is higher than for other services
provided by the clinic.
The midwife is a full time position. She is involved in working with pregnant women from the
time that they suspect a pregnancy (i.e. she provides pregnancy testing and/or refers women with
positive results to physician to confirm the pregnancy) through to the first post-natal visit. Her
role includes education24, arranging for women to have ultrasounds (from a visiting service),
monitoring the progress of a woman’s pregnancy, identifying when women will need to travel to
Darwin prior to a pregnancy and ensuring this occurs, managing emergency childbirths in the
community, and following up women after birth. She works closely with a visiting obstetrician.
Anglicare currently plays the major role in providing education to pregnant women regarding nutrition and
smoking, but the program is due to close, and when it does, the Maningrida midwife will provide this.
24
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The child health nurse takes over the role of caring for children in the clinic from the midwife
from when babies are about eight weeks old. She undertakes vaccinations on Tuesday and
Wednesday each week for children up to four years of age. By that time, each child will get 20 or
more vaccinations. During other times, she monitor’s progress of children (e.g. growth and
nutrition), ensures that children who need regular medication are taking it (e.g. erythromycin
post pneumonia), and identifies children at risk. She works closely with the visiting paediatrician,
who comes once a month for two days at a time. She often needs to organise for children to go
to Darwin for treatment, for example, if they develop a high temperature and the paediatrician is
not there to attend to it.
In addition to the specialised roles, remote area nurses provide a consultation service for patients
who visit the clinic for specific or acute conditions. More complex patients are referred to the
GP. The remote area nurses are also the first point of contact for after-hours services. Most
nurses share a roster.
The nurses and GP are able to consult (at any time) with a District Medical Officer for more
complex cases, for example, where an evacuation to Darwin is required. In less urgent
situations, the GP or nurse may also consult with a specialist who has previously visited
Maningrida, who may also know the patient’s history.
Visiting services
All referrals of patients to visiting specialists are made through the GP. However, this may be
based on advice from a remote area nurse who has seen the patient.
Referrals are made through both the electronic medical record system (the Primary Care
Information System - PCIS) and through a paper based system (including a book in which
appointments are recorded). Several nurses indicated that they needed to spend time reconciling
the referrals made through the electronic system (which seemed to ‘misplace’ some referrals) and
the paper based system.
Around a week prior to a specialist’s visit the relevant nurse will review the referrals, and
reconcile the two systems. The patient list may be discussed with the visiting specialist to ensure
all priority patients are identified. The patient list will also be discussed with a senior Aboriginal
Health Worker who is often aware of which people will be away from Maningrida at the time of
the visit.
Once this list is finalised, reminders/invitations will be prepared. These will be distributed to
patients by one of the drivers employed by the clinic, typically on the day before the visit.
On the day of the visit, some patients will come to the clinic on their own accord. For others, a
driver will try to find the patient and bring them to the clinic. It was reported by several
informants that around 50% of patients on a list will attend on the day. This varies depending
on the specialist and the nature of service being provided.
A range of MSOAP supported and other visiting services are provided into Maningrida. The
visiting services that were identified through this visit are summarised in Table 25.
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Program
Malabam
Malabam
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP
MSOAP-ICD
VOS
NT Govt
NT Govt
NT Govt
Malambam
Malambam
NT Govt
Undetermined
Undetermined
Undetermined
Undetermined
Undetermined
Undetermined
Undetermined
Undetermined
Undetermined
Undetermined
Aust Govt
NT Govt
Table 25 – Visiting health services – Maningrida
Specialty
Number
of visits
per
year
Senior medical officer
23
GP Locum
23
Obstetrics and gynaecology – General
4
Women’s health
Ophthalmology - General
*
Physician – Cardiology (includes capacity to do echo-cardiology,
Registrar also attends)
8
Physician
Psychiatry – Adult
6
Surgery – General
2
ENT specialist
Paediatrician
12
Diabetic/Cardiac Education
4
Optometry (Fred Hollows)
1?
