Health Needs Assessment 2017

Databook

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LIST OF ACRONYMS

Acronyms ABS Australian Bureau of Statistics

ACPR Aged Care Planning Regions

ACT Australian Capital Territory

ADHD Attention Deficit/Hyperactivity Disorder

AEDC Australian Early Development Census

AHPRA Australian Health Practitioner Regulation Agency

AIHW Australian Institute of Health and Welfare

AMS Aboriginal Medical Service

AOD Alcohol and Other Drugs

ARIA Accessibility/Remoteness Index of Australia

ASGC Australian Standard Geographical Classification

ASGC – RA Australian Standard Geographical Classification – Remoteness Area

ATAPS Access to Allied Psychological Services

ATSI Aboriginal and Torres Strait Islanders

AUS Australia

CAMHS Child and Adolescent Mental Health Services

CAODS Calvary Alcohol and Other Drug Services

CKD Chronic Kidney Disease

CL Consultation Liaison

COPD Chronic Obstructive Pulmonary Disease

DRGs Diagnostic related group

DOH Department of Health

ED Emergency Department

EN Enrolled Nurse

KBC Australia P a g e | 2 ENT Ears/Nose/Throat

FACS Family and Community Services

FTE Full Time Employee

GAMS Griffith Aboriginal Medical Service

GP General Practitioner

HACC Home and Community Care

HIV Human Immunodeficiency Virus

HNA Health Needs Assessment

IARE Indigenous Area

IRSEO Indigenous Relative Socioeconomic Outcomes

IRSD Index of Relative Socio-Economic Disadvantage

LGA Local Government Area

LHAC Local Health Advisory Committee

MBS Medical Benefits Schedule

MH Mental Health

MHDA Mental Health Drug and Alcohol

MHECS Mental Health Emergency Care Support

MHNIP Mental Health Nurse Incentive Scheme

MLHD Murrumbidgee Local Health District

MPHN Murrumbidgee Primary Health Network

MPS Multipurpose Service

MVA Motor Vehicle Accident

NCIMS Notifiable Conditions Information Management System

NGO Non-Government Organisation

NHPA National Health Performance Authority

NSW

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OTP Opioid Treatment Program

PBS Pharmaceutical Benefits Scheme

PENCAT Clinical Audit Tool

PHC Primary Health Care

PHIDU Public Health Information Unit

PPH Potentially Preventable Hospitalisations

PHN Primary Health Network

RDAA Rural Doctors Association of Australia

RN Registered Nurse

ROSH Risk of Serious Harm

RU Relative Utilisation

SMHOP Specialist Mental Health Services for Older People

SRG Service Related Groups

TFR Total Fertility Rate

URP Usual Resident Population

UTI Urinary Tract Infection

VMO Visiting Medical Officer

KBC Australia P a g e | 4 Contents

List of Acronyms ...... 2 1 Introduction ...... 9 2 Overview of the Region ...... 9 2.1.1 Sectors in the Murrumbidgee Region ...... 12 3 Summary of MPHN ...... 14 4 Overview of the Health Service System ...... 29 5 Methodology ...... 33 5.1 Data sources and limitations...... 36 5.1.1 Data sources included ...... 36 5.1.2 Data Limitations ...... 37 6 Demographic profile ...... 38 6.1 Population by LGA ...... 38 6.2 Population growth ...... 39 6.3 Age and gender ...... 40 6.4 Births and deaths ...... 43 6.5 Population groups ...... 43 6.5.1 Aboriginal and Torres Strait Islanders ...... 43 6.5.2 People from culturally and linguistically diverse backgrounds ...... 47 6.5.3 People living with a disability ...... 48 6.5.4 Older persons ...... 49 7 Determinants of health ...... 50 7.1 Socio-economic profile ...... 50 7.2 Social determinants ...... 52 7.2.1 Education ...... 52 7.2.2 Industry and Employment ...... 52 7.2.3 Rurality ...... 53 7.2.4 Income ...... 54 7.2.5 Families and households ...... 54 7.2.6 Reported offences ...... 54 7.3 Behavioural determinants ...... 56 7.3.1 Smoking ...... 56

KBC Australia P a g e | 5 7.3.2 Alcohol ...... 56 7.3.3 Exercise, nutrition and obesity ...... 56 7.3.4 High cholesterol ...... 57 7.3.5 High blood pressure ...... 57 7.3.6 Screening ...... 57 8 Health status ...... 59 8.1 Life expectancy ...... 59 8.2 Mortality ...... 59 8.2.1 Median age of death ...... 59 8.2.2 Mortality rates ...... 60 8.2.3 Potentially avoidable deaths ...... 61 8.2.4 Premature mortality ...... 61 8.2.5 Causes of death ...... 62 8.3 Hospitalisations and Potentially Preventable Hospitalisations ...... 63 8.3.1 Potentially preventable hospitalisations ...... 66 8.4 Mental Health ...... 70 8.4.1 Prevalence of mental health in MPHN ...... 70 8.4.2 Mental health related hospitalisations ...... 71 8.4.3 Mental illness in children and young people ...... 72 8.4.4 Adults and mental illness ...... 74 8.5 Alcohol and other drugs (AOD) ...... 75 8.5.1 AOD hospitalisations ...... 75 8.5.2 AOD Services ...... 77 8.6 Suicide ...... 78 8.6.1 Intentional self-harm hospitalisations ...... 78 8.6.2 Suicide rates ...... 80 8.7 Cancer ...... 82 8.8 Chronic disease ...... 82 8.8.1 Comorbid chronic disease ...... 83 8.8.2 Cardiovascular disease ...... 83 8.8.3 Respiratory Disease ...... 88 8.8.4 Chronic Kidney disease ...... 91 8.8.5 Diabetes ...... 91 8.9 Sexual health and Infectious disease ...... 92

KBC Australia P a g e | 6 8.10 Oral health ...... 94 9 Health of population groups ...... 96 9.1 Mothers, infants and young children ...... 96 9.1.1 Fertility ...... 96 9.1.2 Maternal and Infant indicators ...... 96 9.1.3 Infant mortality ...... 98 9.1.4 Immunisation ...... 98 9.1.5 Developmentally vulnerable children ...... 98 9.2 Youth ...... 99 9.3 Older persons ...... 101 9.3.1 Arthritis ...... 102 9.3.2 Dementia ...... 102 9.3.3 Falls ...... 103 9.3.4 Vaccination ...... 103 9.4 Health of Aboriginal and Torres Strait Islanders ...... 103 9.4.1 Chronic and mental illness amongst Aboriginal people ...... 104 9.4.2 Indigenous Health Check ...... 110 10 Health services ...... 111 10.1 Overview of the service system ...... 111 10.2 Referral patterns and patient flows ...... 111 10.3 Primary Care...... 112 10.3.1 Medicare Benefit Scheme (MBS) ...... 114 10.3.2 GP utilisation ...... 115 10.4 Workforce ...... 115 10.4.1 District of workforce shortage ...... 116 10.4.2 Specialist workforce ...... 116 10.4.3 Nursing ...... 116 10.4.4 Dental ...... 117 10.4.5 Pharmacy ...... 118 10.4.6 Podiatrists ...... 118 10.4.7 Occupational Therapists ...... 118 10.4.8 Physiotherapists ...... 118 10.4.9 Psychologists ...... 118 10.5 Hospitals and Health facilities ...... 119

KBC Australia P a g e | 7 10.5.1 Emergency Departments ...... 119 10.6 Health insurance ...... 122 10.7 Aged Care ...... 123 11 Mental Health services ...... 123 11.1.1 Mental Health Nurse Incentive Program ...... 124 11.1.2 Psychological Strategies (formerly known as ATAPS) ...... 125 11.1.3 Better Access and Better Outcomes Services ...... 126 11.1.4 Mental Health Hospitalisations ...... 131 11.2 Non- Government providers ...... 133 11.2.1 Headspace ...... 133 11.2.2 Royal Far West (RFW) ...... 133 11.2.3 Centacare ...... 134 11.2.4 Kurrajong Early Intervention Service ...... 134 11.2.5 Intereach ROAR Program ...... 134 11.2.6 Domestic Violence Program ...... 134 11.3 Community Mental Health ...... 135 11.3.1 Specialist Child and Adolescent Mental Health Services ...... 135 11.3.2 Specialist Youth Mental Health Services ...... 135 11.3.3 Specialist Adult Mental Health Services...... 136 11.3.4 Specialist Mental Health Services for Older People ...... 136 11.4 Acute Mental Health ...... 137 11.5 Drug and Alcohol Services ...... 138 11.5.1 Opioid treatment services...... 139 11.5.2 Specialist addiction counselling ...... 139 11.5.3 Consultation liaison services ...... 139 11.5.4 Withdrawal management ...... 139 11.6 Non-Government AOD services ...... 140 References ...... 142 Appendix 1 ...... 145 Appendix 2 ...... 146 Appendix 3 Facilities and service summary, by sector ...... 148 Appendix 4 ...... 152

KBC Australia P a g e | 8 1 INTRODUCTION

This data book has been prepared as a background technical paper for the Murrumbidgee Primary Health Needs Assessment.

The purpose of the Murrumbidgee Needs Assessment is to provide an evidence base to inform a regional consolidated plan that will provide a blueprint for the design, redesign and investment in health services and programs to improve the health and wellbeing of living in the Murrumbidgee Region.

The Technical Paper includes:

 A demographic profile of the region  A breakdown of the determinants of health  A detailed description of the health status of residents  A detailed description of the health workforce and available health services and  A breakdown of health service utilisation within the region

2 OVERVIEW OF THE REGION

The Murrumbidgee Primary Health Network(MPHN) is located in the south-west of NSW and shares borders with Western NSW, South Eastern NSW, ACT, Gippsland and Murray PHNs in . The MPHN covers a geographic area of 136,919 square kilometres. As a result of local government amalgamations, the number of LGAs in the MPHN has recently reduced from 29 to 21. Data presented in this health needs assessment draws on information as it relates to the newly configured LGAs. The population within the MPHN catchment is 237,680 (ABS, URP 2016 Census) which gives the region a population density of 1.7 persons per km2, the second least densely populated PHN in New South Wales.1 Just under 5% of the population (11,505 persons) identify as Aboriginal and/or Torres Strait Islander peoples.

The region is accessed by numerous north-south transport connections via the Hume, Olympic, Mallee, Silver City, Cobb, Newell highways and the Kidman Way. The Sturt, and Mid-Western highways and Burley Griffin way serve as east-west connections. is situated on the main Southern railway line between and .

Wagga Wagga is the principal commercial centre of the MPHN region, with Griffith as a secondary centre to the region and a key commercial centre for the Murrumbidgee Irrigation Area subregion. The majority of health services, higher education and employment opportunities are located in these larger centres.

The flows east-west through the entire PHN and the at the Victorian border forms part of the boundary in the southern part of the region. Both of these rivers are critical to agriculture, industry, tourism and development in the region.

1 Population density of the Murrumbidgee region lies between Western NSW PHN with a population density of 0.71 persons per square kilometre and Hunter New England and Central Coast PHN with a density of 9.45 persons per square kilometre.

KBC Australia P a g e | 9 The Murrumbidgee region is characterised by extensive alluvial floodplains with low-lying lands, associated with the Murrumbidgee, Murray and Lachlan Rivers. The Murrumbidgee area has a semiarid climate with low, winter-dominant rainfall, hot summers and cool winters. In the higher regions, summers are cool and snow is common during winter. The main industry is agriculture with grains, almonds, , beef, cotton, wine grapes and rice. The Murrumbidgee area is also home for both Army and Air Force bases as well as the major campus of University.

Towns along the Murray river often have ‘twin towns’ on the Victorian side of the river which have a high degree of inter-dependence in terms of services, employment, health, transport links, commerce and education.

KBC Australia P a g e | 10 Figure 2-1 Murrumbidgee PHN boundaries and sectors

KBC Australia P a g e | 11 Under the ASGC Remote Areas classification over 60% of the Murrumbidgee population resides in inner regional areas and 38.7% in outer regional areas. The remaining 1.1% live in remote areas. Figure 2-2 maps the ASGS-RA Categories in the Murrumbidgee region.

Figure 2-2 ASGC – Remoteness category mapped to MPHN

2.1.1 Sectors in the Murrumbidgee Region

The MPHN and Murrumbidgee Local Health District have completely congruent boundaries with the 21 local government areas divided into four geographical sectors for planning purposes. While the Murrumbidgee and Shire Councils merger (to become the ) crosses over the Border and Western sectors, the sector boundaries will remain in place for planning. Despite its location in NSW, the local government area of has not been included in the MPHN or MLHD geographical boundary. The complete LGA of Lachlan is not included in the MPHN geographical area, with only 27% of this LGA comprising the town of Lake Cargelligo and immediate surrounds included.

The new LGAs within MPHN are explained in Table 5-2.

KBC Australia P a g e | 12 Sectors Border Riverina Wagga Wagga Western

No. of 6.5 7 1 6.5 LGAs Berrigan Bland Coolamon Griffith Federation Hay Name of Wagga Wagga LGAs Hilltops Lachlan Lockhart Leeton Snowy Murrumbidgee Murray River Valleys (Murrumbidgee) Murrumbidgee Temora (Jerilderie)

The Border Sector comprises 6.5 local government areas. This sector contains 24% of the Murrumbidgee PHN population. The boundaries stretch from in the west to Lockhart and Greater Hume Shire in the east. The southern boundary of the sector borders the state of Victoria. The population density of this sector ranges from 52 persons/km2 in to 0.2 person/km2 in . The sector consists of outer and inner regional areas with 61% of the population residing in an outer regional LGA.

The Riverina Sector comprises 7 local government areas and 28% of the Murrumbidgee PHN population resides in this sector. The boundaries stretch from Bland and Coolamon in the west to Boorowa, Harden, Gundagai, and in the east. Tumut is the LGA in the sector that borders ACT, while Tumbarumba borders the state of Victoria and south-eastern NSW. Residents in this sector are fairly evenly spread across the geographical catchment consisting of inner and outer regional areas. Sixty two percent (62%) of the population lives in an inner regional LGA.

Wagga Wagga is the only LGA in the Wagga Wagga Sector and contains 26% of the Murrumbidgee PHN population. Wagga Wagga is an inner regional LGA and the third most densely populated LGA in the Murrumbidgee region (13 persons/km2). This follows Deniliquin (52 persons/km2) and Griffith (16 persons/km2).

The Western Sector comprises 6.5 local government areas and is where 22% of the Murrumbidgee PHN population calls home. Hay, Carrathool and part of Lachlan LGAs make up the north and west border of this sector, forming the north-west corner of the PHN. It is the least densely populated sector in the Murrumbidgee region and 49% of the population resides in Griffith LGA. 51.37% of the population in this sector lives in inner regional areas, 43.4% in outer regional and 5.2% in the remote area of Carrathool.

KBC Australia P a g e | 13 3 SUMMARY OF MPHN

Table 3-1 Demographics Issue Key Issue Description of Evidence Population Population density varies across Population of the MPHN is 237,680 (ABS, URP 2016 Census) density and sectors Population density varies in the region. Carrathool LGA is the lowest at 0.1 persons/km2 and Remoteness Griffith LGA the highest at 15.5 persons/km2. Parts of the MPHN remote 60% of the Murrumbidgee population reside in Inner Regional Areas (ASGC-RA), 38.9% in outer regional areas and 1.1% in remote. Western Sector, 5.2% of population reside in remote areas. Population Over next 20 years, small population The region’s population is expected to grow by 1.2% by 2036, which is much lower than NSW Projections growth overall compared with NSW 28.1% and Australia, 33.1%. Population changes differ across the sectors, with Wagga Wagga and Australia, with population expected to grow by 18.4%, but all others projected to decline (Border -3.4%, Western – decline in three sectors 4.9%, Riverina -7.1%). Aboriginal Aboriginal population is higher than From ABS URP 2016, 11,505 people (4.8% of the region’s population) identify as Aboriginal population NSW, with variation across LGAs and (3.0% Border, 4.5% Riverina, 5.6% Wagga Wagga and 6.3% Western). This is higher than sectors NSW (2.9%) and Australia (2.8%). Largest Aboriginal populations are in Wagga Wagga and Griffith. LGAs with highest proportion of Aboriginal people are Lachlan – the Lake Cargelligo Area (17.6%), Narrandera (9.7%), Carrathool (7.9%) and Junee (7.9%). Population Older population profile than NSW, From PHIDU PHN, overall Murrumbidgee has similar population profile to NSW, however, Profile with sector variation greater proportion of the population is over 65 years in Riverina (21.5%) and Border (23.9%) compared with MPHN (18.9%) and NSW (15.7%). Furthermore, in these two sectors, around 50% of the population is over 45 years compared with 45% (MPHN) and 40% for NSW. Small proportion of population is 4.4% (10,144 people) of Murrumbidgee population are born in non-English speaking CALD residents, however recent countries (2011 PHIDU). Between 2009-2013 there were 408 refugees settled in Wagga settlement of refugees Wagga, Griffith, Leeton, Murrumbidgee and Wakool Shires (A report on women’s health: Murrumbidgee Local Health District) Disability Proportion of population with a Similar rates of profound or severe disability in the population compared with NSW (MPHN profound or severe disability similar 5.1%, NSW 4.9%). LGAs with highest proportion of population with severe of profound to NSW disability in , , Temora, Narrandera, Berrigan.

KBC Australia P a g e | 14 Table 3-2 Health Determinants Topic Key Issue Description of evidence Socio-economic Higher levels of disadvantage with From 2011 Census, overall Murrumbidgee region has lower IRSD (969) compared with factors sector variation, and pockets of NSW (996). Wagga Wagga sector has higher IRSD (998) and there is variation between disadvantage within LGAs LGAs within sectors. Of note, LGAs of Narrandera, Hay and Murrumbidgee have IRSD scores placed in Australia’s most disadvantaged quintile. Analysis at SA1 level indicates pockets of disadvantage around Griffith, Harden, Junee, Young, Narrandera and (PHIDU) Geospatial mapping presented in the MPHN MHAOD Needs Assessment 2015-16, identifies the most socially and economically disadvantaged subregions to be: Griffith and ; Lake Cargelligo and Tullibigeal; , Leeton, , , and Gillenbal; and Wagga suburbs including Ashmont, Moorong, San Isidiore and Kapooka. Highly disadvantaged areas for From Aboriginal Health Profile MLHD, 2017, the most highly disadvantaged areas in the Aboriginal people in the Murrumbidgee are around Young, Deniliquin, Gundagai and Griffith [Indigenous Relative Murrumbidgee identified Socioeconomic Outcomes Index (IRSEQ)] Education Lower level of education attainment Attainment of Yr 12 education (or equivalent) in Murrumbidgee is lower than NSW (29.7% v 42.4%), as is university education (19.8% v 30.2%), while attainment of VET qualification is higher (34.6% V 25.1%). Unemployment Generally lower unemployment rates, Unemployment rates fluctuated between 3% and 6% over the last five years (from Small but higher rates in the Aboriginal Area Labour Markets). At June 2016 unemployment in MPHN was 4%, and lower than population NSW (5.4%) and Australia (5.9%). However, unemployment in the Aboriginal population was 17% (ABS 2011). Health Literacy Lower levels of health literacy Clinical Council consultations identified low health literacy evidenced by:  Health behaviours contributing to risk factors  Uptake of cancer screening  Late stage detection of cancers and chronic kidney disease  Poor understanding of chronic conditions, exacerbation of symptoms leading to hospitalisation Income MPHN people access the aged care Murrumbidgee LHD had approximately 31,000 aged pensioners in June 2014, 72 per cent pension and concession cards at of the eligible population compared to 69 per cent in NSW. In June 2014, there were similar rates to NSW, however there approximately 64,400 concession card holders or 27 per cent of the total population is variation across LGAs compared to 24 per cent in NSW. The percentage of concession card holders ranged from

KBC Australia P a g e | 15 Topic Key Issue Description of evidence 35 per cent in Cootamundra, Urana and Murray LGAs to 21 per cent in Carrathool and 23 per cent in Wagga Wagga (PHIDU, 2015). Families and households – lower Proportionally more families in the MLHD reported incomes of less than $600 a week in incomes MLHD* compared to NSW (16.8% and 13.9% respectively), 20.6% of families reported incomes of over $2,000 a week compared to 31.7% of families in NSW. (from MLHD summary population and health profile, 2017). MLHD*- data includes Albury LGA Access to Access to GP services (i.e. MBS billing) On an MBS utilisation basis, similar to NSW. However, MPHN workforce data indicates comprehensive GP comparable to NSW, but high GPs likely to be in under supply services population to GP ratio High Population to GP ratio, and MPHN workforce data (August 2017) indicates that there are 168 GP FTE (213 greater than benchmarks for headcount) working in the MPHN. Ratio of population to GPs is high, with variation sustainable practice across sectors. Riverina 1:1,509, Western 1:1,395; Border 1:1,393, Wagga Wagga 1:1,353 compared with urban benchmark of 1:1,000. RDAA benchmarking (2003) recommended GP: population ratio of 1:1,000 for office based practice and 1:750 where the GP provides VMO services to support sustainable practice. GPs in smaller towns have high on-call LHAC consultations identified towns having difficulties in recruiting GPs. Review of GP demands which can contribute to workforce data indicates that 21 of 39 towns in the MPHN have 1 or 2 doctors. The difficulties in recruitment and majority of these towns also have Community Level hospitals or MPSs where GPs retention operate as VMOs. Accessing specialist Access to health care varies across the Medical specialist services tend to be focused around larger population centres requiring and allied health region people to travel to Wagga Wagga, Griffith, or out of the region (dependent on location) care to access specialist services. Varying service delivery models for allied health and specialist nursing services and programs impact on access to services for people in outer regional and remote locations in the MPHN.

KBC Australia P a g e | 16 Table 3-3 Health Status and Behaviours Topic Issue Description of the Evidence Self reported High satisfaction with health From 2016 NSW Health Survey, 73% of MPHN residents rated their health as either excellent, health status very good or good, compared with 80% for NSW Risk Factors Higher rates of SOME chronic From NSW Health Survey, in 2013 residents of MPHN over 16 years have slightly rates of: disease risk factors  High cholesterol 22.1% MPHN v 20.9%  High blood pressure (hypertension) 33.2% MPHN v 28.4% NSW Higher rates of overweight and From 2016 NSW Health Survey, nearly two thirds of MPHN adults (63.6%) are overweight or obesity than NSW, and highest obese compared with 53.3% for NSW. Trends have been stable over the last 10 years. Obesity obesity rates compared to all rates highest compared with all other NSW PHNs. NSW PHNs Highest age adjusted rate of high High body mass attributes to a number of illnesses including diabetes and cardiovascular disease. body mass attributed admissions In 2014-15, high body mass attributed hospitalisations was 630.0 per 100,000 in MPHN compared amongst all PHNs with 436.8 in NSW. (Source: HealthStats NSW) Some health behaviours and risk factors SIMILAR to NSW Smoking rates comparable to In 2016, smoking rates in MPHN comparable to NSW (MPHN 17%, NSW 15%). Smoking in adults NSW and have been declining has declined from 23% in 2002. Smoking in secondary school students (12-17 years) is declining – 13.9% in 2005 to 4.9% in 2014. Smoking attributable While smoking rates have been declining, smoking attributed hospitalisations in the MPHN are hospitalisations higher than highest amongst all PHNs at 830 per 100,000 compared with 542 per 100,000 for NSW. (This is NSW, and highest among PHNs thought to be related to higher rates of COPD) in NSW Risky alcohol consumption In 2016, risky alcohol consumption was similar to adults in MPHN compared with NSW (29.3% v similar to NSW 29.8%). Risky alcohol consumption has remained stable since 2002. Alcohol attributed death rate is 18.0 per 100,000 in MPHN and similar to NSW 16.1 per 100,000, as is alcohol attributed hospitalisations (MPHN 727.3 v NSW 671.6 per 100,000). MPHN adults exercise at similar From 2015 NSW Health Survey, MPHN adults exercise at a similar rate to NSW adults (43.1% v rate to NSW adults 42.9%). MPHN adolescents exercise at 27.4% of MHLD Children aged 12-17 reported adequate physical activity compared with 21.0% higher rate than NSW NSW children counterparts

KBC Australia P a g e | 17 Topic Issue Description of the Evidence Adequate vegetable 2015 NSW Health Survey, 7.9% MPHN adults reported adequate vegetable consumption consumption higher than NSW compared with 5.8% NSW adults. but still low Cancer Overall, breast screening rates From Cancer Institute NSW, 2017, in 2014-15 53.7% MLHD women aged 50-69 years participated screening comparable to NSW but with sub in breast screening compared with 51.6% NSW. Screening data indicates LGAs in the Border population and regional Sector have lower participation in breast screening. However, people participating in screening differences. interstate may not be captured in the data, which may explain lower screening rates in the Border sector. Sub populations have lower breast screening.  Participation lower for CALD women in MLHD compared to NSW CALD (30.1% v 46.1%).  Participation for Aboriginal women in MHD lower than Aboriginal women in NSW (34.4% v 40.2%) Cervical Cervical screening rates In 2014-15, 55.3% of MLHD women (20-69 years) participated in cervical screening, similar to screening comparable to NSW with some NSW (56%). Cervical screening is predominantly undertaken by GPs (77.4%). Lower screening LGAs showing lower rates identified in Conargo, Snowy Valley, Wakool and Murrumbidgee. Note Border Sector participation Clinical Council identified a gap in Women’s Health Services in the sector. Many of the smaller towns in this sector are 1 or 2 doctors and hence may have limited access to female GP. Bowel Bowel screening comparable to In 2015, 37.2% MLHD people participated in bowel screening compared with 35.1% in NSW. screening NSW Follow up of positive tests by GPs occurred in 71.1% of cases. Life Expectancy Life expectancy similar to NSW Life expectancy in MPHN is 81.6 years for MPHN residents at birth compared with 82.9 for NSW residents (2015; HealthStats NSW) Potentially Potentially Preventable deaths The main causes of avoidable death were circulatory disease including ischaemic heart disease Avoidable higher in MPHN than NSW and external causes (transport and accidents) deaths Hospitalisations MPHN has the highest rate of In 2015-16, Murrumbidgee hospitalisations were 43,305.8 per 100,000 compared with 35043 per hospitalisations amongst all 100,000 for NSW i.e. 1.2 times higher (HealthStats NSW) NSW PHNs 53% of total bed days occupied by people 65 years and over. Digestive system diseases had the highest cause of hospitalisations. Mental health disorders and dialysis were the only conditions where hospitalisations were lower than NSW. Circulatory system disease, Respiratory conditions, injury and poisonings and endocrine disorders had hospitalisation rates >1.4 times NSW rates.

KBC Australia P a g e | 18 Topic Issue Description of the Evidence Highest rates of Potentially From HealthStats NSW, MPHN has the highest rate of total PPH compared to all PHNs in NSW Preventable Hospitalisations (All, and is the 5th highest in Australia (NHPA, My Healthy Community). MPHN has the highest rate of Chronic and Acute) in NSW PHNs chronic PPHs and acute PPHs amongst NSW PHNs, but is the 8th (out of 10) for vaccine preventable. Chronic conditions of particular concern include the Respiratory conditions of COPD, asthma and bronchiectasis; Congestive heart failure, angina and hypertension; Diabetes; Iron deficiency anaemia. Acute PPHs included UTI; Cellulitis; ENT infections; Convulsions and epilepsy. Jerilderie, Lake Cargelligo, Harden, , Urana and Henty Health Services are consistently in the top 10 facilities in the Murrumbidgee with highest rates of chronic and acute PPHs. However, this analysis could be confounded where these facilities are MPS and hence “admissions” may be current residents of the aged care facility. Cancer Cancer incidence is slightly Between 2008-2012, the incidence of cancer (all causes) in the MLHD was 520.5 per 100,000 higher than NSW and mortality compared with 498.8 per 100,000 for NSW. Mortality was 161.0 per 100,000 in the MLHD is slightly lower. comparted with 165.6 per 100,000 for NSW. (Cancer Institute NSW). With respect to mortality, there is no single tumour group that is unexpectedly high or low. Chronic Circulatory disease Circulatory disease accounts for 7% of total hospitalisations. Conditions hospitalisations and mortality In 2015, circulatory disease accounted for 28.9% of all deaths in MPHN in 2015.The rate of higher than NSW, but pleasingly, circulatory disease deaths is higher than NSW (MPHN 163.4 v NSW 155.7) and 3rd highest circulatory disease deaths have amongst PHNs in NSW.) been declining in the Murrumbidgee (2002-03 to 2014-15) While respiratory condition In 2015-16, respiratory hospitalisations in MPHN accounted for 6.2% of the total hospitalisations. hospitalisations 1.6 times higher This equates to a rate of 2683.3 per 100,000 (NSW 1731.3 per 100,000). Of all the PHNs in NSW, than NSW, mortality is only MPHN had the highest rate of respiratory hospitalisations. slightly higher. However, most recent death data (2013-2015) shows the rate of respiratory disease deaths in MPHN has highest COPD MPHN is only slightly higher than NSW (MPHN 52.3 per 100,000 persons; NSW 46.8 per 100,000 hospitalisation rate among all persons). And compared to all ten PHNs in NSW, MPHN had the 4th highest rate of respiratory NSW PHNs (1.7 times NSW) disease deaths per 100,000 persons.

KBC Australia P a g e | 19 Topic Issue Description of the Evidence One fifth of respiratory hospitalisations are for COPD, and more than three quarters of people hospitalised with a respiratory condition are over 65 years. Trend data shows rate of COPD hospitalisations and deaths in the MPHN have been stable over last 10 years Very high rates of Urinary Tract In 2015-16, MPHN has sixth highest rate of kidney and urinary tract infections in Australia (My Infections Healthy Communities), and second most common PPH in Murrumbidgee (HealthStats NSW) Very high rates of 2016 NSW Population Survey estimated 9.7% of MLHD aged 16 years and over had a diabetes or hospitalisations for diabetes but high blood glucose. PENCAT data extraction (August 2017), identified 7% of active GP patients lower mortality than NSW had diabetes. NSW prevalence estimated to be 8.9% (NSW Population Survey). MPHN has fourth lowest rate of diabetes related deaths amongst NSW PHNs and lower than NSW (MPHN 27.8 per 100,000; NSW 29.7 per 100,000). HealthStats NSW Oral health Oral health hospitalisations in 2012-13 to 2014-15, oral health hospitalisations similar MPHN compared with NSW i.e. 0-14 MPHN similar to NSW (across all years 536.8 per 100,000 v 612.3; 15+ years 456 per 100,000 v 466.5; all ages 473.1 per 100,000 v ages) 496.4 per 100,000 (HealthStats NSW)

KBC Australia P a g e | 20 Table 3-4 Lifespan Population Groups needs Topic Issue Description of the evidence Aboriginal people Larger numbers of Indigenous people in some Higher proportion of the Murrumbidgee population identify as Aboriginal LGAs compared with NSW (4.8% v 2.9%). LGAs with the highest number of Aboriginal people are Wagga Wagga and Griffith. The Western Sector LGAs have the highest proportion of Aboriginal people in their population (Western 6.3% - highest is Lachlan, 17.6%) Younger age profile, with more than a third 34.8% of the Aboriginal population in the MPHN are under 15 years compared with under 15 years 18.8% of non-Aboriginal population; 55% are under 24 years v 30.7%; only 4.8% of Aboriginal people in the MPHN are over 65 years compared with 20.5% of non- Aboriginal people. (ABS, Census 2016) Median age of death approximately 20 years Median age at death of Aboriginal people in the MPHN ranges from 56 to 75.5 younger than the MPHN population years (across Indigenous Areas), this compares with 61 years for NSW Aboriginal people and 81 years for the whole MPHN population. (PHIDU Indigenous data) Aboriginal people with a profound or severe 5.6% of Aboriginal population has a profound or severe disability, compared with disability similar to MPHN population as whole 5.1% of MPHM population as a whole (IARE: PHIDU) Higher rates of hospitalisation of Aboriginal In the Murrumbidgee, Aboriginal people are hospitalised at 2.6 times the rate of people for mental and behaviour disorder non-Aboriginal people for mental health related issues (NSW Ministry of Health, hospitalisation data 2011-2012). Mothers and Fertility rate slightly lower than NSW but may In 2015, total fertility rate for MPHN was 1.78 compared with 1.79 for NSW (although children be outflow from the region for birthing recognised limitation to data as MPHN residents have babies in Victoria and ACT). The number of births occurring in the MPHN boundaries is trending downward from 2,788 in 2001 to 2,412 in 2015 (HealthStats NSW). Later attendance to first antenatal visit for both From NSW Perinatal Data Collection (SAPHaRI) 2015, Murrumbidgee women less Aboriginal and non-Aboriginal women likely to attend an antenatal visit early in pregnancy. 75.8% of MPHN non-Aboriginal women had a first antenatal visit before 20 weeks compared to 68% of MPHN Aboriginal women and 87.8% of all pregnant women in NSW. Higher rates of smoking during pregnancy for From NSW Perinatal Data Collection (SAPHaRI) 2015, 49% of Aboriginal mothers both Aboriginal and non-Aboriginal women, reported smoking during pregnancy compared to 15% of non-Aboriginal mothers. although has been trending downward While there is a decreasing trend in both Aboriginal and non-Aboriginal mothers who smoke during pregnancy, rates continue to be higher than the rest of NSW (7%).

KBC Australia P a g e | 21 Topic Issue Description of the evidence Higher proportion of mothers are aged under In 2015 in the Murrumbidgee, 14% of Aboriginal mothers were aged under 20 years 20 years, particularly Aboriginal mums in the compared to 3.8% for non-Aboriginal mothers, this compares with NSW at 2% (LHD Murrumbidgee NSW Mothers and Babies, 2015) Proportion of low birth weight babies is higher In 2015 5.5% of babies born to non-Aboriginal mothers in MPHN were of low birth for Aboriginal mothers in the MPHN compared weight compared with 6.4% of babies born in NSW. with non-Aboriginal mothers. The proportion of low birth weight babies born to Aboriginal mothers in the MPHN is higher (12.1%) compared with non-Aboriginal mothers (5.5%). Immunisation Higher childhood immunisation rates From the Australian Childhood Immunisation Register, 2016, overall childhood (Aboriginal and non-Aboriginal children) than immunisation rates in the Murrumbidgee are higher than NSW. In the MPHN, 95.7% NSW, exceeding the national target of 95% of of non-Aboriginal children and 92.8% of Aboriginal children were fully immunised at children fully immunised (5 year olds) 1 year of age, compared with the NSW general population coverage of 93.3%. At 2 years, 94.0% of non-Aboriginal children and 91.4% of Aboriginal children were fully immunised compared with 91.1% for 2 years in NSW. At 5 years, 96% of non- Aboriginal children and 97% of Aboriginal children were fully immunised, compared with 93.5% of 5 year olds in NSW. Developmental Children in MPHN have similar AEDC scores to 21% of MPHN children were developmentally vulnerable in one or more domain, Vulnerability NSW children, with pockets of increased similar to NSW (20.2%). However, the LGAs of Urana, Hay, Boorowa, Harden and developmental vulnerability Murrumbidgee had between 30% and 42.3% of children scoring as developmentally vulnerable in one or more domain. (PHIDU: PHN: Australian Early Development Census) Children and Overweight and obesity in secondary school From 2016 NSW Health Survey, 23% of secondary school aged children were adolescents students slightly higher than NSW overweight or obese compared with 20.6% for NSW. MPHN 12-17 year olds more active than NSW From 2015 NSW Health Survey, 27.4% of MLHD children aged 12-17 years were counterparts physically active compared with 21.0% for NSW children. Smoking amongst secondary school aged In 2014, 4.9% of secondary school students in the MLHD smoke, compared with children has declined over the last decade 13.9% in 2005. Youth Rate of motor vehicle related hospitalisations In 2012-2014, injury was the leading cause of death amongst 15-24year old’s in are much higher for young men in the MPHN Australia. Suicide (30.5%), and land transport accidents (22.3%), accounted for about compared with Murrumbidgee young women half of all deaths in this age group. Accidental poisoning (including drug overdoses) and NSW youth (aged 15-24 years) was the 3rd leading cause of death, accounting for 5.0% deaths and assault was the 4th leading cause of death accounting for 3.1% of all deaths. Males are over represented in the death rates amongst young people, as 68% of deaths in

KBC Australia P a g e | 22 Topic Issue Description of the evidence group were males (AIHW Source: AIHW. Leading causes of death by sex and age group, 2012-2014) In the MPHN, deaths from motor vehicle accidents (all ages) are much higher in comparison to NSW for all ages (22.4% MPHN, 12.7% NSW). This is also reflected in motor vehicle hospitalisation data for people aged 15-24 years (HealthStats NSW) Vaccination coverage for HPV, dTpa and Vaccination coverage for Varicella is comparable (MPHN 72%, NSW 70%) Varicella are comparable or better for MPHN HPV females (Doses 1,2 and 3) 72% MPHN, 71% NSW students (compared with NSW counterparts HPV males (Doses 1,2 and 3) 71% MPHN, 67% NSW (HealthStats NSW) Older People Population projections indicate increasing From PHIDU 2015, 19% of the MPHN aged 65 years and over, compared with 16% demand for aged care services in the MPHN NSW. Projected persons aged over 65 years in MPHN will increase by 44% between with variation between sectors. 2016 and 2036). However, this is lower than NSW (67%). There is variation between sectors with Wagga projected to increase by 72%, Riverina 29%, Border 37%, Western 48%. Hospitalisations of older people for dementia In 2014-15, dementia related hospitalisations increase with age (for both MPHN and and falls similar to NSW. NSW. Pleasingly, dementia related hospitalisation rates in MPHN have been decreasing over the past 15 years for all age groups (2001-02: 526.6 per 100,000 to 2014-15: 313.8 per 100,000). (HealthStats NSW)

Fall related hospitalisations are also very similar to NSW, with 3,112.4 fall related hospitalisations per 100,000 MPHN person compared to 3,044.1 fall related hospitalisations per 100,000 NSW persons. Fall-related hospitalisations is much higher amongst females 65+ compared to males 65+ in MPHN (Females 3,533.4 per 100,000 vs 2,586.9 per 100,000), which is a consistent trend across NSW. (HealthStats NSW) Vaccinations for influenza and pneumococcal 2015-2016, influenza vaccination MPHN 71.3%, NSW 71.6% similar to NSW Pneumococcal vaccination MPHN 52.2%, NSW 47% Aged care places (inclusive of residential, There are 129 aged care services in the Riverina/Murray Aged Care Planning Region. home care and transition care have increased This includes: 3,039 places in residential care (70.8%); 1,146 places in home care and by more than one third (35%) between 2009- (26.7%); 106 places in transition care (2.5%); with a total of 4,291 places in all aged 2016) care types (100%). (AIHW. My aged care region)

KBC Australia P a g e | 23 Topic Issue Description of the evidence Lower proportion of HACC clients live with a In the MPHN, 41.3% of HACC clients live alone, this is higher than NSW (39%) and carer in MPHN compared with NSW and Australia (37.5%). Australia Similarly, only 10% of HACC clients in MPHN live with a carer, compared with 20.7% (NSW) and 24.9% (Australia). (PHIDU, 2012-2013) High utilisation of hospital for exacerbation of In 2013-14, over 65 year olds account for 41% of hospitalisations. Exacerbation of respiratory and cardiac conditions, and post respiratory conditions, heart failure, rehabilitation and follow up post operative operative care. care are among the top 10 DRGs for older people.

Prolonged length of stay for ill-defined causes “Other factors influencing health status” is second highest DRG for older people requires investigation of contributing factors. (average 25 bed days). The higher proportion of HACC clients living alone and without a carer may be a contributor, and requires further investigation.

KBC Australia P a g e | 24 Table 3-5 Mental Health Topic/Priority Issue Description of Evidence Children and Various data sources indicate the prevalence National prevalence data estimates the number of children (4-11 years) in the Young people of mental health disorders in children and Murrumbidgee with a mental disorder to be approximately 3,000. PenCAT extraction young people in the Murrumbidgee to be identified 388 active patients aged 0-10 years with a mental disorder. (PenCAT similar to national estimates coverage is 62% of the MPHN population, and extrapolates to 626 children. The literature indicates that just over 50% of people with a mental health issues do not seek treatment. Based on this assumption the number of children (0-10 years) with a mental health issue in the Murrumbidgee would be about just around 1,250, which is lower than national prevalence. However, the NSW Schools Students Health Behaviours Survey 2014, Young Minds Matter Survey, 2013-14, and Mindspot service indicate similar prevalence of depression, anxiety and externalising disorders (ADHD, conduct disorder Variation across LGAs in psychosocial and While AEDC data indicates similar rates of developmentally vulnerable children in the developmental risk factors for children and Murrumbidgee compared with NSW (developmentally vulnerable in one domain, young people warrants a deep dive to identify MPHN 21% v NSW 20.2%; two domains MPHN 9.9% v NSW 9.6%) there are locations locations for targeted services with much higher rates of development vulnerability i.e. Urana, Hay, Boorowa, Harden and Murrumbidgee, ranging from 30% to 42%.

There are pockets of disadvantage in the MPHN. Geospatial mapping presented in the MPHN MHAOD Needs Assessment 2015-16, identifies the most socially and economically disadvantaged subregions to be: Griffith and Yoogali; Lake Cargelligo and Tullibigeal; Barellan, Leeton, Yanco, Grong Grong, Boree Creek and Gillenbal; and Wagga suburbs including Ashmont, Moorong, San Isidiore and Kapooka.

Geospatial mapping identified suburbs and sub-regions with very high or high rates of psychological distress to be in the Wagga area listed above, the Hilltops LGA and . Mental health related disorders account for In MLHD facilities, nearly 50% of hospital admissions of non-Aboriginal young people nearly half the hospitalisations of young aged 15-19 years are for psychiatry acute Service Related Group (SRG), and this Aboriginal and non-Aboriginal people aged 15- accounts for just under 40% of admissions for Aboriginal young people in this age 19 years group.

KBC Australia P a g e | 25 Higher rates of self harm by young people in Over the period 2001-02 to 2013-14, hospitalisations for intentional self harm by Murrumbidgee compared with NSW, with people aged 15-24 years has been consistently higher than their counterparts in other some communities at particular risk NSW PHNs, with females having higher rates of self harm than males. Hospitalisations because of self harm were highest in the LGAs of Cootamundra, Young (which is now part of Hilltops), Tumut and Leeton. All age groups Increasing prevalence of multi-morbidities and PENCAT extraction (August 2017) indicates that 44% of patients attending a GP have chronic disease result in limited quality of life, a chronic condition, with the most prevalent being asthma (10.4%), diabetes (7.1%), poorer functioning and premature mortality cardiovascular disease (4.7%) and COPD (3.5%), and 18.5% have a mental disorder with most prevalent being depression (9.6%) and anxiety (5.9%). Note that data extraction could not provide detail of those with a diagnosis of both a chronic condition and a mental disorder.

People with a severe and complex mental illness and participating in the Partners in Recovery (PIR) program in the Murrumbidgee identified physical health as one of their top five unmet need, in addition to issues around social isolation and engagement with other services. Aboriginal Over representation of Aboriginal people with PENCAT extraction (August 2017) indicated that 4.7% of active patients attending people mental health issues attending GPs and general practices and an ACCHO service identified as Aboriginal. However, there were primary care higher representation of Aboriginal people in all mental health disorders analysed i.e. 9.8% of Aboriginal patients had a diagnosis of postnatal depression, autism 7.5%, ADHD 18.4%, depression 8.5%, anxiety 7.8%, bipolar 10.7%, schizophrenia 18.3%, dementia 7%. Higher rates of hospitalisation of Aboriginal In the Murrumbidgee, Aboriginal people are hospitalised at 2.6 times the rate of non- people for mental and behaviour disorder Aboriginal people for mental health related disorders (NSW Ministry of health, compared with non-Aboriginal people. hospitalisation data, 2011-12) However, psychiatry SRG (schizophrenia, major affective disorders and other psychiatry) Analysis of the top 9 Service Related Groups in the Murrumbidgee LHD health also accounts for more than one third of facilities (2013-14) demonstrated that psychiatry-acute accounted for more than 40% admissions for non-Aboriginal people in the of admissions for Aboriginal people aged 25 -64 years, and peaking at 50 -58% of Murrumbidgee. admissions in the 30-49 year age range. This compares with over 30% for non- Aboriginal people 25 – 59 years, and peaking at 45% of admissions in the 40-50 age group.

KBC Australia P a g e | 26 Suicide Suicide accounts for nearly a quarter of deaths In the period 2011-2015, suicide accounted for 23.2% of deaths as a result of injury by injury and poisoning in the MPHN, similar and poisoning in the Murrumbidgee, which is similar to NSW (26.5%). This is higher to NSW. than motor vehicle accidents which cause of 22.4% of injury related deaths in the Murrumbidgee. (HealthStats NSW)

In 2015, 33 people residing in the MPHN died by suicide (14.7 per 100,000 which was not significantly different to NSW (10.6 per 100,000).

KBC Australia P a g e | 27 Table 3-6 Alcohol and Other Drugs Topic/Priority Key Issue Description of the Evidence Drug use Primary drug of concern differs across age People aged 41-50 years access AOD services for alcohol issues. groups People aged 21-30 years are the predominant users of AOD services where the primary drug of concern is cannabis, methamphetamine and amphetamine. Drug related Methamphetamine related hospitalisations Drug related hospitalisations account for 68% of AOD admissions across age groups, hospitalisations are increasing in the region for both alcohol related accounting for 32%. (HealthStats NSW 2009-10 to 2013-14; AOD related increasing Aboriginal and non-Aboriginal people. hospitalisations, 10 years and over, MLHD 2013-14.) Aboriginal Over-representation of Aboriginal people Aboriginal people are over-represented in utilisation of AOD services for all primary people utilising AOD services and alcohol related drugs of concern (alcohol 7% clients are Aboriginal; Cannabis 13%; Methamphetamine accessing AOD hospitalisation. 19%; Amphetamine 19%). services Aboriginal people in the Murrumbidgee are hospitalised for alcohol related issues at 2.5 time the rate of non-Aboriginal people (Aboriginal 1641 v Non-Aboriginal 662 per 100,000) similar to NSW (Aboriginal 1681 v non-Aboriginal 624 per 100,000). Source: MLHD AOD Service Use (2014-15); MLHD hospitalisations, PPH by Aboriginality, 2010-11, NSW Ministry Health 2013 Higher rates of hospitalisation for smoking Aboriginal people in the Murrumbidgee are hospitalised at 2.7 times the rate of non- related issues for Aboriginal people in the Aboriginal people for smoking related issues. Smoking related hospitalisations for Murrumbidgee Aboriginal and non-Aboriginal people in the Murrumbidgee are higher than their NSW counterparts. Source: MLHD hospitalisations, PPH by Aboriginality, 2010-11, NSW Ministry Health 2013. Older People Mental health and drug and alcohol issues National data indicates that 15% of older people consume alcohol daily, 8% use tobacco of older people not well understood in the daily and 3% use pain killers or non-opioid analgesics for non-medical purposes. Murrumbidgee There are a range of risk factors contributing to the mental health of older people With the ageing of the Murrumbidgee including: previous episodes of depression, personality or psychiatric disorders; chronic population, a deep dive into the mental illness; cognitive change; substance dependence, bereavement, life events such as a life health and AOD needs of the older threatening illness or moving to an aged care facility. population is warranted.

KBC Australia P a g e | 28 4 OVERVIEW OF THE HEALTH SERVICE SYSTEM

The health service system in the Murrumbidgee is funded through multiple Commonwealth and State sources. This section provides an overview of the key service providers operating in each sector. A detailed service map is included in Appendix 3 Facilities and service summary, by sector.

Wagga Wagga Sector

Wagga Wagga is the major centre for many of the public sector health services provided by the MLHD. The Wagga Wagga Rural Referral Hospital provides emergency services, acute care, paediatrics, obstetrics, sub-acute care, acute mental health care, sub-acute mental health care (recovery model) radiography and radiology services. It has a key role in training medical, nursing and allied health professionals. The Aged Care Nursing specialist team has a district wide responsibility inclusive of Aged Care Assessment, Regional Assessment, Transition Care program, community nursing, occupational therapy and podiatry under the Commonwealth Home Support Program.