Dental
12
Oral health therapist
Spinal outreach team (rehabilitation physician, South Australia
1
based, NT spinal cord nurse, 2 physiotherapists)
Psychologists
23
Physiotherapist
Mental health nurse
Chronic disease
Child
Podiatrist
Pharmacist
Adult health checks team
Ultrasound service
6
X-ray services
6
Dietitian
Age and disability team (including paediatric OT and SP)
Home medicine review
Australian hearing service (audiologist)
Trachoma screening
Number
of days
per visit
Approx.
patients
per visit
4
3
1
2
1
1
4
1
1
2
1
2
5
5
1
2
10
5
5
5
5
5
1
1
5
5
2
2
Note: This table represents information collected through MSOAP national data and data collected during the site visit to Maningrida. It may not capture all visiting services
* There is funding for an ophthalmologist from Darwin, but this position is currently vacant.
Visiting optometry services to Maningrida are provided by the Fred Hollows Foundation.
Visiting physicians also provide upskilling locally. Thursday afternoons at the clinic are
dedicated for this. In addition to this, it was reported that visiting physicians are generous with
their time in terms of providing one-to-one advice to GPs during their visits and being accessible
outside of visits.
Organisational and resource issues
One of the key issues with visiting services is the organisation that is involved, both for the
specialist and at the local level. A complicating factor is when specialists just ‘turn up’, without
prior notification (or an adequate lead time). This sometimes happens due to errors on either
end.
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The drivers and Aboriginal Health Workers are important resources that all visiting services
compete for. Vehicles and clinic space are also issues. There are currently 16 consulting health
professionals living in Maningrida, as well as the GP, but there are only 13 consulting rooms.
This is managed by rotating health professionals to outstations, and using other parts of the
clinic (e.g. lawns) to provide services.
The Maningrida clinic is currently expanding. A ‘renal ready’ room is being built for home-based
haemodialysis adjacent to the clinic, and a dialysis centre is to be built across the road from the
clinic. Once the dialysis centre is operational, the ‘renal ready’ room will be used for consulting.
A family care centre is also being built across the road from the clinic, where baby checks may be
moved to.
The clinic has a lot of equipment. However, an issue is having people with the training to use it.
One of the issues raised with visiting services from Darwin is that someone needs to organise
them, and needs to champion them at a senior level. If there is no one taking on this role,
physicians would not volunteer on their own, because they are often too busy within the
hospital. This is one of the benefits put forward for MSOAP, that is, that it is a dedicated
program for specialists to visit. Otherwise, with other positions from Darwin, there needs to be
good championing and/or dedicated positions for outreach.
Another issue is the linkage of specialists with primary care locally. That is, primary care staff
need to know when particular specialities are visiting so that they can prepare referrals.
Gaps in specialist services/assessment of need
Eye services in the Top End are generally problematic. For example, there has not been a regular
ophthalmology service for three to four years and cataracts are currently done in Darwin. The
Central Australian model was put forward is a good model. The key features of its success were
quoted as a (skilled) team-based approach bringing their own equipment and integrating with the
primary sector locally.
Another big gap is dental. Currently a dentist visits one week per month, but the need is for at
least one full time dentist.
Other gaps are:



chronic disease management
cardiology (main issue is irregularity of the service)
ENT (e.g. myringotomies done in Katherine).
The visiting GP is an advocate for the health clinic back in Darwin (0.3 of his 0.6 FTE
appointment is spent in Darwin), and he assists in communicating what the needs of the clinic
are. The new LMO may be able to take on this role in the future.
The clinic is currently trying to recruit for the other LMO position. However, even when this is
filled, they will still be shortage of staff. For example, there are 670 people with chronic disease
in the region, with almost all of them needing a six-month review, and some needing a threemonth review.
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One of the issues for the clinic is that like others, it is focussed on the acute burden, and there
are not a lot of resources left for the chronic component.
Malabam and the Maningrida clinic have a shared strategic plan. There is a community reference
group to discuss the needs of the community. However, there are many clans in Maningrida,
and it is difficult to get a consensus for action on many issues.
Therefore, some of the improvements that can be made to services within Maningrida need to
occur locally. These include better planning and assessment of need, for example, looking more
closely at demography, morbidity and mortality, and an analysis what people go to Darwin for
(or use patient transport assistant scheme). Currently about $7 million is spent on evacuation,
for the plane trips alone, and therefore, the service model may need to change. For example,
Maningrida may need a hospital given its population size and health care issues.
Succession planning is also needed for visiting specialists, as continuity suffers when someone
retires or does not visit any longer.