The MLHD provides a range of chronic care services in Wagga Wagga, including diabetes education, cardiac care coordination and rehabilitation, pulmonary rehabilitation. The MLHD offers specialist palliative care services, child and family nursing services, community nursing, wound care, continence care and public dental services. The MLHD Aboriginal Health Unit provides a range of services to inpatients and people in the community including a 48 h follow up post discharge, chronic care support and self-management, aboriginal maternal and infant health, healthy lifestyle programs. The Community Health Team Priority Population Program includes sexual assault services, child protection counselling service, Joint Investigation Response, generalist counselling service, Women’s Health, Out of Home Care, Child Wellbeing Unit Coordinator and Multicultural health.

The MLHD has community based Specialist Mental Health and Drug and Alcohol teams across the District. Sub-specialties include Child and Adolescent Mental Health Services (CAMHS), specialist adult mental health services, youth mental health, perinatal mental health, specialist mental health services for older people, and drug and alcohol clinicians. One of the six mental health and Drug and Alcohol teams is based in Wagga Wagga.

In the private sector, health service providers include general practices, dental practices, and allied health professionals. Some allied health professionals based in Wagga provide visiting services to communities in other sectors under commissioning arrangements through the MPHN. Calvary Health Care Riverina is a private hospital offering cancer care, rehabilitation, inpatient and outpatient drug and alcohol services, cardiovascular and surgical services and maternity services.

The Riverina Medical and Dental Corporation (RivMed) is an Aboriginal Community Controlled Health Organisation and provides a range of primary health care services in Wagga Wagga and surrounding areas including medical services, dental services, paediatric, psychology and counselling, family health, eye health, ear health, transport and visiting specialist services.

There are a range of NGO providers located in Wagga Wagga that provide mental health, alcohol and other drug services, social care services and aged care services. Examples include Partners in Recovery (lead agency is MPHN with consortium including Schizophrenia Fellowship NSW; Intereach; Centacare

KBC Australia P a g e | 29 South West NSW; Lambing Flat Enterprises; and MLHD), Drug and alcohol services (Calvary Healthcare Riverina and Directions), and headspace (Relationships Australia).

There are five residential aged care services in Wagga Wagga. There are ten (10) providers of community aged care packages based in Wagga providing care in Wagga as well to residents in other towns across the region.

Western Sector

The MLHD has hospitals located at Griffith, Leeton, Hay and Narrandera, and Multipurpose Services at Lake Cargelligo and Hillston. Griffith is a Rural Base Hospital and Health Service and provides inpatient acute and sub-acute services, intensive care, emergency services, surgery, renal dialysis, paediatrics, maternity, dental radiology, pharmacy and pathology services. Leeton and Narrandera are District Level Hospital and Health Services and Hay is a Community level Hospital and Health Service.

Private GPs are located in each of these towns and provide GP Visiting Medical Officer (VMO) services to the hospitals and Multipurpose Services. Private general practices are also located in Colleambally and . GP VMOs provide obstetric services to Griffith and Leeton. Narrandera offers antenatal and postnatal care with birthing services at Leeton, Wagga or Griffith.

The MLHD offers chronic care services in the Western Sector inclusive of diabetes educators, based in Griffith, Leeton and Narrandera; cardiac rehabilitation at Griffith, Hay, Hillston, Leeton and Narrandera; and pulmonary rehabilitation programs at Griffith, Hay, Hillston, Leeton and Narrandera. Specialist palliative care services are based in Griffith. Public dental services are provided for children in Hay, Hillston and Leeton, and for children and adults in Griffith. The MLHD provides Child and Family services in this sector. The Priority Population Program has services located in Griffith and Leeton. The LHD also provides residential aged care in Leeton, Hillston and Lake Cargelligo.

The MLHD has Community Mental Health and AOD clinicians located in Griffith and Leeton. Child and Adolescent Mental Health workers are co-located with these teams. The MLHD community mental health and AOD teams provide outreach services across their geographical catchment.

With respect to private sector services, in addition to GP services outlined above, there are private dentists in Griffith, Hay, Leeton and Narrandera. Community pharmacists are located in each LGA in the Western Sector. Private allied health services are predominantly located in Griffith and Leeton. St Vincent’s Private Hospital is co-located with Griffith Base Hospital.

The Griffith Aboriginal Medical Service (GAMS) provides a range of services based in Griffith including enhanced primary care provided by GPs and practice nurse, social and emotional wellbeing, Bringing them Home worker, dietetics and child and maternal health. Visiting services provide clinics at GAMS including sexual health, women’s health, optometry, podiatry, immunisation and psychology. GAMS has established a medical service in Hay two days per week and also provides services to Lake Cargelligo. An Alcohol and Other Drug team (inclusive of a coordinator and four workers) service the communities in the western sector.

There are a range of NGOs operating in the Western Sector providing social care services. headspace is located in Griffith providing mental health services to young people, and is operated by MPHN.

KBC Australia P a g e | 30 There are ten (10) residential aged care facilities located in the western sector, in addition to the Multipurpose services operated by the MLHD. There are five providers of community aged care packages based in Griffith, Hilston and Colleambly providing packages to residents in the sector.

Riverina Sector

The MLHD has hospitals located at Young, Temora, Cootamundra, Tumut (all District Level Hospital and Health Service), West Wyalong and Murrumburrah/Harden (Community Level Hospital and Health Services), and Multipurpose Services at Junee, Gundagai, Batlow and Tumbarumba. GPs are located in each of these towns and provide GP Visiting Medical Officer (VMO) services to the hospitals and Multipurpose Services. Private general practices are also located in Coolamon and Adelong. GP VMOs provide obstetric and maternity services in Young, Cootamundra, Temora and Tumut.

The MLHD offers chronic care services in the Riverina Sector inclusive of diabetes educators based in Junee and Young; cardiac care coordination and cardiac rehabilitation at Cootamundra, Temora, Tumut and Young; pulmonary rehabilitation programs at Cootamundra, Temora, Tumut and Young.

Specialist palliative care services are provided by the MLHD and based at Young. Public dental services are available for children in West Wyalong, Tumbarumba, Tumut, Temora, and Junee and public dental services for adults and children are offered in Cootamundra and Young. The MLHD provides Child and Family services across the sector. The Priority Population Program has services located in Young and Temora. The Women’s Health Service is located in Young, Cootamundra and Tumut, but has coverage across the MLHD area.

The MLHD has Community Mental Health and AOD clinicians located in Young, Tumut and Temora. Child and Adolescent Mental Health workers are co-located with these teams. The MLHD community mental health and AOD teams provide outreach services across their geographical catchment.

With respect to private sector services, in addition to GP services outlined above, there are private dental services in West Wyalong, Coolamon, Cootamundra, Gundagai, Harden, Temora, Tumbarumba, Tumut and Young. Community pharmacists are located in each LGA in the Riverina Sector. Private allied health services are predominantly located in Young, Cootamundra, Temora and Tumut.

There are a range of NGOs operating in the Riverina Sector providing social care services.

Residential aged care services managed by the MLHD are located Batlow, Coolamon, Gundagai, Murrumburrah Harden, Junee and Tumbarumba. Residential aged care services operated by not for profit and for profit providers are located in Young, Tumut, Boorowa, West Wyalong and Harden. There appears to be limited aged community care providers in the Riverina sector.

Border Sector

The MLHD has hospitals located at Deniliquin and (District Level Hospital and Health Services), Finley and Holbrook (Community Level Hospital and Health Services), and Multipurpose Services at Lockhart, Berrigan, Culcairn, Henty, Jerilderie and Urana. GPs are located in each of these towns and provide GP Visiting Medical Officer (VMO) services to the hospitals and Multipurpose Services. Private general practices are also located in , , The Rock, and Barham. GP VMOs provide obstetric and maternity services in Deniliquin.

KBC Australia P a g e | 31 The Viney Morgan Aboriginal Medical Service provides primary health care to the Aboriginal people of Cummeragunja and surrounding areas of Southern NSW. They provide; GP services, podiatry, optometry and chronic disease care.

The MLHD offers chronic care services in the Border Sector inclusive of diabetes educators, based in Corowa, Deniliquin and Finley; cardiac care coordination and cardiac rehabilitation at Corowa, Deniliquin and Finley; and pulmonary rehabilitation programs at Corowa and Deniliquin. Specialist palliative care services are based in Deniliquin. Public dental services for children and adults are available in Deniliquin and Berrigan. The MLHD provides Child and Family services in sector. The Priority Population Program has services located in Deniliquin, Finley and Corowa.

The MLHD has Community Mental Health and AOD clinicians located in Deniliquin. Child and Adolescent Mental Health workers are co-located with these teams. The MLHD community mental health and AOD teams provide outreach services across their geographical catchment.

With respect to private sector services, in addition to GP services outlined above, there are private dental services in Deniliquin, Corowa, Finley and Tocumwal. Community pharmacies are located in each LGA. Private allied health services are predominately located in Deniliquin and Corowa.

There are a range of NGOs operating in the Border Sector providing social care services.

Residential Aged Care facilities managed by the MLHD are located in Berrigan, Barham, Corowa, Culcairn, Henty, Jerilderie, Lockhart, Tocumwal and Urana. Residential aged care facilities operated by not for profit and for profit providers are located in Deniliquin, Corowa, Howlong, Jindera, Henty, Holbrook, Berrigan, Finley, Tocumwal, Moama, and Barham. Many of the providers of aged care packages to communities in this sector are based in Albury and Victoria ().

KBC Australia P a g e | 32 5 METHODOLOGY

The development of this technical report involved extensive analysis of quantitative demographic, health and health service data. Where possible data was presented at the MPHN sector level, so that findings from the last HNA can be compared with this HNA. Throughout the report, data for the Murrumbidgee region has been compared to NSW and NSW PHNs.

The demographic and socio-economic data presented in the report relies mainly on data at the Local Government Area level. Local Government Areas define the MPHN boundaries and the MPHN sectors (with the exception of Murrumbidgee LGA), which enabled data to be grouped under sectors where appropriate. SA3 and SA2 level boundaries do not align with the MPHN boundaries as well as LGA boundaries, and therefore data are not commonly presented at SA2 or SA3 levels in this report. Health data for Aboriginal and Torres Strait Islanders is mainly presented by Indigenous Area (IARE). There are thirteen Indigenous Areas within MPHN (Table 5-1).

Hospital data is often presented by Local Health District (LHD). Murrumbidgee Local Health District (MLHD) has the same boundaries as Murrumbidgee Primary Health Network (MPHN). Hospital data has also been presented by health facility as it often it provides a good indication of patient flow.

Where LGAs, SA2s, SA3s or IARE regions exceed MPHN boundaries or overlap into other sectors a certain proportion has been calculated into the estimate. These proportions are based on population numbers and are defined in Table 5-1 and Table 5-2.

Table 5-1 Indigenous Areas (IARE) within MPHN % in sector Comment Western Carrathool Murrumbidgee  Central Murray IARE is in both the Western and Central Murray 50% Border Sector (therefore a proportion of 50% Griffith- Leeton calculated into population estimates for Western) Lachlan 27%  Lachlan IARE exceeds MPHN boundaries Narrandera (therefore a proportion of 27% calculated into population estimates) Border Central Murray 50%  Some of Wakool LGA is not covered by Central Deniliquin- Murray Murray IARE Upper Murray  Central Murray IARE is in both the Western and Border Sector (therefore a prortion of 50% calculated into population estimates for Border) Riverina Coolamon-Temora West Wylong  Borrowa is not included in the listed IAREs Cootamundra  Coolamon-Temora West Wylong IARE exceeds Gundagai-Junne-Harden MPHN boundary Tumut Young Wagga Wagga

KBC Australia P a g e | 33 Figure 5-1 Indigenous Areas (IARE) within MPHN

Note: Indigenous Areas by sector explained in Table 5-1

KBC Australia P a g e | 34 Table 5-2 New LGAs of MPHN (as of 2016) % in sector Comment Western Carrathool  Lachlan LGA exceeds MPHN boundaries (therefore a Griffith proportion of 27% calculated into population estimates) Hay  Murrumbidgee LGA and Jerilderie LGA amalgamated in Lachlan 27% 2016 to form the new Murrumbidgee LGA- (As PHN sector Leeton boundaries remain unchanged a proportion of 60% was Murrumbidgee 60% calculated into population estimates for Western) Narrandera Border Berrigan  Conargo LGA and Deniliquin LGA amalagmated in 2016 to Edward River form Edward River Federation  Wakool LGA and Murray LGA amalgamated in 2016 to Greater Hume Shire form Murray River LGA Lockhart  Urana LGA and LGA amalgamated in 2016 to Murray River form Federation LGA Murrumbidgee 40%  Murrumbidgee LGA and Jerilderie LGA amalgamated in 2016 to form the new Murrumbidgee LGA- (As PHN sector boundaries remain unchaged a proportion of 40% was calculated into population estimates for Border) Riverina Bland  Young LGA, Borrowa LGA and Harden LGA amalgamated Coolamon in 2016 to form Hilltops LGA Gundagai  Cootamundra and Gundagai LGA amalgamated in 2016 to Hilltops form Gundagai LGA Junee  Tumut Shire LGA and Tumbarumba LGA amalgamated in Snowy Valleys 2016 to form Snowy Valleys LGA Temora Wagga Wagga

KBC Australia P a g e | 35 Figure 5-2 New LGAs of MPHN (as of 2016)

Note: New LGAs by sector explained in Table 5-2

5.1 Data sources and limitations

5.1.1 Data sources included

 Australian Bureau of Statistics (ABS), 2016 Census  National Health Performance Authority (NHPA), Healthy Communities  Health Stats NSW  Australian Early Development Census (AEDC)  Public Health Information Unit (PHIDU), Social Atlas of Australia, data by PHN, data by LGA  Australian Institute of Health and Welfare  Australian Government Department of Health PHN data  Cancer Institute NSW  Murrumbidgee Local Health District reports  Murrumbidgee Primary Health Needs Assessment, November 2016

KBC Australia P a g e | 36  Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment, November 2016  PENCAT

5.1.2 Data Limitations

Throughout this report; contextual factors impacting on the data have been explained where possible. An important factor implicating the majority of data in the Border sector, is its proximity to Victoria. Many databases such as NSW Health, do not capture residents of NSW who have been treated interstate. Therefore, where NSW databases have been used to report health indicators; the Border sector is likely to be underrepresented. Equally areas in Hilltops LGA that primarily use the ACT for services are also likely to be underrepresented in some of the health data.

Furthermore, whilst it can be useful for planning purposes to drill down on particular locations of health inequality, one must be mindful that estimates derived from small sample sizes are more unreliable then estimates from large samples. This is apparent in some of the population surveys that had small sample sizes and health indicators reported for small population areas. To manage this limitation several strategies have been employed throughout the report:

1. Uncertainty around estimates has been quantified by reporting 95% confidence intervals where possible. Note: a 95% confidence interval is a set of values which if estimated repeatedly, would on 95% of occasions contain the true estimate. 2. Prevalence and incidence rates for diseases have been reported at a PHN level and compared with NSW. 3. Consecutive years have been calculated into rates if health indicators have been reported by health facility or LGA. The purpose of this is to account for the variability from year to year, that frequently occurs in small areas.

The final data limitation in this report is associated with service mapping and service utilisation. Services can change on a day to day basis, and therefore we expect that there will be some discrepancies around service availability since this report has been written.

KBC Australia P a g e | 37 6 DEMOGRAPHIC PROFILE

6.1 Population by LGA

Table 6-1 lists the population of each LGA within the Lower Gulf. Each sector within MPHN is around one quarter of the MPHN population. Wagga Wagga LGA has the largest population with 62,383 persons; and Carrathool LGA has the smallest population with 2,723 persons. Approximately 4.8% of MPHN population identify as . Lachlan LGA has the highest proportion of residents who identify as Indigenous (17.6%), however Wagga Wagga has the highest number of residents who identify as Indigenous (3,512 persons).

Table 6-1 Population by Indigenous status and LGA, URP, 2016 Non- Indigenous Not Total % Indigenous stated Indigenous Border 49973 1699 4605 56283 3.0% Berrigan 7433 200 827 8462 2.4% Edward River 7619 360 870 8847 4.1% Federation 11090 208 978 12279 1.7% Greater Hume Shire 9364 333 656 10357 3.2% Lockhart 2758 112 255 3121 3.6% Murray River 10451 368 859 11682 3.2% Murrumbidgee (Old 1258 118 160 1535 3.1% Jerilderie) Riverina 58497 3001 5208 66715 4.5% Bland 5045 261 648 5958 4.4% Coolamon 3720 135 459 4313 3.1% Gundagai 9838 517 790 11144 4.6% Hilltops 16437 816 1237 18497 4.4% Junee 5286 496 515 6295 7.9% Snowy Valleys 12568 631 1196 14398 4.4% Temora 5603 145 363 6110 2.4% Western 44110 3293 4899 52298 6.3% Carrathool 2276 215 231 2723 7.9% Griffith 22079 1232 2332 25635 4.8% Hay 2421 177 348 2945 6.0% Lachlan (part) 1203 294 175 1673 17.6% Leeton 9555 634 972 11167 5.7% Narrandera 4689 565 601 5853 9.7% Murrumbidgee (Old 1888 176 239 2303 4.6% Murrumbidgee) Wagga Wagga 55373 3512 3502 62383 5.6% MPHN 207954 11505 18213 237680 4.8% NSW 6826286 216176 437762 7480228 2.9% Australia 21341231 649171 1411491 23401892 2.8% Source: Australian Bureau of Statistics, URP 2016 Census

The median age of every LGA within the Border and Riverina sector, is higher than the NSW median age of 38, indicating the Border and Riverina sector have an older population (Table 6-2).

KBC Australia P a g e | 38

Table 6-2 Median Age by LGA, NSW and Australia, 2016 Median age Border Berrigan 49 Edward River 45 Federation 49 Greater Hume Shire 44 Lockhart 49 Murray River 49 Murrumbidgee 41 (Jerilderie) Riverina Bland 43 Coolamon 44 Gundagai 47 Hilltops 44 Junee 40 Snowy Valleys 45 Temora 46 Western Carrathool 40 Griffith 37 Hay 46 Lachlan 40 Leeton 40 Narrandera 44 Murrumbidgee 41 (Murrumbidgee) Wagga Wagga 35 NSW 38 Australia 38 Source: Australian Bureau of Statistics, 2016 Census. Quick Stats.

6.2 Population growth

Table 6-3 shows static population growth in the Murrumbidgee region over the next twenty years. Western, Riverina and Border sector populations will decrease by anywhere between 3% to 7%. However, Wagga Wagga population will increase 18% or 12,120 persons by 2036. NSW, in comparison will increase 28% by 2036. Note: Table 6-3 based on 2011 ERP.

Table 6-3 Population percentage change, 2016 to 2036 2016 2036 % change Western 52990 50370 -4.9% Riverina 67120 62360 -7.1% Wagga Wagga 65830 77950 18.4% Border 55970 54060 -3.4% MPHN 241910 244740 1.2% NSW 7748270 9925350 28.1% Australia* 24359761 32426009 33.1%

KBC Australia P a g e | 39 Source: Department of Planning and Environment. (2016). Population projections for LGAs. *Source: Infrastructure Australia. (2015). Population Estimates and Projections: Australian Infrastructure Audit Background Paper. Australian Government.

Figure 6-1 Population projections by MPHN sector, 2016 to 2036 90000

80000

70000

60000

50000 Numberpersons of

40000

30000 2016 2021 2026 2031 2036

Western Riverina Wagga Wagga Border

Source: Department of Planning and Environment. (2016). Population projections for LGAs

6.3 Age and gender

Table 6-4 and

KBC Australia P a g e | 40 Figure 6-2 shows the age breakdown of the MPHN at a sector level. Border and Riverina sector have a higher proportion of their population aged 65 years and over (23.9% and 21.5% respectively), compared to Wagga Wagga, Western and NSW. This indicates an older population in the Border and Riverina sector. Overall MPHN has a similar age breakdown to NSW.

Table 6-4 Estimated resident population by age group and sector in MPHN, 2015 Age Group Population 0-14 15-24 25-44 45-64 65+ n % n % n % n % n % Western 11312 21.1% 7422 13.8% 12573 23.4% 13472 25.1% 8906 16.6% Riverina 13760 20.2% 7212 10.6% 14325 21.1% 18079 26.6% 14600 21.5% Wagga Wagga 12788 20.2% 10547 16.6% 16443 25.9% 14663 23.1% 8987 14.2% Border 10009 17.7% 6000 10.6% 11145 19.7% 15875 28.1% 13493 23.9% MPHN 47971 19.8% 31213 12.9% 54538 22.6% 62199 25.7% 45755 18.9% NSW 18.7% 13.0% 28.0% 24.6% 15.7% Source: PHIDU, PHN data, Age distribution persons broad

KBC Australia P a g e | 41 Figure 6-2 Age Pyramids (2015 ERP)

Western Wagga Wagga

75-79 75-79 60-64 60-64 45-49 45-49 30-34 30-34 15-19 15-19 0-4 0-4 3000 2000 1000 0 1000 2000 3000 4000 2000 0 2000 4000 Number of persons Number of persons

Males Females Males Females

Riverina Border

75-79 75-79 60-64 60-64 45-49 45-49 30-34 30-34 15-19 15-19 0-4 0-4 4000 2000 0 2000 4000 3000 2000 1000 0 1000 2000 3000 Number of persons Number of persons

Males Females Males Females

MPHN NSW

75-79 75-79 60-64 60-64 45-49 45-49 30-34 30-34 15-19 15-19 0-4 0-4 10000 5000 0 5000 10000 300000 100000 100000 300000 Number of persons Number of persons

Males Females Males Females

Source: PHIDU, PHN data, Age distribution- 5 year age groups

KBC Australia P a g e | 42 6.4 Births and deaths

Table 6-5 shows the number of births and deaths. The number of births registered in Border in 2015 is likely to be much higher than 168, as babies born interstate have not been recorded in Health Stats NSW data.

Table 6-5 Registered births and deaths by sector and MPHN Number of Births* Number of Deaths** Western 716 469 Riverina 666 657 Wagga Wagga 865 461 Border 168 560 MPHN 2412 2173 Source: HealthStats NSW; *2015, **Number of deaths per year between 2014 and 2015

6.5 Population groups

6.5.1 Aboriginal and Torres Strait Islanders

In 2016, there were a total of 11,505 (4.8%) Indigenous people living within MPHN (NSW 2.9%). The largest number of Indigenous people reside within Wagga Wagga (3,512 people) and Griffith (1,232 people). However, LGAs with the highest proportion of Aboriginal people are Lachlan (17.6%), Narrandera LGA (9.7%) and Carrathool LGA (7.9%). The LGAs are all within the Western sector of MPHN (Table 6-6).

KBC Australia P a g e | 43

Table 6-6 Population by Indigenous status, 2016 (URP) Indigenous population Total population % Indigenous Border 1699 56283 3.0% Berrigan 200 8462 2.4% Edward River 360 8847 4.1% Federation 208 12279 1.7% Greater Hume Shire 333 10357 3.2% Lockhart 112 3121 3.6% Murray River 368 11682 3.2% Murrumbidgee 118 1535 3.1% (Jerilderie) Riverina 3001 66715 4.5% Bland 261 5958 4.4% Coolamon 135 4313 3.1% Gundagai 517 11144 4.6% Hilltops 816 18497 4.4% Junee 496 6295 7.9% Snowy Valleys 631 14398 4.4% Temora 145 6110 2.4% Western 3293 52298 6.3% Carrathool 215 2723 7.9% Griffith 1232 25635 4.8% Hay 177 2945 6.0% Lachlan (part) 294 1673 17.6% Leeton 634 11167 5.7% Narrandera 565 5853 9.7% Murrumbidgee 176 2303 4.6% (Murrumbidgee) Wagga Wagga 3512 62383 5.6% MPHN 11505 237680 4.8% NSW 216,176 7,480,228 2.9% Australia 649,200 23,401,892 2.8% Source: ABS, URP 2016 census

KBC Australia P a g e | 44 Figure 6-3 shows the Indigenous population pyramid is more triangular in shape, indicating higher fertility and death rates and shorter life expectancy. However the non- Aboriginal population pyramid is more rectangular in shape reflecting lower death rates, with most of the population living to old age.

KBC Australia P a g e | 45 Figure 6-3 Population by Aboriginality, age and sex, Murrumbidgee PHN, NSW 2016

Source: HealthStats NSW

Table 6-7 shows the age profile between Indigenous and non-Indigenous people is extremely different. For example 34.8% of the Aboriginal population in the MPHN are under 15 years of age compared with 18.8% of non-Aborininal people; 4.8% of Aboriginal people in the MPHN are over 65 years compared with 20.5% of non-Aboriginal people.

Table 6-7 Proportion of Indigenous and non-Indigenous people by age, 2016 ERP Indigenous population %

The Indigenous Relative Socioeconomic Outcomes Index (IRSEO)

IRSEO is an Indigenous specific index derived that reflects relative advantage or disadvantage at the Indigenous Area level, where a score of 1 represents the most advantaged area and a score of 100

KBC Australia P a g e | 46 represents the most disadvantaged area. There are approximately 400 Indigenous areas in Australia. (Aboriginal Health Profile MLHD 2017).

The most disadvantaged Indigenous Area within the MPHN was Young, followed by Gundagai-Junee- Harden and Deniliquin-Murray. Young was among the most disadvantaged indigenous areas in NSW but just outside the top third most disadvantaged Indigenous Areas in Australia (Table 6-8).

Table 6-8 Indigenous Relative Socioeconomic Outcomes Index in MPHN, by IARE (2011) Indigenous Area (IARE) Index score Aboriginal population (2011 URP) Young 67 404 Gundagai - Junee - Harden 63 655 Deniliquin - Murray 58 470 Griffith - Leeton 56 1,648 Carrathool - Murrumbidgee 48 418 Narrandera 44 598 Upper Murray 44 550 Tumut 42 499 Coolamon - Temora - West Wyalong 40 517 Cootamundra 39 307 Wagga Wagga 34 2,736 Central Murray 30 480 Source: PHIDU, IARE data, IRSEO

Disability within MPHN Indigenous Areas

It is estimated 5.6% of the Aboriginal population has a profound or severe disability, compared to 5.1% of the MPHN population as a whole (Table 6-9 and Table 6-10).

Table 6-9 ATSI persons with a profound or severe disability, MPHN Western Riverina Wagga Border MPHN Wagga Estimated ATSI persons with a 175 138 142 80 534 profound or severe disability* % of ATSI persons with a profound 5.5% 6.0% 5.1% 6.26% 5.6% or severe disability living in the community* ATSI persons aged 15+yrs 282 255 277 177 991 providing unpaid assistance to persons with a disability** % ATSI persons aged 15+yrs 12.6% 13.6% 12.8% 16.9% 13.6% providing unpaid assistance to persons with a disability** Source: PHIDU, IARE data, disability (*2011; **2016). Note: Sectors formed by IARE boundaries

6.5.2 People from culturally and linguistically diverse backgrounds

In 2011, eighty-seven percent of MPHN residents were born in Australia (68.6% NSW); 3.3% were born overseas in English speaking countries and 4.4% were born overseas in non-English speaking countries

KBC Australia P a g e | 47 (2011, PHIDU). Less than one per cent of the MLHD population who were born overseas had difficulty speaking English compared to 3.4% in NSW. Most of religious affiliations reported were Christian- based (75.7 % in MLHD and 64.5% in NSW). (The MLHD 2017: Summary population and health profile, derived from PHIDU)

From 2009 to 2013 areas within MLHD have received approximately 4,155 new settlers, 777 of these were “humanitarian arrivals” or refugees, 284 of which were women (Department of Immigration Settlement Statistics Reports). The major areas settled were, Wagga Wagga (292) and Griffith (75), with smaller numbers in Leeton (31), Narrandera, Murrumbidgee and Wakool Shires.

The major ethnic backgrounds of settlers arriving in MLHD were Burmese in Wagga Wagga; Afghanis in Griffith, Leeton, Narrandera and Wagga; as well as the African nations of Sierra Leone, Rwanda, Democratic Republic of Congo and Sudan in both Albury and Wagga Wagga. (A report on women’s health: Murrumbidgee Local Health District, 2014)

6.5.3 People living with a disability

Persons with a profound or severe disability are defined as needing help or assistance on one or more of the three core activity areas of self-care, mobility and communication because of a long-term health condition (six months or more), a disability (lasting six months or more), or old age. In 2011, there were 11,284 persons residing in MPHN with a profound or severe disability, which equates to 5.1% of the MPHN population, (NSW 4.9%) (Table 6-10).

Table 6-10 People with profound or severe disability, MPHN and NSW, 2011 MPHN NSW Number % % People with a profound or severe disability, all ages 11284 5.1%* 4.9% People with a profound of severe disability living in 9378 4.2%* 4.1% the community People with a profound or severe disability, 0-64 5176 2.8%** 2.6% years People with a profound or severe disability and 5022 2.7%** 2.5% living in the community, 0-64 years People with a profound or severe disability, 65 + 6268 16.0%*** 18.3% years People with a profound or severe disability and 4470 11.4%*** 13.6% living in the community, 65+ years Source: PHIDU, PHN, disability: * Number of people with a disability out of total population; **Number of people with a disability out of population aged 0-64 years; ***Number of people with a disability out of population aged 65 years and over

Table 6-11 LGAs with the highest % of population with a profound or severe disability, all ages Number % of LGA population Urana 85 7.6% Cootamundra 526 7.3% Temora 394 7.0% Narrandera 396 6.8% Berrigan 497 6.4% Source: PHIDU, PHN, disability

KBC Australia P a g e | 48 6.5.4 Older persons

In 2016 there was an estimated 47,370 persons aged 65 years and over living in MPHN, which constituted 20% of the MPHN population. The majority of older people reside in the Border and Riverina sector, followed by Wagga Wagga and Western sector. Over the next twenty years, it is projected Wagga Wagga will have the largest increase in older people (72%). Overall the MPHN will increase by 44% by 2036 (

Figure 6-4 and Table 6-12).

Figure 6-4 Population projections for persons aged 65 years and over in MPHN

21000

19000

17000

15000

13000

11000

9000 Numberpersons of

7000

5000 2016 2021 2026 3031 2036

Border Riverina Western Wagga Wagga

Source: Department of Planning and Environment. (2016). Population projections for LGAs

Table 6-12 Population change in persons aged 65years+, 2016-2036 2016 2036 % change Border 14030 19250 37% Riverina 14740 19050 29% Western 9190 13640 48% Wagga Wagga 9410 16150 72% MPHN 47370 68090 44% NSW 1240760 2072580 67% Source: Department of Planning and Environment. (2016). Population projections for LGAs

KBC Australia P a g e | 49 7 DETERMINANTS OF HEALTH

7.1 Socio-economic profile

The Index of Relative Socio-Economic Disadvantage (IRSD) ranks geographical areas in terms of their relative socio-economic disadvantage in Australia. The index focuses on low-income earners, relatively lower educational attainment, high unemployment, and dwellings without motor vehicles. Low index values represent areas of most disadvantage and high vales represent areas of least disadvantage. The mean score for Australia is 1000.

KBC Australia P a g e | 50 Figure 7-1 maps IRSD scores for LGAs within MPHN. Narrandera, Hay and Murrumbidgee LGAs experiences the greatest disadvantage within the MPHN. These LGAs all have IRSD scores placed Australia’s most disadvantaged quintile (quintile 5). (Murrumbidgee Primary Health Needs Assessment; November 2016)

Analysis of IRSD scores at a lower geographical area (SA1 level), show that there are pockets are high disadvantage scattered across the region. The most socially and economically disadvantaged suburbs/sub-regions in the Murrumbidgee PHN, are:

 Griffith and Yoogali (cluster 1);  Lake Cargelligo and Tullibigeal (cluster 2);  Barellan, Leeton, Corbie Hill, Yanco, Merungle Hill, Grong Grong, Gillenbah, Boree Creek (cluster 3); and  Wagga Wagga, Ashmont, Moorong, San Isidore, and Kapooka (cluster 4). (Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016)

KBC Australia P a g e | 51 Figure 7-1 Index of Relative Socio-Economic Disadvantage (IRSD) by LGA, MPHN, 2011

Legend: 925.2-941.5

941.6-954.1

954.2-963.8

963.9-987.7 2011 IRSD Border 973* 987.8-1040.1 Riverina 953* Wagga Wagga 998

Western 952* MPHN 969 NSW 996 Australia 1000 Source: Murrumbidgee Primary Health Needs Assessment; November 2016: *Average ISRD score

Source: PHIDU, Maps

7.2 Social determinants

7.2.1 Education

Seventy-eight per cent of sixteen-year old’s in MLHD were full-time participants in secondary school compared to eighty per cent in NSW (in 2011). Of school leavers, fourteen percent from MLHD were enrolled in higher education in 2016, compared to thirty three percent in NSW (2016) (PHIDU). However, Table 7-1 shows MLHD has a higher percentage of Level III and IV Trade Certificates compared to NSW (34.6% vs 25.1%).

Table 7-1 Highest Level of Education, MLHD, 2011 MLHD NSW Year 12 (or equivalent) 29.7% 42.4% University (bachelor’s degree or higher) 19.8% 30.2% Level II and IV Trade Certificates 34.6% 25.1% Source: MLHD Strategic Plan, 2013-2018, based on 2011 census data

7.2.2 Industry and Employment

Unemployment rates within the MPHN have fluctuated between 3% and 6% over the last five years. (Small Area Labour Markets). Currently unemployment rates within MPHN are lower in comparison to NSW and Australia (Table 7-2). 2011 Census data also showed that the unemployment rate in the Aboriginal population was 17.1% compared to 4.38% in non-Aboriginal people. This difference highlights significant social and economic inequality among the Aboriginal people in the Murrumbidgee region. (Murrumbidgee Primary Health Needs Assessment; November 2016)

KBC Australia P a g e | 52 Table 7-2 Unemployment rates, June 2016 Population Unemployment rate (June 2016)* MPHN 4.0% NSW 5.4% Australia 5.9% Industry Percentage of employed (2011)** Agriculture, forestry, and fishing 15% Retail 10.8% Healthcare and social assistance 10.7% Manufacturing 10% Education and training 8.2% Public administration and safety 7% *Source: PHIDU, PHN data, Labour force: **Source: Murrumbidgee Primary Health Needs Assessment; November 2016

Of those who are employed within MPHN, the majority work in agriculture, forestry, and fishing industry.

7.2.3 Rurality

The majority of the MLHD population live in areas categorised as “accessible” or “moderately accessible” under the ARIA+ 2011 classifications. The north-west of MLHD is however considered “remote” – which is (excluding Hay township area) and most of , as well as Lake Cargelligo part of . The map shows the outline of LGAs in MLHD overlaying the ARIA+ Remoteness Areas (A report on women’s health: Murrumbidgee Local Health District, 2014).

Figure 7-2 Map of ARIA+ Remoteness Areas and LGAs of MLHD (2011)

KBC Australia P a g e | 53 Source: A report on women’s health: Murrumbigee Local Health District (2014); retrieved from ABS-, Remoteness Areas. Produced by Epidemiology, MLHD (2014)

7.2.4 Income

Murrumbidgee LHD had approximately 31,000 aged pensioners in June 2014, 72 per cent of the eligible population compared to 69 per cent in NSW. In June 2014 there were 14,600 Health Care Card holders in MLHD and 50,000 Pensioner Concession Card holders making a total of approximately 64,400 concession card holders or 27 per cent of the total population compared to 24 per cent in NSW. The percentage of concession card holders ranged from 35 per cent in Cootamundra, Urana and Murray LGAs to 21 per cent in Carrathool and 23 per cent in Wagga Wagga (The MLHD 2017: Summary population and health profile, derived from PHIDU; 2015).

7.2.5 Families and households

There were approximately 121,000 occupied private dwellings in the MLHD* in 2011, 72,000 family households (69% of households) with 72,855 families (some households accommodate more than one family) and 29,132 lone person households (24%). Of the 72,855 families, 30,800 (42.3%) were couple families with no children, 29,798 (40.9%) couples with children, and 11,255 (15.4%) one parent families. NSW had a higher proportion of one parent families (16.3%) than MLHD* and more couple families with children (45.0%), most likely due to a younger age structure than MLHD*. More families, proportionally, reported incomes of less than $600 a week in MLHD* compared to NSW (16.8% and 13.9% respectively), 20.6% of families reported incomes of over $2,000 a week compared to 31.7% of families in NSW. In 2006, there were 8,038 children under 15 years in jobless families (or 14.4% of all children under 15 years compared to 15.9% in NSW), this varied by LGA with the highest percentage of children in jobless families in Urana (21.6%), Cootamundra (19.2%) and Narrandera (19.1%) and the lowest in Conargo (3.4%) and Wakool (6.3%). (The MLHD 2017: Summary population and health profile, derived from PHIDU, 2011). Note: *MLHD- data includes Albury LGA.

7.2.6 Reported offences

LGAs with the highest rates of criminal offenses within MPHN are reported in Table 7-3. Lachlan LGA has nearly double the rates of non-domestic and domestic assault in comparison to NSW. Note; rates for LGA populations with less than 3000 are not calculated in the crime statistics.

Table 7-3 Reported offenses, MPHN and NSW, 2017 (rates per 100,000 persons) 2017 non-domestic assault 2017 domestic assault Lachlan 738.9 753.7 Narrandera 709.5 489.9 Wagga Wagga 599.1 616.4 Griffith 584.9 896.6 Tumut 420.8 604.8 NSW 415.2 379.7 Source: Bureau of Crime Statistics and Research (2017). Crime statistics.

There were on average 1,600 females who were victims of assaults reported to police in MLHD per year from 2008 to 2013. Of all assaults 1,250 per year were domestic violence related and alcohol related assaults averaged around 1,500 per year for the same period (assaults could be both domestic

KBC Australia P a g e | 54 violence related and involve alcohol). Rates of sexual offences (Figure 7-3) and domestic assaults (Figure 7-4) where a female was the victim were considerably higher in some MLHD LGAs than the NSW rates. (A report on women’s health: Murrumbidgee Local Health District)

Figure 7-3 - Sexual offences by LGA

Source: A report on women’s health: Murrumbidgee Local Health District (2014)

Figure 7-4 - Domestic violence related assaults by LGA

Source: A report on women’s health: Murrumbidgee Local Health District (2014)

KBC Australia P a g e | 55 7.3 Behavioural determinants

7.3.1 Smoking

The proportion of adults currently smoking in MPHN is comparable to NSW (MPHN 17%; NSW 15%). Smoking rates are slowly declining in MPHN, as it was reported 23% of adults smoked in 2002 compared to 17% in 2016. Smoking amongst secondary school students in MLHD/Southern NSW LHD is also declining. In 2005 it was reported 13.9% of children aged 12-17 years smoked compared to 4.9% in 2014.

Smoking is believed to have contributed to 2,614 hospitalisations in 2014-2015 in MPHN. The rate of smoking attributable hospitalisations in MPHN is much higher compared to NSW (830.1 per 100,000 persons vs 542.1 per 100,000) and the highest amongst all PHNs in NSW for both males and females. It is likely the high rate of COPD hospitalisations in the MPHN attributes to this statistic considerably. (HealthStats NSW)

7.3.2 Alcohol

Risky alcohol consumption is defined as consuming more than two standard drinks on a day when drinking alcohol. In 2016 29.3% of MPHN adults reported risky alcohol consumption, compared to 29.8% in NSW. Since 2002 the risky alcohol consumption trend has remained stable in MPHN.

It is estimated in 2012-2013, 51 deaths in the MPHN were attributed to alcohol. The alcohol attributed death rate of 18.0 per 100,000 in MPHN is similar to the NSW rate of 16.1 per 100,000. Similarly, hospitalisations attributed to alcohol are comparable to the NSW rate (MPHN 727.3 vs NSW 671.6 per 100,000). Males have higher rates of alcohol related deaths and hospitalisation compared to females, which is consistent throughout NSW. (HealthStats NSW)

7.3.3 Exercise, nutrition and obesity

The 2016 NSW Health Survey found 35.1% of MPHN adults are obese and 63.6% of MPHN adults are overweight or obese. These rates are considerably higher compared to NSW (Obese 21.4%; Overweight and obese 53.3%). Obesity rates in MPHN are also the highest compared to all other PHNs in NSW. Obesity and overweight trends have remained stable over the past ten years.

It is pleasing to note overweight and obesity rates are lower than many NSW PHNs for secondary school aged children in MLHD/Southern LHD. In 2016 23% of MPHN secondary school aged children were reported to be overweight or obese compared to 20.6% of NSW.

High body mass attributable hospitalisations are those where high body mass is considered to have contributed to the underlying illness on admission, for example a proportion of diabetes and cardiovascular disease admissions. In 2014-2015 MPHN had the highest age-adjusted rate of high body mass attributable admissions amongst all PHNs in NSW for both males and females. For all persons, the rate of high body mass attributable hospitalisations was 630.0 per 100,000 in MPHN and 436.8 per 100,000 in NSW in 2014-2015.

Surprisingly rates of physical exercise in MPHN are higher compared to NSW (43.1% MPHN; 42.9% NSW), as is adequate vegetable consumption (MPHN 7.9% NSW 5.8%) (2015 NSW Health Survey). For children aged 2-15 years 10% reported eating adequate vegetables (7.7% NSW) (2014-2015); and

KBC Australia P a g e | 56 27.4% of MLHD/Southern LHD children aged 12-17 years reported adequate physical activity (21.0% NSW) (2014). (HealthStats NSW)

7.3.4 High cholesterol

Data collected from the NSW Health population survey shows that in 2013; 22.1% of MLHD aged 16 years and over have been told by a doctor that they have high cholesterol (20.9% NSW). Trend data from 2002 shows the prevalence of high cholesterol in MLHD has remained stable (2002- 23.2%; 2013- 22.1%). (HealthStats NSW)

7.3.5 High blood pressure

The prevalence of high blood pressure (also known as hypertension) in 2013 in MLHD residents was 33.2% (NSW 28.4%). High blood pressure prevalence has increased since 2002 from 24.4%, however it is unclear if the 9% difference is significant. Compared to other LHDs in NSW, the prevalence of high blood pressure in MLHD ranks 5th greatest out of the 15 LHDs. (HealthStats NSW)

7.3.6 Screening2

Breast screening

In 2014-2015 53.7% of MLHD women aged 50-69 participated in biennial breast screening compared to 51.6% in NSW. Although MLHD breast screening rates are just higher than NSW, it is still below the BreastScreen Australia goal of 70% (Womens Health Profile). For culturally and linguistically diverse MLHD women, breast screening participation rates were much lower compared to NSW (30.1% vs 46.1%) (2014-2015). As were, participation rates for Aboriginal MLHD women compared to Aboriginal women in NSW (MLHD 34.4%; NSW 40.2%).

Cervical screening

In 2014-2015 55.3% of MLHD women aged 20-69 participated in biennial cervical screening compared to 56.0% of women in NSW. Of the MLHD women participating in cervical screening; 77.4% was undertaken by the GP, 10.2% by a Gynaecologist and 7.3% by a women’s health nurse.

Bowel

In 2015, 37.2% of MLHD people aged 50-74 years old participated in annual bowel screening, compared to 35.1% in NSW. Of the MLHD people who had a positive faecal occult blood test, 71.1% were followed up by the GP and 28.9% had no GP follow up recorded.

2 Cancer Institute NSW. (2017). Cancer control in NSW. Annual performance report 2016.

KBC Australia P a g e | 57 Table 7-4 Screening rates by LGA in MPHN LGA Breast screening Cervical screening Bowel cancer (50-69 year old) (20-49 year old) screening (50-74 year old) Berrigan Lower participation rates Conargo Lower participation rates Lower participation rates Corowa Deniliquin Greater Hume Shire Jerilderie Lockhart Murray Lower participation rates Urana

Border Wakool Lower participation rates Lower participation rates Bland Boorowa Coolamon Cootamundra Gundagai Harden Junee

Temora Tumbarumba Lower participation rates Tumut

Riverina Young Carrathool Griffith Hay

Lachlan Leeton Narrandera Lower participation rates

Western Murrumbidgee Lower participation rates Wagga Wagga Source: Murrumbidgee Primary Health Needs Assessment; November 2016, p79 to 81

Table 7-4 is from data in the 2016 MPHN HNA. Screening rates by LGA are compared with the NSW rate. LGAs with screening rates that are lower than the NSW rate have been summarised above. This data has low reliability because many of the LGAs listed have a low population and rates are based on only one year of data (2013-14). Therefore, only rates with a 95%CI below the NSW rate have been included in the table. In addition, people participating in screening interstate may not be captured in the data, which may explain lower screening rates in the Border sector.

KBC Australia P a g e | 58 8 HEALTH STATUS

In the 2016 NSW population health survey, 72.8% of MPHN residents rated their health as either excellent, very good or good (80% NSW). This percentage has dropped over past years (83.4% 2002; 72.8% 2016- difference 10.6%); however, it is unclear if the decrease is significant (HealthStats NSW, self-rated health).

8.1 Life expectancy

Life expectancy is an estimate of how long a person born today would live (on average) if current mortality rates in every age group remained constant throughout a person’s life. Life expectancy in MLHD is slightly lower for both males and females compared to NSW.

Table 8-1 Estimated life expectancy by gender, MPHN and NSW, 2015 Persons Males Females MPHN- at birth 81.6 79.5 83.9 NSW- at birth 82.9 80.9 85.0 MPHN- at 65 years 86.0 84.5 87.4 NSW- at 65 years 86.3 85.0 87.6 Source: HealthStats NSW, Life expectancy

8.2 Mortality

8.2.1 Median age of death

The median age at death is an important measure of outcome based on factors affecting the health of the individual prior to death. Median age of death is used to report differences in population groups and over time.

The median age at death data was compiled by PHIDU from deaths data based on the 2010 to 2014 Cause of Death Unit Record Files supplied by the Australian Coordinating Registry and the Victorian Department of Justice, on behalf of the Registries of Births, Deaths and Marriages and the National Coronial Information System.

The median age of death in MPHN is the same as NSW for both males and females. Across MPHN sectors there is minimal variation in the median age of death (Table 8-2).

Table 8-2 Median age of death, 2010 to 2014 Persons Males Females Border* 80 77 83 Riverina* 80 77 84 Wagga Wagga 81 77 85 Western* 79 77 82 MPHN 81 78 84 NSW 81 78 84 Source: PHIDU, PHN, Median age at death by sex

KBC Australia P a g e | 59 8.2.2 Mortality rates

The MPHN male death rate is higher than females (MPHN Male 771.3; MPHN Female 502.4 per 100,000- 2015) and higher than NSW (NSW Male 643.4; NSW Female 457.7 per 100,000- 2015). This has been a consistent trend since 2001.

Table 8-3 Death rates for 2015 (Rate per 100,000 population) MPHN 603.1 95%CI (577.1- 629.9) NSW 546.0 95%CI (541.3- 550.7) Highest death rates (5 yr av) 10/11 to 14/15 Lowest death rates (5 yr av) 1. Lachlan (755.3) 1. Coolamon (362.7) 2. Berrigan (691.7) 2. Bland (524.8) 3. Carrathool (690.4) 3. Murrumbidgee (538.9) Source: HealthStats NSW, Deaths from all causes

Death rate data at the LGA level can be an unreliable indicator as small changes in the number of deaths can affect the rate considerably. This is particularly evident in LGAs with small populations, such as Carrathool. The death rate was averaged over five years to account for variably from year to year, however it should be noted other factors could influence these rates such as the number of coronial inquests and therefore delays in the number of deaths registered in a particular year.

Table 8-3 shows Lachlan LGA had the highest death rates over five years. This equates to anywhere between 63 and 84 deaths per year. Coolamon had the lowest death rate on average over five years (362.7 per 100,000 persons), which is lower than the NSW five year average of 552.8. Table 8-3 also shows that Murrumbidgee PHN had a higher death rate than NSW in 2015. This is a consistent trend, which is shown in Figure 8-1. Figure 8-1 also shows death rates are steadily declining for both MPHN and NSW.