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Appendix 2.h – Tele-Derm, Australian
College of Rural and Remote Medicine
Background
Tele-Derm is a program run by the Australian College of Rural and Remote Medicine (ACRRM)
to provide specialist dermatology support and education to rural and remote GPs. The program
began in 2003, building on an existing relationship that ACRRM had developed with a
dermatologist. Through the dermatologists work providing training for the College, he realised
that many cases could be diagnosed very quickly using very basic information (i.e. pictures). This
realisation led to a proposal to one Queensland fundholder (now called General Practice
Queensland) for the provision of teledermatology services for rural and remote Queensland
doctors.
At the time, there was extra funding in the fundholder’s budget which allowed for the service to
be rolled out as a trial. Initially, only doctors from Queensland were allowed to use the service
due to funding and medical licensing restrictions. Because of the success of the program the trial
was expanded to the rest of the country and funding was transferred to the national DoHA
office. In order to achieve this expansion, the medical licensing for the dermatologist was
increased to allow him to practice in all states. At the same time, through the MSOAP funding,
ACRRM added a teleradiology service in addition to the Tele-Derm program.
Program structure
The Tele-Derm program has been integrated as part of the Rural and Remote Education Online
(RRMEO) portal. RRMEO provides access to a broad range of tools that support education and
development for rural and remote doctors. Including Tele-Derm within the portal allows for the
infrastructure and audience that has already been developed for RRMEO to be directly
integrated with MSOAP. ACRRM has approximately 3,000 members, with an additional 7,000
people who are members of organisations that have purchased access to RRMEO, including
groups such as registrars and John Flynn Scholars. Of the ~10,000 people with access to
RRMEO, greater than 7,500 would be eligible to register for Tele-Derm.
For individuals that are eligible to register for RRMEO, a separate registration process is still
required to participate in Tele-Derm. As part of the funding that MSOAP provides, any doctor
eligible for MSOAP funding can apply for access to Tele-Derm. For doctors who register
through MSOAP, they are provided access solely to the Tele-Derm portion of the RRMEO
portal.
There are two main components to the Tele-Derm portal, a specific telemedicine component
and a telehealth component. Telemedicine in this case is defined as traditional clinical medical
services provided over a distance using electronic communication. With Tele-Derm, the
telemedicine component is delivered through a store and forward (asynchronous) method where
a doctor submits pictures and case information to the site for the dermatologist to diagnose and
respond. This type of service is in contrast to ‘real-time’ telemedicine where a live teleconference
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occurs between patients and doctors. Telehealth in this case is defined as the use of information
and communication technology for administration and education in addition to clinical services.
ACRRM has made education a major component of Tele-Derm, indicating that the educational
component is as or more important than the direct clinical services that are provided through the
program.
The telemedical component of the program is based on the store and forward model, where
cases are submitted by doctors and then at a later time the dermatologist provides a response
that can then be accessed by the doctor. A doctor will submit a set of pictures and case
information to the website, a process which feedback has indicated takes around 20-40 minutes
for the GP to prepare. The GP does not receive any payment from ACRRM or Medicare for this
service. Once the case is submitted, the ACRRM dermatologist accesses the case and writes a
response that is made available to both the submitting doctor and all other Tele-Derm users. The
case information is always left deidentified, but ACRRM does keep a record of the doctor who
submitted the case.
In general, responses by the dermatologist are returned within 24 hours of initial submission,
though the turnaround can be significantly shorter. A new feature has been developed for urgent
cases to use SMS notification to speed up the process. When an urgent case is submitted, the
dermatologist receives a SMS notifying him of the submission. When he responds, the doctor
who submitted the request receives a SMS to alert them that a response has been posted.
Within the Tele-Derm portal there are several main areas that can be accessed by registered
users: submitted cases, a dermoscopy atlas, a condition index, tips from the dermatologist and
discussion forums. All cases that have been submitted can be viewed by all registered users of
the program. Overall, there are 543 standard cases plus 186 dermoscopy cases that can be viewed
by doctors to read and learn from, including the ability to guess at diagnoses and then have the
answer revealed. Both the dermoscopy atlas and the condition access are designed to allow
doctors to educate themselves on conditions and improve their self-diagnostic capabilities
without having to submit every case directly. There is also an educational section written by the
dermatologist to provide tips and tricks related to dermatology. For example, there is
information on procedures, including biopsies and cryosurgery, how to take a good skin history
from a patient, how to take good dermatology photographs and a list of other useful websites.
Finally, the online discussion forums allow for doctors and the dermatologist to interact, learn
and discuss dermatology cases.