Figure 8-1 Death rates in MPHN and NSW over ten years, 2006 to 2015 700

650

600 MPHN NSW

550 Rest of NSW Rate per Rate 100,000 persons

500

450 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

KBC Australia P a g e | 60 Source: HealthStats NSW, Deaths from all causes

8.2.3 Potentially avoidable deaths

Potentially avoidable deaths comprise of potentially preventable deaths and potentially treatable deaths. Potentially preventable deaths are those which are amenable to screening and primary prevention, such as immunisation. Deaths from potentially treatable conditions are those amenable to therapeutic interventions. In 2014-2015 there were 344 potentially avoidable deaths in MPHN, which equates to 129 per 100,000 persons. The rate of potentially avoidable deaths was higher in MPHN males compared to females (Males 158.1; Females 98.7 per 100,000) and higher compared to NSW (MPHN 129; NSW 105.9 per 100,000).

Table 8-4 shows the causes of avoidable deaths. The main differences between MPHN and NSW were the rates of circulatory disease including ischemic heart disease and external causes (transport, accidental drownings).

Table 8-4 Avoidable deaths by cause for persons aged 0 to 74 years by average annual ASR per 100,000 persons (2010 to 2014) MPHN NSW Cancer 30.7 29.2 - Colorectal cancer 8.8 9.0 - Breast cancer 16.8 16.7 Diabetes 5.0 5.2 Circulatory system diseases 47.9 37.9 - Ischaemic heart disease 31.2 23.8 - Cerebrovascular disease 9.0 8.8 Respiratory system disease 11.3 9.2 - COPD 10.5 8.6 External causes (falls; suicide; burns) 13.1 11.3 - Suicide and self-harm 11.1 9.4 Other external causes (transport, 22.8 15.5 accidental drownings) Source: PHIDU, PHN, Avoidable mortality by selected cause

8.2.4 Premature mortality

Table 8-5 shows (akin to avoidable deaths) the main differences between MPHN and NSW were the rates of circulatory disease including ischemic heart disease and external causes (particularly road accidents).

KBC Australia P a g e | 61 Table 8-5 Premature mortality by cause for persons aged 0 to 74 years by average annual ASR per 100,000 (2010 to 2014) MPHN NSW Cancer 109.5 101.9 - Colorectal cancer 8.7 8.8 - Lung cancer 24.6 21.7 - Breast cancer 16.8 16.7 Diabetes 5.0 5.2 Circulatory system diseases 59.1 46.1 - Ischaemic heart disease 31.2 23.8 - Cerebrovascular disease 9.0 8.8 Respiratory system disease 17.8 15.3 - COPD 10.5 8.6 External causes 35.8 26.8 - Suicide and self-harm 11.1 9.4 - Road accidents 8.7 4.3 Source: PHIDU, PHN, Premature mortality by selected cause

8.2.5 Causes of death

Table 8-6 shows respiratory deaths are higher in MPHN than NSW (60 vs 47.3 per 100,000) and deaths from mental and behavioural disorders is higher in NSW than MPHN (32.2 vs 25.0 per 100,000).

Table 8-6 Causes of death in MPHN, 2015 (Rate per 100,000) MPHN MPHN % of NSW NSW % of all deaths all deaths Cancer 192.1 30.6% 162.2 28.4% Circulatory disease 159.9 28.9% 153.5 29.6% Respiratory disease 60.0 10.5% 47.3 8.9% Injury and poisoning 48.1 5.9% 35.7 5.7% Endocrine diseases 26.1 4.1% 22.6 4.1% Mental and behavioural disorders 25.0 4.9% 32.2 6.5% Digestive system diseases 23.7 3.7% 19.1 3.5% Nervous system & sense organ disorders 23.5 3.9% 26.5 4.9% Genitourinary diseases 10.3 1.7% 10.6 2.1% Certain infectious and parasitic disease 8.2 1.3% 11.1 2.0% Ill-defined and unknown causes 7.8 1.4% 7.2 1.3% Remaining causes of death 6.9 1.0% n.a. 1.4% Other neoplasms 6.5 1.1% 4.9 0.9% Musculoskeletal & connective tissue disease 5.2 0.9% 4.4 0.8% All causes 603.1 100% 546.0 100% Source: HealthStats NSW, Deaths by category of cause

KBC Australia P a g e | 62 8.3 Hospitalisations and Potentially Preventable Hospitalisations

Figure 8-2 Hospitalisations for all causes, NSW, MPHN and Western NSW PHN, 2001-02 to 2015-16 50000

45000

40000

35000

30000

25000 All PHNs

20000 Murrumbidgee Western NSW

15000 Rate per Rate 100,000 persons 10000

5000

0

Source: HealthStats NSW, Hospitalisations for all causes

In 2015-2016 there were 120,512 hospitalisations for all causes in MPHN. Figure 8-2 shows the rate of hospitalisations in MPHN is increasing and is higher compared to NSW and Western NSW PHN. Table 8-7 also shows that in 2015-2016 MPHN had the highest hospitalisations rate amongst all PHNs in NSW.

Table 8-7 Hospitalisations for all causes, NSW PHNs and NSW (2015-2016) Rate per 100,000 LL95%CI UL 95%CI Central and Eastern Sydney 34066.8 33975.2 34158.5 Hunter New England and Central Coast 35508.6 35407.5 35609.8 Murrumbidgee 43305.8 43050.3 43562.4 Nepean Blue Mountains 33176.1 32991.1 33361.9 North Coast 36954.1 36790.8 37118 Northern Sydney 34997.5 34879.8 35115.5 South Eastern NSW 32028 31889.6 32166.8 South Western Sydney 35691.7 35571.7 35811.9 Western NSW 34626.5 34423.7 34830.2 Western Sydney 34366.1 34245.3 34487.2 NSW 35043 35002.2 35083.8 Source: HealthStats NSW, Hospitalisations for all causes

Data from the 2016 MPHN HNA showed 53% of the total bed days were in MLHD facilities were occupied by people over 65 years. On average persons aged over 65 years of age spent 4.2 days in hospital per admission compared to 3.2 days for all MLHD persons (Murrumbidgee Primary Health Needs Assessment; November 2016).

KBC Australia P a g e | 63 Table 8-8 Hospitalisations by cause, MPHN and NSW, 2015-16 (rate per 100,000 population) MPHN MPHN MPHN NSW Females Males persons persons Blood & immune diseases 653.8 466.1 554.8 445.4 Circulatory diseases 2014.2 3031.1 2511.3 1713.3 Dialysis 4128.4 4243.2 4147.4 4356.6 Digestive system diseases 5076 4884.1 4967 3641.7 Endocrine diseases 812.5 624.4 714.5 506.9 Genitourinary diseases 2800.3 1869.8 2316.1 1740.4 Infectious diseases 810.2 813.9 809.2 601 Injury & poisoning 2958.4 4220.7 3608.8 2521.5 Malignant neoplasms 1176.2 1937 1544.1 1259.7 Maternal, neon. & congenital 5981 859.5 3383.7 2695.7 Mental disorders 1154.3 1396.7 1276.4 1800.3 Musculoskeletal diseases 2133.2 2313.9 2226.8 1761.4 Nervous & sense disorders 2597.8 2550.6 2566.3 2456.3 Other factors infl. health 5168.3 4616.3 4873.7 3667.4 Other neoplasms 858.9 725.2 787.2 744.3 Respiratory diseases 2595.8 2798.3 2683.3 1731.3 Skin diseases 610.1 785.1 697.3 577 Symptoms & abnormal findings 3573.2 3724.4 3633.5 2786.1 Total 45108.6 41863 43305.8 35043 Source: HealthStats NSW, Hospitalisations by category of cause

Table 8-8 shows except for hospitalisations due to mental health conditions and dialysis, Murrumbidgee hospitalisations are higher for every other condition compared to NSW. The main cause of hospitalisation in MPHN relate to digestive system diseases.

KBC Australia P a g e | 64 Figure 8-3 Service related groups by five year age group.

Source: Murrumbidgee Primary Health Needs Assessment; November 2016

KBC Australia P a g e | 65 Figure 8-3 categorises service related groups by five-year age groups. It shows palliative care/rehabilitation; orthopaedics, cardiology and gastroenterology are predominately represented by the 60 years and over age group. Whereas the service attendance related to mental health, alcohol and other drugs is predominantly represented by the 15 to 39 year group.

8.3.1 Potentially preventable hospitalisations

In 2015-16 there were a total of 8,367 potentially preventable hospitalisations (PPH) out of the total 120,512 hospitalisations in MPHN (6.9%). Since 2008-09 MPHN has had the highest rate of PPH amongst all PHNs in NSW. Table 8-9 shows that rates of acute and chronic PPH were also the highest amongst all PHNs in NSW for 2015-16.

COPD is of particular concern as not only does MPHN have the highest rate of potentially preventable COPD admissions in NSW, but it also has the third highest rate in Australia.

Table 8-9 Hospitalisation rates for selected conditions in MPHN and NSW, (2015-2016) Hospitalisation Rates (per 100,000) MPHN NSW Rank (out of 10 NSW PHNs) All causes 43305.8 35043 Highest (1) Potentially Preventable Hospitalisations Total PPH 2893.8 2126.3 Highest (1) 5th (Aus)* Chronic PPH 1394.9 922.3 Highest (1) 3rd (Aus)* COPD 359.9 217.6 Highest (1) 3rd (Aus)* Congestive cardiac failure 213.5 154.9 Highest (1) Iron deficiency anaemia 203.5 140.6 2nd Diabetes 191.2 127.9 Highest (1) Asthma 171.6 123.9 2nd Angina 129.1 97.5 Highest (1) Hypertension 62.1 29.9 Highest (1) Bronchiectasis 52.8 20.3 Highest (1) Acute PPH 1411.4 1072.1 Highest (1) UTIs (including pyelonephritis) 337.7 230.1 Highest (1) 6th (Aus)* Cellulitis 309.3 259.6 2nd ENT infections 243.3 158.7 Highest (1) Dental conditions 227.2 219.2 6th Convulsions and epilepsy 205.3 141.0 Highest (1) Pneumonia and influenza 66.7 63.8 4th Vaccine preventable PPH 98.6 148.8 8th Source: HealthStats NSW, Potentially preventable hospitalisations; *Source: NHPA, My Healthy Community

KBC Australia P a g e | 66 Figure 8-4 shows the total number of potentially preventable hospitalisations over four years divided by the total number of hospitalisations over four years. Four years of data was used provide a more robust estimate of PPH by facility and reduce the variability from year to year that can occur in small facilities. Of concern is that every health facility in MLHD had a higher proportion of potentially preventable hospitalisations compared to NSW.

In fact, potentially preventable hospitalisations constituted one quarter of all hospitalisations in Jerilderie and Lake Cargelligo, compared to 6% in NSW.

KBC Australia P a g e | 67 Figure 8-4 Proportion of total PPHs of total hospitalisations (2013/14 to 2016/17) 30% 25% 20% 15% 10% 5%

0%

Lake Cargelligo Lake

Hay Health Service HayHealth

Junee Health Service Junee

Finley Health Service FinleyHealth

Henty Health Service HentyHealth

Urana Health Service UranaHealth

Young Health Service Young

Wagga Wagga Health… Wagga Wagga

Tumut Health Service Tumut

West Wyalong Health… Wyalong West

Leeton Health Service Leeton

Batlow Health Service Batlow

Griffith Health Service Griffith

Harden-Murrumburah…

Hillston Health Service Health Hillston

Corowa Health Service CorowaHealth

Temora Health Service Temora

Barham Health Service Barham

Culcairn Health Service Culcairn

Berrigan Health Service Berrigan

Lockhart HealthService Lockhart

Boorowa Health Service Health Boorowa

Jerilderie Health Service Jerilderie

Holbrook Health Service Holbrook

GundagaiHealth Service

Deniliquin Health Service Deniliquin

Coolamon Health Service Coolamon

TocumwalHealth Service

Narrandera Health Service NarranderaHealth

Tumbarumba Health Service Tumbarumba Cootamundra Health Service Cootamundra

MLHD NSW

Source: MLHD, hospitalisation data (unpublished)

Figure 8-5 and Figure 8-6 show Jerilderie, Lake Cargelligo, Harden, West Wyalong, Urana and Henty Health Services are consistently in the top ten facilities in the Murrumbidgee with the highest rates of chronic and acute PPHs. However, this analysis could be confounded where these facilities are MPS’s and hence “admissions” may be current residents of the aged care facility.

Figure 8-5 Proportion of chronic PPHs of total hospitalisations (2013/14 to 2016/17) 18%

14%

10%

6%

2%

-2%

Lake Cargelligo Lake

Hay Health Service HayHealth

Junee Health Service Junee

Finley Health Service FinleyHealth

Henty Health Service HentyHealth

Urana Health Service UranaHealth

Young Health Service Young

Tumut Health Service Tumut

Leeton Health Service Leeton

Batlow Health Service Batlow

Griffith Health Service Griffith

Hillston Health Service Health Hillston

Corowa Health Service CorowaHealth

Temora Health Service Temora

Barham Health Service Barham

Culcairn Health Service Health Culcairn

Berrigan Health Service Berrigan

Lockhart HealthService Lockhart

Boorowa Health Service Boorowa

Jerilderie Health Service Jerilderie

Holbrook Health Service Holbrook

GundagaiHealth Service

Deniliquin Health Service Deniliquin

Coolamon Health Service Coolamon

TocumwalHealth Service

Narrandera Health Service NarranderaHealth

Tumbarumba Health Service Tumbarumba

Cootamundra Health Service Cootamundra

Wagga Wagga Health Service Wagga Wagga

West Wyalong HealthService Wyalong West Harden-Murrumburah Health… Harden-Murrumburah

MLHD NSW

Source: MLHD, hospitalisation data (unpublished)

KBC Australia P a g e | 68

Figure 8-6 Proportion of acute PPHs of total hospitalisations (2013-14 to 2016/17) 12%

10%

8%

6%

4%

2%

0%

Lake Cargelligo Lake

Hay Health Service HayHealth

Junee Health Service Junee

Finley Health Service FinleyHealth

Henty Health Service HentyHealth

Urana Health Service UranaHealth

Young Health Service Young

Tumut Health Service Tumut

Leeton Health Service Leeton

Griffith Health Service Griffith

Hillston Health Service Health Hillston

Corowa Health Service CorowaHealth

Temora Health Service Temora

Barham Health Service Barham

Culcairn Health Service Culcairn

Berrigan Health Service Berrigan

Lockhart HealthService Lockhart

Boorowa Health Service Boorowa

Jerilderie Health Service Jerilderie

Holbrook Health Service Holbrook

GundagaiHealth Service

Deniliquin Health Service Deniliquin

Coolamon Health Service Coolamon

TocumwalHealth Service

Narrandera Health Service NarranderaHealth

Tumbarumba Health Service Tumbarumba

Cootamundra Health Service Cootamundra

Wagga Wagga Health Service Wagga Wagga

West Wyalong HealthService Wyalong West Harden-Murrumburah Health Service Harden-Murrumburah

MLHD NSW

Source: MLHD, hospitalisation data (unpublished)

KBC Australia P a g e | 69 8.4 Mental Health

Results from the 2015 Population Health Survey show 10.8% (95%CI 6.8%-14.8%) of persons aged 16 years and over residing in MPHN experience high or very psychological distress. This result is not significantly different to NSW (NSW 11.8%; 95%CI 10.6%-13.0%). Psychological distress was determined using the Kessler 10 questionnaire. (HealthStats NSW)

8.4.1 Prevalence of mental health in MPHN

PENCAT is a database that contains specific de-identified patient data from 62% (51 out of 82) of GP practises within MPHN. PENCAT is a very useful resource to obtain prevalence estimates for mental illness in MPHN. This is because most people diagnosed with a mental illness will have contact with their GP at some stage during their illness. Data reports on active patients only. An active patient, is defined as patients who have been seen at least three times in the last two years.

Table 8-10 shows 18.5% of MPHN patients are diagnosed mental illness. This is a similar estimate obtained from the National Health Survey (Australia: 17.5%). Depression is the most common mental illness diagnosed in MPHN (9.6%), followed by anxiety (5.9%). Table 8-11 shows ADHD and Autism are the most common mental illness in children, whereas anxiety and depression are the most common diagnosis in youth, adults and older persons.

Table 8-10 Prevalence estimates for mental illness, PENCAT vs National Health Survey *National Health Survey Mental illness PENCAT (2017) (2014-15) Anxiety 5.9% 11.6% Depression 9.6% 9.3% Schizophrenia 0.4% n.a. Bipolar 0.8% n.a. Dementia 0.4% n.a. ADHD 0.7% n.a. Autism 0.3% n.a. Post-natal depression 0.3% n.a. Total Mental illness 18.5% 17.5% Source: MPHN, PENCAT (unpublished); *Source: ABS, National Health Survey

In 2015, the Commonwealth Government of Australia released a report into the Mental Health of Children and Adolescents. The report indicated that 13.6% of 4-11 year old’s were assessed a having mental disorders in the previous 12 months. Applying the national prevalence data to the number of children (4-11 years) in the Murrumbidgee equates to around 3,000 children. PENCAT extraction identified 388 active patients aged 0-10 years with a mental disorder, which extrapolates to 626 children (PENCAT coverage is 62%). The literature indicates that just over 50% of people with a mental health issues do not seek treatment. Based on this assumption the number of children (0-10 years) with a mental health issue in the Murrumbidgee would be around 1,250, which is lower than national prevalence. (Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016)

KBC Australia P a g e | 70 Table 8-11 Total number of active patients with mental illness on GP database, 2017

Persons Age group (years) Diagnosis 0-10 11-24 25-64 65+ TOTAL (%) Anxiety 98 1437 6473 2293 10301 (33%) Depression 11 1714 11124 3916 16765 (53%) Schizophrenia 0 56 612 95 763 (2%) Bipolar 0 144 1060 153 1357(4%) Dementia 2 2 37 700 741 (2%) ADHD 185 766 200 3 1154 (4%) Autism 140 327 63 4 534 (2%) Age group TOTAL (%) 436 (1%) 4446 (14%) 19569 (62%) 7164 (23%) 31615 (100%) Source: MPHN, PENCAT (unpublished)

Table 8-12 and Table 8-13 shows male children and youth have higher numbers of mental illness diagnoses compared to females. Male children and youth have a higher number of ADHD, autism, anxiety and schizophrenia diagnoses compared to female children and youth. Throughout all age groups there are a higher number of females diagnosed with depression, anxiety, bipolar and dementia; and a higher number of males diagnosed with schizophrenia, ADHD and Autism.

Table 8-12 Number of active MALE patients with mental illness on GP database, 2017 Males Age group (years) Diagnosis 0-10 11-24 25-64 65+ TOTAL (%) Anxiety 52 950 2251 723 3976 (31%) Depression 7 561 4109 1531 6208 (48%) Schizophrenia 0 45 417 29 491 (4%) Bipolar 0 63 459 58 580 (5%) Dementia 0 1 23 284 308 (2%) ADHD 137 585 135 2 859 (7%) Autism 113 251 43 4 411 (3%) Age group TOTAL (%) 309(2%) 2456 (19%) 7437 (58%) 2631 (21%) 12833 (100%) Source: MPHN, PENCAT (unpublished)

Table 8-13 Number of active FEMALE patients with mental illness on GP database, 2017 Females Age group (years) Diagnosis 0-10 11-24 25-64 65+ TOTAL (%) Anxiety 46 487 4222 1570 6325 (34%) Depression 4 1153 7015 2385 10557 (56%) Schizophrenia 0 11 195 66 272 (1%) Bipolar 0 81 601 95 777 (4%) Dementia 2 1 14 416 433 (2%) ADHD 48 181 65 1 295 (2%) Autism 27 76 20 0 123 (1%) Age group TOTAL (%) 127 (1%) 1990 (11%) 12132 (65%) 4533 (24%) 18782 (100%) Source: MPHN, PENCAT (unpublished)

8.4.2 Mental health related hospitalisations

Table 8-14 shows although schizophrenia only accounts for 10% (381/3648) of mental health admissions (i.e. separations), schizophrenia accounts for the highest number of mental health bed

KBC Australia P a g e | 71 days. Table 8-14 also shows Aboriginals are markedly overrepresented for childhood mental disorders (36.4% of separations).

Table 8-14 Number of mental health related bed days [and number of separations (-)] by condition and age group, MLHD 2013/14 Mental health related MLHD Hospitalisations, 2013/14 Condition 10-24 years 25-39 years 40-64 years 65+ years Total % ATSI Anxiety 218 (26) 109(26) 187(66) 214 (55) 728 (173) 2.5 (5.8) disorders Childhood 55 (10) 0 (0) 6 (1) 0 (0) 61 (11) 42.6 (36.4) mental disorders Eating and 787 (32) 9 (3) 0 (0) 1 (1) 797 (36) 0.5 (2.8) Obsessive- Compulsive Disorders Major Affective 884 (68) 996 (86) 2,213 (166) 475 (35) 4,572 4.6 (5.9) Disorders Age (355) <70 W/O Catastrophic or Severe CC Major Affective 16 (2) 47 (3) 402 (13) 1,232 (67) 1,697 (85) 11.4 (12.9) Disorders Age >=70 or W Catastrophic or Severe CC Mental health 335 (335) 412 (412) 829 (829) 114 (114) 1,690 11.0 (11.0) treatment, (1,690) same day Other affective 328 (78) 358 (67) 569 (119) 427 (66) 1,682 2.6 (5.5) disorders (330) Paranoia and 270 (19) 133 (21) 162 (27) 130 (8) 695 (75) 6.3 (8.0) acute psychotic disorders Personality 546 (141) 959 (175) 1,091 (149) 485 (47) 3,081 5.9 (8.2) disorders (512) Schizophrenia 529 (25) 3,106 (149) 2,993 (194) 359 (13) 6,987 9.2 (10.3) disorders (381) Total 3,968 (736) 6,129 (942) 8,452 3,441 21,990 7.04 (9.3) (1,564) (406) (3,648) Source: Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016

8.4.3 Mental illness in children and young people

In the Murrumbidgee, there were 23,757 mental health related general practice consultations during 2014/15, and of these, young people represented 22.8% of all mental health related general practice visits (MBS). Of the young people accessing mental health services through General Practice in the Murrumbidgee, depression was the most common mental health issue (49.6%), followed by anxiety (33.4%), and drug abuse (5.5%).

KBC Australia P a g e | 72 In 2014/2015 in the Murrumbidgee, 3,136 young people aged 12-24 years accessed their General Practitioner for mental healthcare (MBS). In the same period, 2,072 young people aged 12-24 years accessed a Better Access (MBS) or Better Outcomes (ATAPS) clinician. Of the young people using ATAPS, mood disorders were the most common mental health issue (31.0%), followed by anxiety and stress-related conditions (29.5%). Similarly, the most common mental health issues of young people accessing ATAPS who identify as Aboriginal and/or Torres Strait Islander were mood disorders (24.4%) and, anxiety and stress-related conditions (24.4%). (Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016)

High psychological distress

Of the 399 secondary school aged students aged 12-17 years that were surveyed from the Murrumbidgee and Southern LHD, 30.5% (33.3% NSW) had experienced feelings of unhappiness, sadness or depression in the last 6 months that were ‘worse than usual’, ‘quite bad’ or ‘almost more than I could take’. (HealthStats NSW; NSW School Students Health Behaviours Survey- 2014)

Young Minds Matter

In 2013-14 6,310 Australian families were randomly selected and interviewed as part of the Young Minds Matter survey, which looked at the emotional and behavioural development of children and young people aged between 4 and 17 years. Survey results have been provided for MPHN, however due to small survey numbers for MPHN, the results should be interpreted with caution.

Table 8-15 shows there are similar rates of internalising and externalising disorders amongst NSW and MPHN children.

Table 8-15 Twelve-month prevalence estimates of mental disorders among 4-17year old’s in MPHN, by type of disorder and severity of disorder (2013-14) Mild Moderate Severe Total MPHN Internalising disorder 7.7% 2.4% 1.3% 7.9% Externalising Disorder 6.1% 2.2% 1.1% 9.4% All Disorders 8.8% 4.0% 2.0% 14.8% Australia Internalising disorder 7.5% 2.3% 1.5% 8.1% Externalising Disorder 5.6% 1.9% 1.1% 8.6% All Disorders 8.4% 3.6% 2.1% 14.1% Source: Department of Health, PHN, Secure data, Young Minds Matter survey

NOTE: Internalising disorder: comprises of anxiety disorders (social phobia, separation anxiety disorder, generalised anxiety disorder and obsessive-compulsive disorder) and major depressive disorder Externalising disorders: comprises of attention-deficit/Hyperactivity Disorder (ADHD) and conduct disorder

KBC Australia P a g e | 73 Table 8-16 also shows there is minimal difference in the prevalence of mental disorders between MPHN children compared with NSW and MPHN youth compared with NSW.

Table 8-16 Twelve-month prevalence estimates of mental disorders among 4-17year old’s In MPHN, by age group and severity (2013-14) Mild Moderate Severe Total MPHN 4-11 years 10.4% 3.2% 1.2% 14.7% 12-17 years 6.8% 5.1% 3.0% 14.8% Total 8.8% 4.0% 2.0% 14.8% Australia 4-11 years 10.1% 2.8% 1.2% 14.2% 12-17 years 6.2% 4.5% 3.2% 13.9% Total 8.4% 3.6% 2.1% 14.1% Source: Department of Health, PHN, Secure data, Young Minds Matter survey

8.4.4 Adults and mental illness

MindSpot is a digital mental health service providing a free service for Australian adults experiencing difficulties with stress, depression and low mood through online screening assessments and treatment courses. Table 8-17 lists the demographic attributes of MPHN persons who participated in a MIndSpot assessment.

Table 8-17 Demographic attributes of MPHN persons who participated in MindSpot assessments, 2016 MPHN Australia Total number of assessments 154 16930 K-10 at assessment (score >30 =severe mental disorder) 31.4 31.7 PHQ9 at assessment (score of 15= moderately severe depression) 15.1 14.9 GAD7 at assessment (score of 10= moderate anxiety, 15= severe anxiety) 12.3 12.5 Mean age 38.6 36.6 Female 69.5% 71.8% Self-reported current anxiety 81.2% 82.3% Self-reported current depression 74.7% 71.9% Current GP 77.9% 69.9% Has GP and would speak with GP regarding mental health 53.2% 43.4% Currently prescribes medication for mental health 33.8% 28.4% Lives in a capital city or surrounding suburb 5.2% 59.8% Lives in other urban region 12.3% 19.3% Lives in rural or remote region 82.5% 20.9% Bon in Australia 93.5% 78.3% Aboriginal or Torres Strait Islander 5.8% 3.1% Employment (fulltime or part-time) 57.1% 54.8% Married/ Defacto 50% 38.5% Recent suicidal thoughts 23.4% 28.3% Recent suicidal thoughts + suicidal intension 2.6% 3.6% Source: Department of Health, PHN, Secure data, MindSpot data summary

Data regarding MPHN residents who completed a MindSpot treatment course, showed there was a 40.5% improvement in K10 scores at post treatment. The mean K10 score at assessment was 31.5 (indicating severe mental disorder) and the K10 score post treatment was 22.8 (indicating mild mental disorder).

KBC Australia P a g e | 74 Comorbid chronic disease

The National Health Survey, 2014/15, determined that people with a mental illness were almost twice as likely than the general population to report having diabetes (8.1% compared with 4.5%), almost three times as likely to report chronic obstructive pulmonary disease (COPD) (5.7% compared with 2.0%) and around twice as likely to report osteoporosis (6.3% compared with 2.9%).

In addition to having higher risk across all chronic diseases (Table 8-18), people with mental illness are more likely to die within 5 years of being diagnosed with a chronic disease (National Health Survey: Mental Health and co-existing physical health conditions, Australia, 2014/15).

Table 8-18 Prevalence of chronic diseases among people with mental illness, 2014/15 Chronic disease General People with Mental Difference (times population (%) and Behavioural more prevalent) Problems (%) Arthritis 15.3 23.9 1.6 Asthma 10.8 17.6 1.6 Back 16.2 27.7 1.7 Cancer 1.8 2.2 1.2 Chronic obstructive pulmonary 2.6 5.7 2.2 disease Diabetes mellitus 5.1 8.1 1.6 Diseases of the circulatory system 18.3 25.6 1.4 Source: ABS, National Health Survey- 2014/15

8.5 Alcohol and other drugs (AOD)

8.5.1 AOD hospitalisations

Table 8-19 shows drug-related separations dominate the younger age groups (<40 years), whereas the proportion of alcohol and drug separations is similar for those aged 40-65 years old.

Table 8-19 Number of AOD-related hospital bed days and age group, MLHD 2013/14. 10-24 years 25-39 years 40-65 years 65+ years Total Alcohol-related 993 1,065 2,323 662 5,043 (34%) separations* (26%) (27%) (45%) (36%) Drug-related 2,783 2,825 2,854 1,118 9,651 (66%) separations** (74%) (73%) (55%) (60%) Total 3,776 3,890 5,177 1,851 14,694 (100%) (100%) (100%) 100%) (100%) Source: Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016

In MPHN, the rate of methamphetamine-related hospitalisations and persons hospitalised due to methamphetamine has dramatically spiked since 2012-13 (

KBC Australia P a g e | 75 Figure 8-7). In 2015-16 there were 198 methamphetamine related hospitalisations (rate: 132.8 per 100,000) and 155 persons hospitalised due to methamphetamine (rate: 103.3 per 100,000) in MPHN. These rates are comparable to NSW (hospitalisations: 124.4 per 100, 000; persons hospitalised 87.2 per 100,000). (HealthStats NSW)

KBC Australia P a g e | 76 Figure 8-7 Methamphetamine-related hospitalisations

Source: HealthStats NSW, Drug misuse

8.5.2 AOD Services

Between January 2014 and November 2015, 1,605 people accessed Calvary Healthcare Alcohol and Other Drugs Services. The majority of clients (75.5%) self-referred indicating a high degree of help- seeking behaviour. Of the people accessing service, 33.3% were aged between 30-39 years of age; 29.8% were aged between 20-29 years of age and 22.3% aged between 40-49 years of age.

Most people accessing Calvary Healthcare Riverina AOD services were male (73%), with females accessing the services at much lower rates (27%). 17.5% of clients identified as Aboriginal and/or Torres Strait Islander. (Table 8-20)

Table 8-20 MLHD DA Service Use by Primary drug of Concern and Number of Clients, 2014/15 Primary Drug of Number and % of clients who % of clients who Age group of Concern Percentage of are Aboriginal are Non- highest service Clients Aboriginal use (% of total) Alcohol 704 (36.1%) 7% 93% 41-50yrs (25%) Cannabis 267 (17.3%) 13% 87% 21-30yrs (42% Methamphetamine 231 (14.6%) 19% 81% 21-30yrs (44%) Amphetamine 112 (5.9%) 19% 81% 21-30yrs (48%)

KBC Australia P a g e | 77 Source: Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016

Table 8-21 shows of clients using Calvary Healthcare Riverina, Alcohol was the primary drug of concern (43%), followed by amphetamine (21%) and methamphetamine (18%).

Table 8-21 Calvary Healthcare Riverina, AOD Services – Primary and Secondary Drug Type and Client numbers/percentage, January 2014- November 2015 Primary Drug of Number and Secondary Drug of Number and Concern Percentage of Clients Concern Percentage of Clients Alcohol 684 (42.5%) Nicotine 956 (41.52%) Amphetamine 337 (20.9%) Cannabis 512 (22.24%) Methamphetamine 287 (17.8%) Alcohol 267 (11.59%) Cannabis 225 (13.98%) Amphetamine 174 (7.55%) Heroin 30 (1.86%) Heroin 81 (3.51%) Other Stimulants and 11 (0.68%) Methamphetamine 74 (3.21%) Hallucinogens Source: Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016

8.6 Suicide

8.6.1 Intentional self-harm hospitalisations

There are many factors that can put a person at greater risk of self-harming, including: alcohol, tobacco and drug use; and childhood maltreatment such as abuse or neglect. Research shows that the incidence of self-injuries were: 3.3 times higher for tobacco smokers; 4.2 times higher for those drinking to get drunk; between 2.1 and 6.0 times greater for those having ever used opioids, inhalants, stimulants, hallucinogens and marijuana; 3.9 times higher for those who reported neglect; 5.8 times greater for those reporting physical abuse; and 5.9 times the odds for those reporting sexual abuse; compared to those who do not self-harm (Martin et al., 2010). Experiences of bullying can also contribute to self-harm (Fisher et al., 2012), and internet addiction can also contribute to poor mental health (Morrison & Gore, 2010; Young & Rogers, 1998). Some researchers also suggest that the internet can sometimes foster suicide or self-harming behaviours (Swannell et al., 2010), with some websites offering advice on particular techniques.

KBC Australia P a g e | 78 Figure 8-8 shows both MPHN males and females aged between 15 and 24 years have the second highest rate of intentional self-harm hospitalisations amongst NSW PHNs. MPHN females have three times the rate of intentional self-harm hospitalisations compared to males (Females 783.8 vs 258.6 per 100,000). For all ages, there was a total of 437 MPHN residents hospitalised due to intentional self-harm in 2015 (267 female; 170 male). HealthStats NSW

KBC Australia P a g e | 79 Figure 8-8 Intentional self-harm hospitalisations

Source: HealthStats NSW, Intentional self-harm

8.6.2 Suicide rates

There are many groups who are at increased risk of suicide, these include:

 Young people aged 15-24  Aboriginal and Torres Strait Islander people  Men living in rural and remote Australia  People who have been bereaved by suicide  Lesbian, gay, bisexual, transgender, intersex and other sexuality, sex and gender diverse people (LGBTI)  People experiencing mental illness  People who have previously attempted suicide or who engage in self-harm  People who’ve experienced an unexpected situational stressor (e.g., job loss, relationship breakdown)

Over the past 15 years (2001 to 2015) suicide rates in MPHN have been volatile. In 2015, 33 persons residing within MPHN committed suicide. This equates to a rate of 14.7 per 100,000 (95%CI 10-20.8). Although this rate is higher than NSW it is not significantly different [NSW; 10.6 per 100,000 (95%CI 9.9-11.3)].

KBC Australia P a g e | 80 Figure 8-9 shows of suicide/ self-harm attempts involving Wagga Local Area Command police, over half were related to mental illness and one quarter related to alcohol. Wagga Local Area Command data also showed of the attempts; 44% identified as Aboriginal, 56% as non-Aboriginal; (an immense over representation of Aboriginal people). The data also showed; 68% were females and 32% male (Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016, p163).

Figure 8-9 Related factors for suicide and self-harm, Wagga Local Area Command data, (2013-2015)

Alcohol related Domestic violence related Drug related Mental illness related No associated factor Personal violence related Police visability Transit related

0 10 20 30 40 Number of suicide attempts and self harm

Source: Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016

KBC Australia P a g e | 81 8.7 Cancer

Table 8-22 Cancer incidence, MLHD and NSW, Directly standardized rate per 100,000 (2008-2012) Tumour Group n MLHD rate NSW rate Urogenital 2193 144.3 115.5 - Prostate 1766 115.2 87.9 Colorectal 1046 69.3 62.5 Breast 821 58.6 60.9 Respiratory 762 49.7 47.6 Skin 737 53.0 53.9 Lymphohaematopoietic 669 46.0 49.9 Upper gastrointestinal 548 35.4 37.5 Gynaecological 293 20.8 20.6 Unknown primary 198 12.4 12.3 Head and neck 192 13.1 13.6 Neurological 94 7.1 7.2 Thyroid/endocrine 83 6.7 12.5 Bone and connective tissue 42 3.0 3.6 Eye 18 1.3 1.2 All cancers 7696 520.5 498.8 Source: Cancer Institute NSW

In comparison to NSW, the cancer incidence rate in MLHD is slightly higher and the mortality rate is slightly lower. Incidence and mortality data also show that the proportions of cancers by tumour group in MLHD is similar to NSW, meaning there is no single tumour group in MLHD that is unexpectedly high or low.

Table 8-23 Cancer mortality, MLHD and NSW, Directly standardized rate per 100,000 (2008-2012) Tumour Group N_MLHD MLHD rate NSW rate Respiratory 547 35.3 36.3 Upper gastrointestinal 373 23.8 26.7 Colorectal 348 22.1 20.9 Urogenital 326 20.3 19.7 - Prostate 209 12.8 11.7 Lymphohaematopoietic 273 17.5 17.0 Breast 156 10.4 11.6 Unknown primary 149 9.3 8.9 Gynaecological 97 6.4 6.8 Skin 89 5.8 6.3 Head and neck 72 4.7 4.5 Neurological 51 3.6 4.7 Bone and connective tissue 16 1.1 1.1 Thyroid/endocrine 5 0.3 0.6 All cancers 2506 161.0 165.6 Source: Cancer Institute NSW

8.8 Chronic disease

Accurate prevalence estimates for chronic disease are difficult to obtain. National and state estimates are primarily attained from patient surveys; which can be unreliable if a small number is sampled or

KBC Australia P a g e | 82 biased if the survey respondent has a poor awareness of their health. Below we have used data from GP Practices within the MPHN, to estimate the prevalence of chronic disease in MPHN. Whilst there is a high reliability in the number diagnosed, some chronic illnesses may be underrepresented; due to patients being diagnosed elsewhere (such as hospitals or by other health professionals) and it not reported back to the GP.

Table 8-24 Estimated prevalence of chronic disease, PENCAT vs National Health Survey Chronic illness PENCAT (2017) *National Health Survey (2014-15) CKD 1.6% 0.9% Diabetes 7.1% 5.1% COPD 3.5% 2.6% Asthma 10.4% 10.8% Cardiovascular disease 4.7% 5.2% Hypertension 16.1% 11.3% Heart failure 1.0% n.a. Total chronic 44.4% Source: MPHN, PENCAT (unpublished); *Source: ABS, National Health Survey

Table 8-24 compares the prevalence estimates from the National Health Survey and PENCAT. Estimates obtained from PENCAT and National Health Survey are quite similar, meaning that the PENCAT data does provide a reasonable estimate of chronic illness in MPHN. Note, both PENCAT and the National Health Survey report the prevalence of chronic illness across all ages (i.e. children are not excluded from the estimate).

8.8.1 Comorbid chronic disease

Unfortunately, PENCAT data is unable to report the number of patients with multiple chronic conditions. The National Health Survey estimates that out of 100 patients, 50 have no chronic illness, 27 have one chronic disease, 14 have two chronic diseases and 9 have three or more chronic diseases. (ABS, National Health Survey, 2014-2015)

8.8.2 Cardiovascular disease

Circulatory disease hospitalisations made up 7% of total hospitalisations (8303/120512) in 2015-16.

KBC Australia P a g e | 83 Figure 8-10 shows the cardiovascular hospitalisation rates for MPHN, Western NSW and NSW. Data from the past 10 years shows, that out of all PHNs in NSW, MPHN has consistently had the highest rate of cardiovascular hospitalisations, followed by Western NSW. Thus

KBC Australia P a g e | 84 Figure 8-10 shows that there is a large gap in cardiovascular hospitalisation rates between MPHN and every other PHN in NSW.

KBC Australia P a g e | 85 Figure 8-10 Cardiovascular disease hospitalisations, MPHN, Western NSW and NSW, (01-02 to 15- 16) 3500

3000

2500

2000 All PHNs

1500 Murrumbidgee Western NSW

Rate per Rate 100,000 persons 1000

500

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Source: HealthStats NSW, cardiovascular disease

In 2015, circulatory disease accounted for 28.9% of all deaths in MPHN (Table 8-25). The rate of circulatory disease deaths is higher than NSW (MPHN 163.4 v NSW 155.7 per 100,000) and 3rd highest amongst PHNs in NSW.

KBC Australia P a g e | 86 Figure 8-11 shows that the rate of circulatory disease deaths in MPHN is steadily decreasing as is the gap between males and females.

Table 8-25 Circulatory disease deaths by disease type, 2014-2015 (rate per 100,000) n_MPHN MPHN_rate NSW_rate Coronary heart diseases 242 64.3 66.8 Peripheral Vascular disease 25.5 6.9 5.6 Heart failure 61 14.5 11.1 Stroke 102.5 26.6 28.2 Other circulatory diseases 199 51.0 44.0 All circulatory disease 630 163.4 155.7 Source: HealthStats NSW, cardiovascular disease

KBC Australia P a g e | 87 Figure 8-11 Circulatory disease deaths by gender, MPHN, (2002-03 to 2014-15) 400

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Source: HealthStats NSW, cardiovascular disease

8.8.3 Respiratory Disease

Respiratory diseases include acute diseases (such as influenza and pneumonia), and chronic diseases (such as asthma, chronic obstructive pulmonary diseases and lung cancer). In 2015-16, respiratory hospitalisations in MPHN accounted for 6.2% of the total hospitalisations (7472/120512). This equates to a rate of 2683.3 per 100,000 (NSW 1731.3 per 100,000). Of all the PHNs in NSW, MPHN had the highest rate of respiratory hospitalisations.

However, the most recent death data (2013-2015) shows the rate of respiratory disease deaths in MPHN is only slightly higher than NSW (MPHN 52.3 per 100,000 persons; NSW 46.8 per 100,000 persons). And compared to all ten PHNs in NSW, MPHN had the 4th highest rate of respiratory disease deaths per 100,000 persons.

KBC Australia P a g e | 88 Figure 8-12 shows the rate of respiratory hospitalisations in MPHN is increasing, and conversely Figure 8-13 shows the respiratory death rate in MPHN is decreasing.

KBC Australia P a g e | 89 Figure 8-12 Respiratory hospitalisations, MPHN and NSW (2001-02 to 2015-16) 3000

2500

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1500

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Source: HealthStats NSW, respiratory disease

Figure 8-13 Respiratory deaths, MPHN and NSW (2001-03 to 2013-15) 80

70

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Source: HealthStats NSW, respiratory disease

Chronic Obstructive Pulmonary Disease

In 2015-16 one fifth of all respiratory hospitalisations in MPHN were due to COPD (1476/7472). Of the 1476 COPD hospitalisations, 1155 (78%) of the persons hospitalised were aged 65 years and over. MPHN has the highest COPD hospitalisation rate amongst all of the PHNs in NSW for those aged 65years+, which equates to 1.7 times the NSW COPD hospitalisation rate (MPHN 2473.8 per 100,000;

KBC Australia P a g e | 90 NSW 1462.8 per 100,000). As for COPD deaths, there was an average of 118.5 per annum in MPHN between 2014 and 2015. MPHN had the 2nd highest rate of COPD deaths amongst all PHNs in NSW (MPHN 32.2 per 100,000; NSW 24.3 per 100,000). Trend data shows the rate of COPD hospitalisations and deaths in MPHN have remained stable over the past ten years.

8.8.4 Chronic Kidney disease

Chronic Kidney disease is the occurrence of kidney damage or decreased kidney function for a period of three or more months. In 2013, there were over 700 patients in Wagga Wagga cared for by one Nephrologist in collaboration with local General practitioners and 231 patients were attending renal outpatient clinics in Griffith. (MLHD Renal Clinical Service Plan 2013-2017)

Kidney and Urinary Tract Infections

Until recently, MPHN had the highest rate of kidney and urinary tract infections in Australia. Recent data (2015-2016) now shows MPHN has the sixth highest rate of kidney and urinary tract infections in Australia, with a rate of 385 per 100,000 (Australia 288 per 100,00) (My Healthy Communities). Kidney and UTI infections are the second most common PPH in the Murrumbidgee region resulting in 1022 hospitalisations in 2015-16. Figure 8-14 shows the rate of urinary tract infections (including pyelonephritis) is increasing in both NSW and MPHN, and that the gap between NSW and MPHN is widening.

Figure 8-14 Rate of urinary tract infections, MPHN and NSW (2001-02 to 2015-16) 400

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Source: HealthStats NSW, potentially preventable hospitalisations

8.8.5 Diabetes

The prevalence of diabetes is based upon the NSW Population Health Survey. In 2016 in MLHD it is estimated 9.7% (95%CI: 6.8% to 12.6%) of persons aged 16 years and over have, (or have had), either diabetes or high blood glucose levels at some stage. Note, gestational diabetes is excluded from this

KBC Australia P a g e | 91 prevalence estimate. Diabetes prevalence in MLHD is similar to NSW prevalence of 8.9% and has remained stable over the past 14 years. (HealthStats NSW)

PENCAT data (GP Practice data), estimate diabetes prevalence in MPHN to be 7.1% (2017). Of the active patients who are diagnosed with diabetes; 5.4% are Indigenous; 74.5% are non-Indigenous and 20.1% did not state their ethnicity.

Hospitalisation data shows in 2014-15 there were 730 MPHN patients admitted with diabetes as the principle diagnosis. This equates to a rate of 266.3 per 100,000 persons, which is the highest rate amongst all NSW PHNs and much higher than the NSW rate of 148.0 per 100,000 persons. Diabetes hospitalisations have increased slightly over the past five years in MPHN from 223.8 per 100,000 persons in 2010-11 to 266.3 per 100,000 persons in 2014-15. (HealthStats NSW)

However, in 2015, out of the ten PHNs in NSW, MPHN had the fourth lowest rate of diabetes-related deaths, and a rate lower than NSW (MPHN 27.8 per 100,000; NSW 29.7 per 100,000). (HealthStats NSW)

8.9 Sexual health and Infectious disease

Notifiable Conditions in NSW

Under the NSW Public Health Act 2010, there are approximately fifty conditions which are notifiable to the Ministry of Health via local Public Health Units across NSW. Legislated notifiers include pathology laboratories, hospitals, medical practitioners, primary schools and child care centres.

The most frequently notified conditions in MPHN for 2015 were influenza, chlamydia, pertussis, hepatitis C, Salmonellosis, and Giardiasis (Table 8-26). Influenza numbers were particularly high in MPHN in 2015 compared to previous year’s averages, as were chlamydia and giardia notifications. The 2015 influenza season was particularly severe across MPHN and all NSW.

Q fever was the only infectious disease that was markedly higher in MPHN compared to NSW (7.2 vs 3.4 per 100,000).

Table 8-26: Notified conditions in MPHN for 2015, with 2010 to 2014 average and crude rates per 100,000 population, MPHN and NSW Crude rate per MPHN 100,000 population Notified Condition Number 2010-2014 2015 2015 MPHN notified, 2015 Average NSW Blood borne and sexually transmitted 1,131 978 Chlamydia (genital) 905 764 303.5 296.6 Gonorrhoea 27 29 9.9 71.3 Hepatitis B – acute viral <5 0 0.4 Hepatitis B – other 35 34 11.6 30.9 Hepatitis C – acute viral <5 <5 1.0 0.4 Hepatitis C – other 149 140 51.0 46.8 Hepatitis D – unspecified <5 0 0.1 Lymphogranuloma venereum <5 0 0.2 Syphilis 12 8 2.4 9.8 Enteric 384 297 Cryptosporidiosis 57 22 20.2 13.8

KBC Australia P a g e | 92 Table 8-26: Notified conditions in MPHN for 2015, with 2010 to 2014 average and crude rates per 100,000 population, MPHN and NSW Crude rate per MPHN 100,000 population Notified Condition Number 2010-2014 2015 2015 MPHN notified, 2015 Average NSW Giardiasis 144 84 50.0 45.0 Haemolytic uraemic syndrome <5 0 0.1 Hepatitis A <5 0 0.9 Hepatitis E <5 0 0.3 Listeriosis <5 <5 0.3 0.8 Rotavirus 34 28 11.3 13.7 Salmonellosis 143 159 50.7 53.0 Shigellosis <5 <5 1.4 2.3 Typhoid <5 <5 0.3 0.5 Verotoxin producing E. coli <5 0.3 0.4 Respiratory and other 967 335 Blood lead level 13 50 4.5 5.3 Influenza 914 251 311.4 397.5 Invasive pneumococcal infection 24 21 8.2 6.4 Legionella longbeachae infection <5 <5 Legionella pneumophila infection <5 <5 Legionnaires’ disease (other) <5 <5 2.1 1.3 Leprosy <5 0 0.0 Meningococcal infection (invasive) 5 <5 1.7 0.6 Tuberculosis 5 7 1.4 5.8 Vaccine – preventable 495 550 H. influenzae b infection (invasive) <5 0 0.1 Measles <5 0 0 Mumps <5 <5 0.3 0.8 Pertussis 494 548 177.8 160.8 Rubella <5 0 0.1 Vectorborne 99 135 Arboviral infection (other) 10 <5 Barmah Forest virus <5 18 0.7 2.4 Malaria <5 <5 0.7 0.6 Ross River virus 85 111 28.1 21.3 Zoonoses 23 13 Anthrax <5 0 0 Leptospirosis 5 0 0.2 Psittacosis <5 <5 0.3 0.2 Q fever 21 8 7.2 3.4 Miscellaneous <5 <5 Creutzfeldt–Jakob disease <5 Chlamydia (congenital) <5 <5 0.3 0.4 Grand Total 3,100 2,313 Source: Murrumbidgee Primary Health Needs Assessment; November 2016- retrieved from Ministry of Health, NCIMS database

ENDING HIV

In 2015 for NSW, there were 350 newly diagnosed cases of HIV, 81 per cent among gay men, 15 per cent among heterosexuals, 2 per cent among Aboriginal people and 1 per cent injecting drug users. In

KBC Australia P a g e | 93 MPHN (including the Albury LGA population) there have been 17 people with newly diagnosed HIV infection from 2011 to 2015, an average of 3.4 new cases annually.