Evidence indicates that many of the users of the portal are there for educational purposes rather
than a direct clinical need. For example, registrars will often visit to learn and study for their
training. Medical students can use the portal for similar purposes.
In order to generate interest and participation in the program, ACRRM has a case of the week
that is e-mailed to all users. This involves a picture and a short description. Users can then click
on the case to read the full details and then submit a response of their diagnosis of the case. At
the end of the week, the ACRRM dermatologist provides a full discussion and diagnosis of the
case in addition to responding to all of the comments posted throughout the week. Overall, the
dermatologist provides about 1,000 comments per year in response to postings in the forums.
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General marketing of the Tele-Derm program is through the ACRRM website and
advertisements are placed in all of the state specialist directories.
Rural and Remote Education Online (RRMEO) portal
RRMEO is a unique online portal for education that ACRRM has internally developed. In order
to access the portal users must register with ACRRM. Depending on their membership and
eligibility, they will be provided access to portions of the portal. Everything that ACRRM
accredits is available and searchable, such as classes (online and in person), workshops, training
posts and educational resources. A learning planner is also provided for ACRRM members that
allow educational activities and documentation to be tracked and stored for easy submission to
accreditation organisations. The other main component of RRMEO is the online modules. TeleDerm is one of these, in addition to other educational tools in a variety of clinical areas and live
learning through virtual classrooms. Other features of the portal include the ability to download
clinical guidelines on mobile devices, take tests online and many other components that allow
rural and remote doctors to be educated and trained without leaving their community.
Funding
Funding for Tele-Derm is currently through MSOAP and is provided as part of a contract with
ACRRM to support the service. The budget has remained fairly stable through the course of the
program and has only increased marginally to adjust for inflation. The amount of funding
received is defined by DoHA and specifies the exact levels of expenditure for individual
components of the program such as wages and promotional activities. While the overall budget
provided to ACRRM includes both Tele-Derm and teleradiology, the funding for each is clearly
defined.
The dermatologist that ACRRM employs for the program is paid an hourly wage that is defined
by MSOAP based on a standard rate for specialist services. Payments are then made to the
dermatologist on a sessional basis. National licensing that is required for the services to be
provided are reimbursed for the dermatologist by ACRRM from their budget.
Usage
Currently there are around 1,500 subscribers to the ACRRM Tele-Derm program. Subscribers
include doctors, registrars and medical students amongst others. In order to register for the TeleDerm program a user must be a member of ACRRM, a member organisation that subscribes to
RRMEO or be a doctor that is eligible for MSOAP (i.e. not in a major city). As part of the
budget DoHA provides funding to support subscription of eligible doctors to the Tele-Derm
portal. Of the 1,500 subscribers to the service, approximately 300 are registered through the
eligibility that MSOAP provides. Many participants access the program for educational purposes
and do not submit any cases directly. Anecdotal evidence indicates that many doctors would like
to submit cases, but due to time constraints or other barriers have not done so. However, once a
doctor submits a case and become familiar with the process, they seem to subsequently submit
cases consistently.
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The program grew rapidly after its initial introduction, quickly attracting 500-600 members. By
the 2005-06 financial year there were 20,000 hits to the site and over 150 cases submitted25.
Currently, the website attracts between 4,500 and 7,000 hits per month (Table 26) and receives
approximately one new case per day.
Table 26 – Tele-Derm web site hits
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
4842
6915
8151
4409
5760
6838
4948
May11
5881
Jun-11
4462
Jul-11
6479
Aug-11
7237
Dermatologist experience
Dr. Jim Muir is the dermatologist employed by ACRRM to provide the clinical support for the
Tele-Derm program. As previously discussed he responds to cases, supports the online
education and responds to online posts by doctors. He has been involved with the Tele-Derm
program since its inception in 2003, with additional involvement with ACRRM prior to the
commencement of the program. During his early career Dr. Muir was involved in outreach to
rural locations and also participated in one year of video based telemedicine services.
The idea for telemedicine began through Dr. Muir’s involvement in receiving e-mails of cases
from rural doctors early in his career. The catalyst came when he received an e-mail with a photo
of necrosis and saw that he could diagnose acute cases through e-mail. There are other doctors
and hospitals that provide dermatologically based telemedicine programs, but their scope is
limited and they do not provide any educational services.