Priorities of the ENDING HIV program include increasing testing for people at risk and ensuring they are tested more often. The initiative has a focus on supporting general practice to deliver HIV testing as part of routine primary health care, and strengthening shared care arrangements between GPs and HIV specialists to support the health needs of people with HIV.

8.10 Oral health

Oral health is a good indicator of general health. Poor oral health is likely to exist when general health is poor, and vice versa. Table 8-27 and Table 8-28 shows oral health hospitalisations across all ages MPHN is similar to NSW.

Table 8-27 Removal and restoration of teeth for dental caries: Total hospitalisations for MPHN and NSW Population Ages Number Rate (per 100,000 persons) MPHN 0-4 years 37 243.5 5-14 years 134 409.3 15+ years 148 80.1 NSW 0-4 years 1684 343.5 5-14 years 4088 430.5 15+ years 3207 51.0 Source: HealthStats NSW, Oral health

Table 8-28 Oral health hospitalisations in MPHN and NSW (2012-13 to 2014-15) Population Ages Number Rate (per 100,000 persons) MPHN 0-14 years 258 536.8 15+ years 800 456.6 All ages 1058 473.1 NSW 0-14 years 8553.7 612.3 15+ years 27167.3 466.5 All ages 35721.0 496.4 Source: HealthStats NSW, Oral health

KBC Australia P a g e | 94 Figure 8-15 Oral health hospitalisations by reason, all ages, MPHN 2001-04 to 2012-15 300

250

200

150

100 Rate per Rate 100,000 persons 50

0

Dental caries Developmental disorders of teeth Injury Other diagnoses Other infection of teeth or gums

Source: Source: HealthStats NSW, Oral health

KBC Australia P a g e | 95 9 HEALTH OF POPULATION GROUPS

9.1 Mothers, infants and young children

9.1.1 Fertility

The total fertility rate (TFR) represents the number of children a female would bear during her lifetime if she experienced current age-specific fertility rates at each age of her reproductive life. In 2015, MPHN total fertility rate was 1.78 per women (NSW 1.79). This has decreased slightly from 2001, where the total fertility rate was 1.95 per women. Note, TFR in MPHN is likely to be higher than the figure reported, as babies born interstate have not been recorded in Health Stats NSW data. (HealthStats NSW)

9.1.2 Maternal and Infant indicators

Teenage mothers

There were close to 200 mothers aged less than 20 years in 2013 who live in MLHD, 54 of which were Aboriginal. Teenage mothers made up 5.8 per cent of all mothers for that year – and 21 per cent of all Aboriginal mothers were teens (A report on women’s health: Murrumbidgee Local Health District, 2014). In NSW in 2015, 3.8 per cent of mothers were aged less than 20 years and 14.0 per cent of Aboriginal mothers were teens (HealthStats NSW).

Table 9-1 shows higher proportion of MPHN Indigenous mothers smoked during pregnancy, were less than 20 years old and had babies that were preterm and of low birthweight compared to MPHN non- Indigenous mothers. A lower proportion of MPHN Indigenous mothers had an antenatal visit before 20 weeks and exclusively breastfed prior to discharge compared to MPHN non-Indigenous mothers. Smoking rates are particularly high in MPHN Indigenous mothers, with 49% of Aboriginal mothers smoking during pregnancy compared to 15% of non-Aboriginal mothers. While there is a decreasing trend in both Aboriginal and non-Aboriginal mothers who smoke during pregnancy (Figure 9-1), rates continue to be higher than the rest of NSW (9%).

KBC Australia P a g e | 96 Table 9-1 Maternal and infant indicators by Indigenous status, 2015 MPHN NSW Indigenous women Smoking during pregnancy 49.4% 45.0% First antenatal visit before 14 weeks 52.3% 55.6% First antenatal visit before 20 weeks 68.0% 76.0% Low birth weight (<2500g) 12.1% 11.3% Infants discharged from hospital who were 51.7% 63.3% exclusively breastfed Preterm births 14.4% 12.7% Births to mothers <20 years of age* 14.0% 15.4% Non-Indigenous women Smoking during pregnancy 14.8% 7.4% First antenatal visit before 14 weeks 55.3% 64.7% First antenatal visit before 20 weeks 75.8% 87.8% Low birth weight (<2500g) 5.5% 6.4% Infants discharged from hospital who were 78.9% 79.6% exclusively breastfed Preterm births 8.7% 7.7% Births to mothers <20 years of age* 3.8% 2.0% Source: HealthStats NSW, Mothers and babies; *Source: Aboriginal Health Profile MLHD 2017, derived from NSW Mother and babies, 2015

Figure 9-1 Smoking at all during pregnancy among Aboriginal and non-Aboriginal mothers. MPHN and NSW (2001 to 2015)

Source: HealthStats NSW, Mothers and babies

KBC Australia P a g e | 97 9.1.3 Infant mortality

The infant mortality rate is a measure of the number of deaths of children under one year of age per 1000 live births. Table 9-2 shows the infant mortality rate in MPHN was 4.2 per 1000 births, which is similar to the NSW infant mortality rate of 3.7 per 1000 births. MPHN child mortality rates are also comparable to NSW, however the MPHN youth mortality rate is higher than NSW (50.3 vs 34.2). This may be linked to the higher number of youth road accidents in MPHN compared to NSW (Table 9-6).

Table 9-2 Infant, child and youth mortality rates, MPHN and NSW (2010-2014) MPHN NSW Number Rate- Ave Annual Rate- Ave Annual Infant (<1yr) 62 4.2 (per 1,000) 3.7 (per 1,000) Child (1-4yrs) 14 21.0 (per 100,000) 15.6 (per 100,000) Youth (15-24yrs) 77 50.3 (per 100,000) 34.2 (per 100,000) Source: PHIDU, PHN data, Child and youth health

9.1.4 Immunisation

Overall, immunisation rates in MPHN are higher compared to NSW. At five years 96% of non- Aboriginal children and 97% of Aboriginal children were fully immunised, compared to 93.5% of five- year olds in NSW. These immunisation rates in MPHN exceed the 95% target set by Chief Health Officers of Australia (Table 9-3).

Table 9-3 Immunisation rates of MPHN and NSW children, 2016 MPHN NSW Indigenous children 1 year 92.8% 93.3% 2 years 91.4% 91.1% 5 years 97.0% 96.5% Non-Indigenous children 1 year 95.7% 93.3% 2 years 94.0% 90.8% 5 years 96.0% 93.3% All children 1 year 95.4% 93.3% 2 years 91.4% 91.1% 5 years 96.1% 93.5% Source: HealthStats NSW, Immunisation

9.1.5 Developmentally vulnerable children

The Australian Early Development Census (AEDC) is a nationwide measure that looks at how well children are developing by the time they reach school. The AEDC looks at five different domains that are important for child development. These include;  Physical health and wellbeing  Social competence  Emotional maturity  Language and cognitive skill (school- based); and  Communication skills and general knowledge.

KBC Australia P a g e | 98 Twenty-one per cent of MPHN children were developmentally vulnerable in one or more domain, which is similar to NSW (20.2%). However, the LGAs of; Urana, Hay, Boorowa, Harden and Murrumbidgee had 30% to 42.3% of children scoring as developmentally vulnerable in one or more domain (Table 9-4).

Table 9-4 Developmentally vulnerable children by domain, 2015 MPHN NSW One or more domains 21.0% 20.2% Two or more domains 9.9% 9.6% Physical health and well being 10.0% 8.5% Social competence 8.6% 9.2% Emotional maturity 7.6% 6.8% Language and cognitive 5.4% 4.8% Communication skills and general knowledge 7.3% 8.1% No of children with valid score 3124 90956 Source: PHIDU, PHN, Australian Early Development Census

Table 9-5 Five highest LGAs with children categorised as; Developmentally vulnerable in one or more domains, 2015 LGA Percentage No with a valid score 1. Urana 42.3% 26 2. Hay 33.3% 39 3. Boorowa 31.4% 35 4. Harden 31.0% 42 5. Murrumbidgee 30.0% 40 MPHN 21.0% 3124 NSW 20.2% 90956 Australia 22.0% 286041 Source: PHIDU, PHN, Australian Early Development Census

9.2 Youth

In 2012-2014, injury was the leading cause of death amongst 15-24year old’s in Australia. Suicide (30.5%), and land transport accidents (22.3%), accounted for over half of all deaths in this age group. Accidental poisoning (including drug overdoses) was the 3rd leading cause of death, accounting for 5.0% deaths and assault was the 4th leading cause of death accounting for 3.1% of all deaths. Males are over represented in the death rates amongst young people, as 68% of deaths in the age group were males. (AIHW- Leading causes of death by sex and age group 2012-2014)

Death rates in young people are declining, as over the last 16 years the death rate in Australia has fell by 47% from 74 deaths per 100,000 in 1997 to 39 per 100,000 in 2012. Road accidents have also markedly declined from 20 per 100,000 in 1997-1999 to 11 per 100,000 in 2011-12. (AIHW- Young Australians; Their Health and Wellbeing)

Table 9-6 shows the percentage of deaths from motor vehicle accidents is much higher in comparison to NSW. This is also reflected in motor vehicle hospitalisation data for people aged 15-24 years (Figure 9-2).

KBC Australia P a g e | 99

Table 9-6 Top five causes of injury and poisoning deaths for all ages, MPHN and NSW (2011-2015) MPHN NSW 1. Suicide (23.2%) Suicide (26.5%) 2. Motor vehicle transport (22.4%) Fall (17.6%) 3. Fall (15.0%) Poisoning (unintentional) (13.7%) 4. Exposure to unspecified factor (11.4%) Exposure to unspecified factor (13.3%) 5. Poisoning (unintentional) (8.5%) Motor Vehicle transport (12.7%) Source: HealthStats NSW, Injury and poisoning

It should also be noted in Figure 9-2 that despite the rate of motor vehicle hospitalisations being much higher for MPHN males, it has declined since 2008-09.

Figure 9-2 Motor Vehicle Accidents in NSW and MPHN for those aged 15-24 years old (2001-02 to 2014-15) 1600

1400

1200

1000

800

600

Rate per Rate 100,000 persons 400

200

0

Murrumbidgee PHN Females Murrumbidgee PHN Males Total NSW Females Total NSW Males

Source: HealthStats NSW, Injury and poisoning

Table 9-7 shows data from the NSW School Vaccination program. Vaccination coverage rates are calculated using the number of vaccine doses administered in the program and the number of eligible students based on enrolment data sourced from schools at the beginning of each school year. Therefore, these figures do not provide information on vaccination given in other settings, for example by a medical practitioner privately.

Vaccination rates for MPHN youth are similar if not slightly better compared to NSW.

KBC Australia P a g e | 100 Table 9-7 Immunisation by school year for MLHD and NSW, 2016 Vaccine Type MLHD NSW HPV- Females (yr7)- Dose 1 90% 86% HPV- Females (yr7)- Dose 2 85% 83% HPV- Females (yr7)- Dose 3 72% 71% HPV- Males (yr7)- Dose 1 85% 83% HPV- Males (yr7)- Dose 2 81% 80% HPV- Males (yr7)- Dose 3 71% 67% dTpa (yr7)- Dose 1 87% 85% Varicella 72% 70% Source: HealthStats NSW, Immunisation

9.3 Older persons

Nearly four percent of separations for those aged 70 years and over are due to rehabilitation and other factors influencing health, yet they make up over a quarter of the total bed days for this age group. Other factors influencing health, has the highest average length of stay (25 bed days) of all the diagnostic groups. The long length of stay in this group may be related to patients waiting for a residential aged care facility placement or because the patient does not have carer support. Over 80% of heart failure and shock with and without catastrophic complications and other follow up after surgery or medical care with catastrophic complications are related to persons over 70 years of age (Table 9-8).

KBC Australia P a g e | 101 Table 9-8 Top 10 Diagnostic Related Groups (DRGs) in 70+ year olds, MLHD separations, 2013- 2014 Average % of total % of 70+ length 70+ separations separations Diagnostic Related Groups (DRGs) Bed of stay Separations in 70+ aged 70+ of Days (bed years all ages days) Rehabilitation 19,006 1,063 17.9 2.6% 66% Other Factors Influencing Health 10,821 433 25.0 1.1% 65% Status Chronic Obstructive Airways 4,403 933 4.7 2.3% 63% Disease W/O Catastrophic CC Other Follow Up After Surgery or 4,198 562 7.5 1.4% 63% Medical Care W/O Catastrophic CC Heart Failure and Shock W/O 3,456 581 5.9 1.4% 81% Catastrophic CC Other Follow Up After Surgery or 3,280 262 12.5 0.7% 80% Medical Care W Catastrophic CC Lens Procedures 2,602 2,598 1.0 6.5% 75% Respiratory Infections/Inflammations W 2,172 255 8.5 0.6% 77% Catastrophic CC Respiratory Infections/Inflammations W Severe 2,148 415 5.2 1.0% 66% or Moderate CC Heart Failure and Shock W 2,111 199 10.6 0.5% 81% Catastrophic CC Source: Murrumbidgee Primary Health Needs Assessment; November 2016

9.3.1 Arthritis

Arthritis is one of the leading causes of chronic pain and disability in Australia. It is a condition where a person’s joints become inflamed, which may result in pain, stiffness, disability and deformity. The symptoms often have a significant impact on quality of life. The prevalence of arthritis increases with age. For Australians aged 75 years and over 52.1% suffered arthritis (59.9% women; 42.3% males). By applying the Australian prevalence rate to the MPHN population, it is estimated there are 11,238 arthritis suffers over the age of 75 years residing in MPHN. (National Health Survey-2011-2012)

9.3.2 Dementia

Dementia is a major health problem in Australia and Australia’s second leading cause of death (2014). It is an umbrella term describing a group of symptoms that are characterised by impaired brain function. Dementia predominantly affects the elderly and in 2015; 1 in 10 Australians aged 65+ years and 3 in 10 Australians aged 85+ years had dementia (AIHW-Dementia). People with dementia eventually become dependent on their carer in most, if not all areas of daily living, and thus it is unsurprising that 44.3% of MPHN residents in permanent residential aged care had a diagnosis of dementia in 2016 (AIHW- My aged care region).

KBC Australia P a g e | 102 The prevalence of dementia in MPHN is not known. However, HealthStats NSW, reports the number of hospitalisations where dementia was a principal diagnosis or listed as a co-morbidly. Table 9-9 shows hospitalisations related to dementia increase significantly with age and that MPHN rates are similar to the NSW rate. Dementia related hospitalisation rates in MPHN have been decreasing over the past 15 years for all age groups (2001-02: 526.6 per 100,000 to 2014-15: 313.8 per 100,000). This is a good finding considering the number of dementia suffers is increasing due to an ageing population.

Table 9-9 Dementia as a principal diagnosis or as a comorbidity; hospitalisations, MPHN and NSW 2014-2015 MPHN NSW 65-74 Years 372.8 530.3 75-84 years 3525.6 3031.8 85+ years 9590.3 9472.5 Source: HealthStats NSW, Dementia hospitalisations

9.3.3 Falls

Data from the 2015 NSW Population Health Survey, reports in the 12 months prior to the survey, 25.0% of MPHN persons aged 65 years and over had a fall (NSW 22.7%). Fall related hospitalisations are also very similar to NSW, with 3112.4 fall related hospitalisations per 100,000 MPHN persons compared to 3044.1 fall related hospitalisations per 100,000 NSW persons. Fall-related hospitalisations is much higher amongst females 65+ compared to males 65+ in MPHN (Females 3533.4 per 100,000 vs 2586.9 per 100,000), which is a consistent trend across NSW. (HealthStats NSW,Falls)

9.3.4 Vaccination

Influenzna and pneumococcal immunisation rates in MPHN residents aged over 65 years are similar if not better than NSW (Table 9-10).

Table 9-10 Influenzna and pneumococcal disease immunisation for MPHN and NSW, persons aged 65 years and over- 2015-2016 MPHN NSW Influenza 71.3% 71.6% Pneumococcal 52.2% 47.0% Source: HealthStats NSW, Immunisation

9.4 Health of Aboriginal and Torres Strait Islanders

The data presented in Table 9-11 and Table 9-12 includes only Aboriginal people. Premature death rates of Aboriginal males in the Lachlan Indigenous Area are much higher than death rates for NSW

KBC Australia P a g e | 103 Aboriginals. This result does not translate in the median age of death, as Lachlan Aboriginal males have a similar median age of death to NSW Aboriginals.

Table 9-11 Premature mortality 0-74 years- Aboriginal persons, ASR per 100,000 (2010 to 2014) Indigenous Areas Males Females Persons Coolamon-Temora- West Wyalong 293.6 323.6 308.4 Griffith- Leeton 261.7 327.5 295.1 Lachlan 782.2 385.9 589.1 Wagga Wagga 187.6 260.9 223.4 NSW 276.6 203.5 240.2 Source: PHIDU, IARE data, Premature mortality. Note: Not all IARE have not been reported due to small numbers

The median age of death for MPHN Aboriginal persons is 20 years lower than for MPHN persons (MPHN persons: 81 years- Table 8-2). And within the Indigenous Areas of MPHN, Wagga Wagga Aboriginals have the lowest median age of death (56 years old) and Narrandera the highest (75.5 years old).

Table 9-12 Median Age at death, Aboriginal persons, 2010 to 2014 Indigenous Areas Males Females Persons Coolamon-Temora- West Wyalong 56 68 63.5 Deniliquin- Murray 65.0 78.5 66.5 Griffith- Leeton 56.0 60.0 60 Lachlan 57.5 68.5 61.5 Narrandera 65.5 79.5 75.5 Wagga Wagga 46 63 56 NSW 58 65 61 Source: PHIDU, IARE data, Median age at death. Note: Not all IARE have not been reported due to small numbers

9.4.1 Chronic and mental illness amongst Aboriginal people

Approximately 51 out of the 82 (62%) GP practices in MPHN upload specific de-identified data into the PENCAT database every three months. Of the 51 participating GP practices, there is one Aboriginal Medical Service (AMS). Table 9-13 shows that the representation of Aboriginal persons in the PENCAT database is similar to the percentage in the MPHN population. This means the proportions of Indigenous and non-Indigenous patients diagnosed with either a chronic or mental illness should provide a reasonable estimate. It should also be noted that data reports on active patients only. An active patient, is defined as patients who have been seen at least three times in the last two years.

Table 9-13 Percentage of active Indigenous and non-Indigenous patients recorded on PENCAT (GP database) % Indigenous % non-Indigenous % not stated *MPHN population 4.8% 87.5% 7.7% Active patients on PENCAT 4.7% 72.3% 23.1% Source: MPHN, PENCAT (unpublished): *Source: Australian Bureau of Statistics, URP 2016 Census

Table 9-14 shows there is a higher proportion of Indigenous people with asthma compared to non- Indigenous people (19.8% vs 13.1%) and a lower proportion with hypertension, heart failure and

KBC Australia P a g e | 104 cardiovascular disease. The proportion of Indigenous patients diagnosed chronic kidney disease is similar to non-Indigenous patients; and diabetes and COPD are only slightly higher in the Indigenous population. It should be noted that Aboriginal status not stated for 13% to 20% of PENCAT patients diagnosed with COPD, diabetes and kidney disease, so it is difficult to know the true prevalence by aboriginal status for these diseases (Figure 9-3).

Table 9-14 Estimated prevalence of chronic disease in MPHN, by Indigenous status, 2017 % of all active % Indigenous (of all % non-Indigenous (of all Chronic illness patients Indigenous active patients) non-Indigenous active patients) CKD 1.6% 1.7% 1.7% Diabetes 7.1% 8.2% 7.3% COPD 3.5% 4.5% 3.9% Asthma 10.4% 19.8% 13.1% Cardiovascular disease 4.7% 4.2% 6.2% Hypertension 16.1% 11.7% 21.6% Heart failure 1.0% 0.8% 1.4% Total chronic 44.4% 51.1% 55.2% Source: MPHN, PENCAT (unpublished)

Figure 9-3 Percentage of Indigenous and non-Indigenous patients diagnosed with a chronic disease

Heart failure 3.8% 96.2%

Hypertension 3.4% 96.6%

Cardiovascular disease 4.2% 95.8%

Asthma 8.9% 91.1%

COPD 6.1% 80.9% 13.0%

Diabetes 5.4% 74.5% 20.1%

CKD 5.1% 79.8% 15.1%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Indigenous non-Indigenous not-stated

Source: MPHN, PENCAT (unpublished)

Table 9-15 shows there is a higher proportion of MPHN Indigenous people with a mental illness compared to non-Indigenous people. Depression is the most common mental illness in MPHN Indigenous people (17.5%), followed by anxiety (9.9%).

Figure 9-4 also shows that there is a much higher proportion of Aboriginal patients with mental illness then expected i.e. MPHN Aboriginal constitute around 5% of the population but make up around 10%

KBC Australia P a g e | 105 of patients with a mental illness. This data shows there is particularly an overrepresentation of schizophrenia (18%) and ADHD (19%) amongst Aboriginal people. Dementia is the only mental illness in (

Figure 9-4) of which Indigenous people are underrepresented (1.7%).

Table 9-15 Estimated prevalence of mental illness in MPHN, by Indigenous status, 2017 % of all active % Indigenous (of all % non-Indigenous (of all Mental illness patients Indigenous active patients) non-Indigenous active patients) Anxiety 5.9% 9.9% 7.5% Depression 9.6% 17.5% 12.2% Schizophrenia 0.4% 1.7% 0.5% Bipolar 0.8% 1.9% 1.0% Dementia 0.4% 0.1% 0.5% ADHD 0.7% 2.7% 0.8% Autism 0.3% 0.5% 0.4% Post-natal depression 0.3% 0.7% 0.4% Total Mental illness 18.5% 35.0% 23.3% Source: MPHN, PENCAT (unpublished)

Figure 9-4 Percentage of Indigenous and non-Indigenous patients diagnosed with a mental illness

Post-natal depression 9.8% 90.2%

Autism 7.5% 92.5%

ADHD 18.6% 81.4%

Dementia 1.7% 98.3%

Bipolar 10.7% 89.3%

Schizophrenia 18.3% 81.7%

Depression 8.5% 91.5%

Anxiety 7.8% 92.2%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Indigenous non-Indigenous

Source: MPHN, PENCAT (unpublished)

The figure below compares the hospital separations for the Aboriginal and non-Aboriginal population. Non-Aboriginal separations are predominantly distributed over 65-years, whereas for Aboriginal people, the distribution is primarily grouped among under 5 years old, between 15 – 29 years of age and between 40 – 59 years of age. There are relatively few beyond separations 69 probably reflecting the gap in life expectancy.