Benefits of store and forward
The use of store and forward provides significant benefits for dermatology relative to real time
telemedicine services. Currently, most models of real time telemedicine require both the patient
and a clinician to be present for the consultation with a specialist. Logistically and resource wise,
this arrangement is both costly and difficult to arrange. Due to rebates, some dermatologists
provide real time telemedicine services, but often ask for high resolution photos and a case
history prior to the video conference. The use of store and forward allows the case to be brought
forward anytime of the day, it uses higher quality images and responses can be sent back rapidly
and made available to the referring doctor at their convenience.
Relationship between visiting services and Tele-Derm
Dermatology is fairly unique in the medical field in that diagnosis is the most challenging aspect
of the practice. Generally, prescribing and treatment are fairly straightforward. What this means
is that the speciality is extraordinarily well suited to telemedicine as such a large percentage of
cases can be diagnosed through pictures and case histories. This means that a significant portion
of visiting dermatology service can be replaced with Tele-Derm.
Australian College of Rural and Remote Medicine 2010, 'ACRRM Medical Specialist Outreach Assistance
Program Annual Plan', Report to DoHA.
25
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The other important issue in telemedical services is the treatment and follow up of issues that
have been diagnosed. Traditional visiting services required patients to wait for the visiting
specialist to return or for their local doctor to follow up with their care. Often the visits by the
specialist could be far apart and the local doctor might not have sufficient initiative, knowledge
or information to provide comprehensive care.
Tele-Derm addresses a lot of these issues through the combination of education and
telemedicine services. Having the doctor take pictures and a case history involves the doctor in
the case directly, providing both knowledge, ownership and initiative in the treatment of the
patient. Furthermore, the availability of educational resources on the Tele-Derm site provides the
resources to allow GPs to perform many procedures that are essential for dermatology. Many of
these are straightforward and most competent doctors can already do or learn them through the
tutorials Dr. Muir has provided online. Cases can also be addressed through the back log of cases
provided online, allowing GPs to research a condition and make a diagnosis without consulting a
dermatologist directly.
The overall assessment of telemedicine versus visiting dermatology services is that they do not
have to be as good as face to face, they just have to be better than what is currently available. In
the public sector, there are six month to year long waiting lists for dermatology, whereas TeleDerm can have a turnaround of less than a day. Most dermatologists are located in major cities
or large regional centres, meaning that a significant amount of travel time is required by rural
patients. Tele-Derm only requires them to travel to their local GP. Overall, the service offers
significant benefit and provides no more risk of misdiagnosis or mistreatment than a face to face
consultation with a dermatologist. One final benefit of the Tele-Derm program is that it can
reduce professional isolation for doctors, increase their confidence in diagnosis and help them to
feel more connected to the medical profession.
Improvement and expansion
In order to improve and expand the service, the goal would be to minimise work for the
referring doctor as possible. While it might be easier for the patient to participate in Tele-Derm,
it is still less time and effort to refer the patient to a dermatologist directly, since referring GPs
are not paid for the time they put into Tele-Derm. If the system could engage an assistant to take
some case history and pictures, then there is the opportunity to get more GPs involved.
Areas where there is room for expansion of services includes:







nursing homes
inpatient units
ships at sea
locations where it is logistically or economically not feasible to visit
follow up services
anywhere where waitlists are long
emergency consultation.
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Function and future directions
The program seems to be well accepted by dermatologists as there are a small number that are
practicing in Australia, with most having a waiting list of around six months. The role that the
dermatologist plays for ACRRM does not threaten other practices and is not the result of a tech
savvy business, but rather the desire to meet a strong need that exists in the community.
The experience of ACRRM is that teledermatology could not replace outreach, but could further
integrate and coordinate the services that are going out. A wider adoption of the Tele-Derm
program could first and foremost reduce the number of cases that need direct outreach by a
dermatologist. The educational component of the program could upskill many GPs who could
diagnose more cases without specialist referral and could send additional cases to the online
system for remote diagnosis. For other cases, information could be sent prior to visits so that
dermatologists were better prepared to make efficient use of time during outreach visits.
Potentially, a whole electronic coordination and diagnostic system could be developed to direct
patients and doctors to the most efficient path for diagnosis and treatment. The current program
run by ACRRM has the capability to expand further to cover more cases and doctors across
Australia and provide additional services to aide in dermatology outreach in general.
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Population and Housing, ABS, Canberra, viewed 10/8/2010,
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