KBC Australia P a g e | 106 Figure 9-5 Five-year age break down of hospital separations, Aboriginal and non-Aboriginal population in the Murrumbidgee PHN compared, 2013/14 14%

12%

10%

8%

6%

4%

2% Proportion of Hospitalseparations 0% 0 to 45 to 9 10 to 15 to 20 to 25 to 30 to 35 to 40 to 45 to 50 to 55 to 60 to 65 to 70 to 75 to 80 to 85 Years Years 14 19 24 29 34 39 44 49 54 59 64 69 74 79 84 Years Years Years Years Years Years Years Years Years Years Years Years Years Years Years Years and Over

% of total non-ATSI Separations % of total ATSI Separations

Source: Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016

The difference in pattern of service utilisation in terms of hospital bed days between Aboriginal and the non-Aboriginal population emerges by comparing

KBC Australia P a g e | 107 Figure 9-6 and Figure 9-7.  The highest proportion of non-Aboriginal hospital bed days are utilised for acute psychiatric patients 15-24 years at age which accounts for between 40-50% of total bed days. This proportion peaks again between the ages of 40 to 49 for non-Aboriginal hospital bed days. Occupancy of hospital beds peaks for acute psychiatric service in Aboriginal patients between 30 to 39 years.  Renal dialysis is substantially higher for Aboriginal patients which peaks between 55 to 69 years of age, suggesting many of these patients do not live beyond this age.  Aboriginal patients above 55 have higher proportions of respiratory medicine SRGs compared to the non-Aboriginal group.  The proportion of bed days for non-Aboriginal patients above 55 years of age is significantly greater. This reflects the difference in life expectancy.

These patterns of service utilisation reflect lower admission rates of Aboriginal patients for acute psychiatric services at younger age groups, higher utilisation of hospital based beds for renal dialysis and respiratory medicine services and lower utilisation of orthopaedics and rehabilitation services by the Aboriginal patients.

KBC Australia P a g e | 108 Figure 9-6 Distribution of the top 9 Service related groups by 5-year age groups in the Murrumbidgee Local Health District facilities for Aboriginal patients, 2013/14

80 to 84 Years

70 to 74 Years

60 to 64 Years

50 to 54 Years

40 to 44 Years

30 to 34 Years

20 to 24 Years

10 to 14 Years

0 to 4 Years 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Psychiatry - Acute Renal Dialysis Non Subspecialty Medicine Respiratory Medicine Obstetrics Orthopaedics Non Subspecialty Surgery Rehabilitation Gastroenterology

Source: Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016

Figure 9-7 Distribution of the top 9 Service related groups by 5-year age groups in the Murrumbidgee Local Health District facilities in non-Aboriginal patients, 2013/14

85 Years and Over 80 to 84 Years 75 to 79 Years 70 to 74 Years 65 to 69 Years 60 to 64 Years 55 to 59 Years 50 to 54 Years 45 to 49 Years 40 to 44 Years 35 to 39 Years 30 to 34 Years 25 to 29 Years 20 to 24 Years 15 to 19 Years 10 to 14 Years 5 to 9 Years 0 to 4 Years 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Psychiatry - Acute Renal Dialysis Non Subspecialty Medicine Respiratory Medicine Obstetrics Orthopaedics Non Subspecialty Surgery Rehabilitation Gastroenterology

KBC Australia P a g e | 109 Source: Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016

9.4.2 Indigenous Health Check

AIHW data shows that there were 2,770 Indigenous health checks conducted in MPHN for 2013/2014. This equates to a usage rate of 23.4%, which was the third highest rate compared to the PHNs in NSW. Figure 9-8 shows that the number of Indigenous Health checks conducted is increasing.

Figure 9-8 Number of Indigenous Health Checks in MPHN (2011-12 to 2013-14) 3000

2500

2000

1500

1000 Numberchecks of

500

0 2011-12 2012-13 2013-14

Source: AIHW, Indigenous health check (MBS 715) data tool

KBC Australia P a g e | 110 10 HEALTH SERVICES

10.1 Overview of the service system

Murrumbidgee Local Health District has a wide range of inpatient acute and sub-acute hospital services. There is one regional referral hospital (Wagga Wagga); one rural base hospital (Griffith); eight District level hospitals; ten community level hospitals and health services; 11 multipurpose services and 14 community health posts (MLHD 2012). Wagga Wagga Rural and Referral Hospital is a 265 bed facility and includes: general medical, cardiothoracic, renal and paediatric wards. A more comprehensive overview is provided in Chapter 4: Overview of the Health Service System.

Figure 10-1 Map of MLHD facilities

Source: The MLHD 2017: Summary population and health profile

10.2 Referral patterns and patient flows

Of all hospitalisations for Murrumbidgee residents in 2012/13, 12% were to facilities in Victoria (and Albury Hospital); 1.7% to ACT and 1.2% to rest of NSW. 11% of private hospital volumes were to outside Murrumbidgee in other parts of NSW (Sydney). Victoria and ACT are not considered in private patient flows (MLHD, Murrumbidgee Action Plan, 2015).

KBC Australia P a g e | 111 Figure 10-2 Patient flows within MLHD

Source: MLHD, Murrumbidgee Action Plan, 2015

10.3 Primary Care

MPHN workforce data (Table 10-1) indicates that there are 168 GP FTE (213 headcount) working in the MPHN. The ratio of population to GPs is low compared to national benchmarks. i.e. RDAA benchmarking (2003) recommended a GP: population ratio of 1:1,000 for office based practice and 1:750 where the GP provides VMO services. In comparison GP: population ratios in MPHN sectors vary from 1:1,509 in Riverina to 1:1,353 in Wagga Wagga. Furthermore, review of GP workforce data indicates that 21 of 39 towns in the MPHN have 1 or 2 doctors and the majority of these towns also have Community Level hospitals or MPSs where GPs operate as VMOs.

GP registrars have not been counted in the GP to population ratios as training requirements often require them to relocate at some point during their course.

Table 10-2 to Table 10-5 display MBS data pertaining to GP service utilisation. Despite the data showing that GP service claims per head of population are similar to NSW, the MBS data should be interpreted with caution as MBS data is a reflection of office based services and does not account for the amount of GP work undertaken in local hospitals. Therefore, consideration of all GP sources shows, there is an undersupply of GPs in MPHN.

KBC Australia P a g e | 112 Table 10-1 Number of GPs in MPHN (2017) Border Riverina Western Wagga Wagga Town GPs FTE Town GPs FTE Town GP FTE Town GP FTE Barham 2 Adelong 2 0.5 Wagga Wagga 46.1 Berrigan 1 Booroowa 3.5 Darlingtin Pt 0.5 Corowa 7.4 Coolamon 1 Griffith 19.5 Culcairn 1 Cootamundara 4.7 Hay 1 Cummeragunja 2 Gundagai 1.2 Hillston 0.8 Deniliquin 7.8 Harden 2.9 Lake Cargelligo 2 Finley 4 Junee 4 Leeton 9.6 Henty 2 Temora 4.8 Narrandera 3.6 Howlong 1 Tumbarumba 2 Jerilderie 2 Tumut 5.8 Jindera 2 Young 8.3 Moama 3.8 West Wyalong 4 Tocumwal 2 0.1 Urana 1 Lockhart 1 The Rock 0.3 TOTAL FTE 40.4 TOTAL FTE 44.2 TOTAL FTE 37.5 TOTAL FTE 46.1 Border Population 56283 Riverina Population 66715 Western Population 52298 Wagga Wagga Population 62383 Population: GP 1393 Population: GP 1509 Population: GP 1395 Population: GP 1353 Registrars 8 Registrars 14 Registrars 12 Registrars 12 MPHN: Total GP FTE 168 Total GP headcount 213 Total Registrars 46 Source: MPHN workforce dataset: Note; FTE; Full time equivalent

KBC Australia P a g e | 113 10.3.1 Medicare Benefit Scheme (MBS)

In the 2014-15 financial year there were 1,337,003 Medicare claims for GP services for people residing within MPHN’s catchment – an average of 5.53 claims per head of population. As shown in Table 10-2, utilisation of GP services is slightly lower in MPHN than in NSW.

Table 10-2 Medical Benefit Schedule claims for GP services, 2014-15 MPHN NSW Number of MBS claims for GP services 1,337,003 46,999,047 Population 241,487 7,467,976 GP services claims per head of population 5.53 6.29 Source: Murrumbidgee Primary Health Needs Assessment; November 2016- derived from Department of Health – Primary Health Network Dataset

Table 10-3 and Table 10-4 present data for selected GP item numbers. There are more claims per head of population in MPHN than NSW for Standard Health Assessments and GP Management Plans, but fewer claims per head of population in MPHN than NSW for Mental Health Treatment Plans (Table 11-1).

Table 10-3 Medical Benefits Schedule Item 703 – Standard Health Assessment, 2014-15 MPHN NSW Population 241,487 7,467,976 Number of Providers 222 6,274 Population: GP ratio 1,088 1190 Number of Item 703 claims 3,180 91,206 Item 703 claims per 1,000 population 13.2 12.2 Source: Murrumbidgee Primary Health Needs Assessment; November 2016- derived from Department of Health – Primary Health Network Dataset

Table 10-4 Medical Benefits Schedule Item 721 – GP Management Plan for Patient with a Chronic or Terminal Condition, 2014-15 MPHN NSW Population 241,487 7,467,976 Number of Providers 299 9,324 Population: GP ratio 808 801 Number of Item 721 claims 28,724 768,396 Item 721 claims per 1,000 population 119 103 Source: Murrumbidgee Primary Health Needs Assessment; November 2016- derived from Department of Health – Primary Health Network Dataset

General practitioners can claim for a Diabetes Annual Cycle of Care (Item 2521) after undertaking detailed management steps, including measurements of HbA1c, weight, height, and blood pressure; eye and feet examinations, and patient education about self-care. This MBS Item number is utilised relatively infrequently when compared to the estimated number of people living with diabetes. As shown in Table 10-5, there were approximately 44 claims in 2014-15 for every 1,000 people estimated to be living with diabetes in Murrumbidgee. It is important to note that the absence of an Item 2521 claim does not mean that a patient is not having their diabetes clinically managed by their general practitioner. However, the number of 2521 claims per annum provides some indication of the degree to which patient care is being optimised for people living with diabetes.

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Table 10-5 Medical Benefits Schedule Item 2521 – Diabetes Annual Cycle of Care, 2014-15 MPHN NSW Population 241,487 7,467,976 Number of Item 2521 claims 1,158 32,668 Estimated number of people living with diabetes (all ages), 26,081 701,990 MPHN 10.8%, NSW 9.4% Item 2521 claims per 1,000 people estimated to be living with 44.4 46.5 diabetes Source: Murrumbidgee Primary Health Needs Assessment; November 2016- derived from Department of Health – Primary Health Network Dataset

10.3.2 GP utilisation

Table 10-6 displays results from the 2015-2016 Australian Bureau of Statistics Patient Experience Survey. The survey collected information from 28,276 people throughout Australia. Therefore, the number of respondents residing within MPHN is likely to be small and percentages reported are potentially unreliable. Percentages have been highlighted yellow where the MPHN and Australian 95% confidence intervals have not overlapped. (Note: a 95% confidence interval is a set of values which if estimated repeatedly, would on 95% of occasions contain the true estimate).

The Patient Experience Survey shows a higher proportion of MPHN visit a GP, go to the emergency department and see multiple health professionals for a specific condition compared to Australia. This means MPHN residents are accessing health services to a similar or greater extent than Australian residents as a whole.

Table 10-6 Experiences of health services in MPHN, 2015-16 MPHN Australia Percentage of adults who saw three or more health 25.6% 16.3% professionals for the same condition in the preceding 12 months Percentage of adults who saw a GP in the preceding 12 months 87.5% 81.9%

Percentage of adults who saw a medical specialist 43.6% 36.4% Percentage of adults who saw a GP more than 12 times in the 12.3% 10.8% preceding 12 months Percentage of adults who went to any ED for their health 23.9% 13.5%

Percentage of adults who had a preferred GP 80.6% 79.7% Percentage of adults who felt they waited longer than 18.4% 22.6% acceptable to get an appointment with a GP Percentage of adults who needed to see a GP but did not 13.3% 14.1%

Source: NHPA, My healthy community

10.4 Workforce

Figure 10-3 presents the annual counts of general practitioners, medical specialists, specialist in- training and hospital non-specialists in the Murrumbidgee area from the year 2010 to 2014. The Murrumbidgee medical workforce comprises of 44% GPs, 28% specialists and 15% specialist-in-

KBC Australia P a g e | 115 training and 14% non-specialists working in the hospital. Over the past four years, the number of specialists and specialists in training in the Murrumbidgee region has increased. This is pleasing as it suggests that there will be a more sustainable specialist workforce in the Murrumbidgee into the future. (National Health Workforce dataset)

Figure 10-3 Trend in the number of medical practitioners across job areas in MPHN (2010-2014) 250

200

150

100

50 NumberMedical of Practitioners

0 2010 2011 2012 2013 2014

General Practitioner Specialist Specialist-in-training Hospital non-specialist

Source: Murrumbidgee Primary Health Needs Assessment; November 2016- derived from National Health Workforce Dataset

10.4.1 District of workforce shortage

A district of workforce shortage is a geographical area in which the local population has less access to Medicare-subsidised medical services when compared to the national average. These areas are identified using the latest Medicare billing statistics (accessed Sept 2017). Except for the five localities (Leeton, Griffith, Wagga Wagga, Deniliquin and Tumut); every other locality within MPHN is classified as a district of GP shortage. (DoctorConnect- District of workforce shortage)

10.4.2 Specialist workforce

A district of specialist workforce shortage is identified using the latest Medicare billing statistics in SA3 areas. Wagga Wagga SA3 has a specialist shortage in diagnostic radiology and psychiatry. It does not have a specialist shortage in anaesthetics; cardiology; general surgery; obstetrics and gynaecology; ophthalmology or medical oncology. (DoctorConnect- District of workforce shortage)

10.4.3 Nursing

In 2013-14, 20% of the nurses in the Murrumbidgee region work in aged care, 47% work in acute or critical care including medical, mixed medical/surgical, emergency, perioperative, surgical, critical care A further 20% work in primary healthcare-related areas including practice nursing, community nursing, maternity care, child and family health, rehabilitation and disability, palliative care and health

KBC Australia P a g e | 116 promotion. Less than 5% of the nursing workforce are allocated to mental health and drug and alcohol. (National Health Workforce dataset).

Population to nurse ratios for the 2014 nursing workforce are calculated into Table 10-7 and compared to the national ratios. While we are not aware of population benchmarks for specialist nursing services, the ratio of population to mental health nurses is much higher for MPHN compared to Australia indicating an undersupply. This is confirmed by MPHN executive, who have indicted difficulty in recruiting mental health nurses for the Mental Health Nurse Incentive Program. (MHNIP).

Table 10-7 Number of nurses in MPHN and Australia, 2014 Australia MPHN 2014 ERP 23,490,736 241,587 Number of % of total RN Number of % of total RN nurses or EN nurses or EN Total RN 293678 100% 2441 100% Aged Care 26985 9.2% 301 12.3% RN PHC 47950 16.3% 467 19.1% MH 19360 6.6% 107 4.4% Hospital 125197 42.6% 1039 42.6% Total EN 59160 100% 832 100% Aged Care 17898 30.3% 251 30.2% EN PHC 8742 14.8% 88 10.6% MH 3287 5.6% 19 2.3% Hospital 18702 31.6% 323 38.8% Number of Population: Number of Population: RN/EN Combined Nurses Nurse Ratio Nurses Nurse Ratio Total RN + EN 352838 67:1 3273 74:1 Aged Care 44883 523:1 552 438:1 PHC 56692 414:1 555 435:1 MH 22647 1037:1 126 1917:1 Hospital 143899 163:1 1362 177:1 Source: Murrumbidgee Primary Health Needs Assessment; November 2016- derived from National Health Workforce Dataset

Note: PHC = primary healthcare includes the work areas of community nursing, child and family health, practice nursing palliative care, health promotion, maternity care, rehabilitation and disability. MH = mental health includes the work areas of drug and alcohol and mental health nursing. Hospital includes the work areas of critical care, emergency, medical, surgical, mixed medical/surgical, paediatrics, perioperative.

10.4.4 Dental

In 2014 there were a total of 83 Dentists working across MPHN. The 2016 MPHN Needs Assessment indicated that the Riverina and Wagga Wagga Sectors, are relatively well serviced by a dental workforce. However, in the Western Sector, there is reduced access to dental services in the LGAs; Carrathool and Murrumbidgee. And in the Border Sector, there is reduced access to dental services in the LGAs; Greater Hume Shire, Jerilderie, Lockhart, Urana, Conargo, Wakool and Murray. These LGAs rely on services in Deniliquin, Wagga Wagga and Corowa to supply their dental care. (Murrumbidgee Primary Health Needs Assessment; November 2016)

KBC Australia P a g e | 117 10.4.5 Pharmacy

There were 242 pharmacists on the AHPRA register in 2014 working in the Murrumbidgee region. Seventy-five percent (182) of these pharmacists work in community pharmacies and 5% work in hospitals. Pharmacists also work in medical centres (3 in Wagga Wagga), community health service (3 in Deniliquin), the defence workforce (4 in Wagga Wagga) and other government department or agency (3 in Leeton). The ratio of population to community pharmacist is 1,327 people to 1 community pharmacist.

Pharmacists are evenly located across the Murrumbidgee region with at least 3 pharmacists in the LGAs of Jerilderie, Lockhart, Wakool, Harden, Carrathool and Hay to 30 pharmacists in Griffith and 71 in Wagga Wagga. The exception to the above rule is Conargo LGA where there is no practicing pharmacist. Conargo relies on the neighbouring communities of Deniliquin and Jerilderie where there are both local medical practitioners and pharmacists. (National Health Workforce dataset)

10.4.6 Podiatrists

There were 34 podiatrists working in the Murrumbidgee region in 2014. Half of the podiatrists in the Murrumbidgee region are in Wagga Wagga, others are in Temora, Murray, Griffith, Deniliquin and Bland LGAs (three podiatrists in each of the five LGAs). (National Health Workforce dataset)

10.4.7 Occupational Therapists

In total, there were 106 occupational therapists working across MPHN in 2014. Of the 106 occupational therapists; 54 were working within the Wagga Wagga Sector; 24 in the Riverina Sector; 15 in the Western sector (12 out of the 15 were working in Griffith); and 13 in the Border sector. In terms of workplace setting; 43 (41%) were working in community health, 23 (22%) in private practice and 19 (18%) in the hospital. It is likely some OTs work across multiple settings, however only the primary workplace setting was recorded. (National Health Workforce dataset)

10.4.8 Physiotherapists

There was a total of 116 registered practitioners in MPHN in 2014. Fifty-seven percent of physiotherapists practiced in musculoskeletal physiotherapy; 13% in aged care; 3.1% in cardiorespiratory physiotherapy; 3.1% in neurological physiotherapy and 3.9% in paediatrics. Of 116 registered physiotherapists; 57 physiotherapists were working in Wagga Wagga Sector, 24 in the Western Sector, 19 in the Border Sector and 16 in the Riverina Sector. In terms of workplace setting; the majority of physiotherapists worked in private practice (47%), followed by the hospital (27%). (National Health Workforce dataset)

10.4.9 Psychologists

In 2014, there were 122 registered psychologists in the Murrumbidgee region. Of the 122 psychologists, 60% (72 psychologists) were in Wagga Wagga, is followed by nine psychologists in Young, six in Griffith and Deniliquin and five in Cootamundra. Other LGAs with psychologists include Berrigan, Corowa, Greater Hume Shire, Gundagai, Junee, Tumbarumba, Tumut Shire and Lachlan. In terms of primary workplace setting; 35 (29%) worked in private practice, 19 (16%) in community

KBC Australia P a g e | 118 mental health, 11 (9%) in correctional and defence and 20 (16%) in education (2014). (National Health Workforce dataset)

10.5 Hospitals and Health facilities

10.5.1 Emergency Departments

Figure 10-4 shows medication administration is the number one reasons patients present to ED. These presentations accounted for 18% of all presentations in 2016/17.

Figure 10-4 Top ten presenting problems to ED (2016/17)

Care - medication administration 18%

Unwell 12%

Care - patient review 9%

Pain, chest 9%

Injury - upper limb 8%

Injury - lower limb 7%

Care - wound care / dressing 9%

Injury - laceration 7%

Respiratory - shortness of breath 7%

0% 5% 10% 15% 20%

Source: MLHD, hospitalisation data (unpublished)

KBC Australia P a g e | 119 Figure 10-5 shows drug dependence is the top diagnosis in emergency departments within MPHN. Drug dependence accounted for 18% of diagnoses in MPHN emergency departments in 2016/17.

KBC Australia P a g e | 120 Figure 10-5 Top ten diagnosis in ED (2016/17)

Drug dependence 18%

Abdominal pain 16%

Chest pain 11%

Laceration - injury 9%

Urinary tract infectious disease 9%

Backache 8%

Gastroenteritis 7%

Viral disease 7%

Viral upper respiratory tract infection 7%

Did not wait for treatment 5%

0% 5% 10% 15% 20%

Source: MLHD, hospitalisation data (unpublished)

Figure 10-6 shows over one quarter of emergency presentations are to Wagga Wagga Health Service. This is an expected finding considering around one quarter of the MPHN population reside in Wagga Wagga.

Figure 10-6 Top ten MPHN emergency departments accessed

Wagga Wagga Health Service 27%

Griffith Health Service 14%

Young Health Service 7%

Deniliquin Health Service 6%

Leeton Health Service 5%

Tumut Health Service 4%

Corowa Health Service 4%

Cootamundra Health Service 3%

Temora Health Service 3%

Narrandera Health Service 2%

0% 5% 10% 15% 20% 25% 30%

Source: MLHD, hospitalisation data (unpublished)

Relative utilisation is an age/sex standardised comparison of attendance rates compared to the National average (where the National average is set to 100). Areas with RU>100 have higher than average ED attendance rates. Triage 4 and 5 (less urgent ED presentations) were examined in this report as high numbers of non-urgent presentations can indicate that patients have poor access to a GP. MPHN has a RU rate of 95, which is just below the national average and about mid-range compared to other PHNs in NSW (It should be noted that data only includes Griffith and Wagga Wagga Hospital, as only emergency departments with a 24hr Nurse Unit Manager were included in the data.

KBC Australia P a g e | 121 Figure 10-7). It should be noted that data only includes Griffith and Wagga Wagga Hospital, as only emergency departments with a 24hr Nurse Unit Manager were included in the data.

Figure 10-7 Relative utilisation of emergency departments throughout NSW PHNs, triage 4 and 5 (2013-14) 180

160

140

120

100

80

60 Relative Relative Utilisation

40

20

0

Australia

Source: Department of Health, PHN, secure data

10.6 Health insurance

It is estimated 73,025 people aged 18 years and over in MPHN hold private health insurance. This equates to a rate of 41.2 per 100 persons, which is lower compared to NSW (51.4 per 100 persons). LGAs with the lowest private health insurance rates included:

 Narrandera 34.8 per 100  Leeton 35.5 per 100  Tumut shire 35.9 per 100  Young 35.9 per 100

LGAs with the highest rates of private health insurance included:

 Greater Hume Shire 55.6 per 100  Tumbarumba 47.1 per 100  Lockhart 46.3 per 100  Wagga Wagg 45.7 per 100

KBC Australia P a g e | 122 Source: PHIDU, PHN data, Private health insurance hospital cover

Note: PHIDU obtained result from National Health Survey, conducted by ABS in 2014-15. Whereas My Healthy Community uses patient experience survey 2015-2016 and reports 56.2% of Murrumbidgee covered by private health insurance vs 57.4% nationally.

10.7 Aged Care

Aged care services in Australia are funded and delivered in regions called Aged Care Planning Regions (ACPR). Riverina/Murray ACPR has similar boundaries to MPHN. Within Riverina/Murray ACPR there are:

 129 aged care services  3,039 places in residential care (70.8%)  1,146 places in home care and (26.7%)  106 places in transition care (2.5%)  4,291 places in all aged care types (100%)

Places in aged care services in Riverina/Murray ACPR have increased 35% over the past seven years. In 2009 there were a total of 3,180 places in aged care compared to 4,291 aged care places in 2016. (AIHW- My aged care region) The MPHN have developed a comprehensive list of community and aged care providers by town.

Table 10-8 shows MPHN has higher proportion of clients living alone compared to NSW and Australia and a lower proportion of clients living with a carer. This may be contributing to the high number of hospitalisations for older people aged 70 years and over in MLHD.

Table 10-8 Demographics of HACC clients (2012/13) MPHN NSW Australia Clients living alone 41.3% 39.0% 37.5% Clients living with carer 10.1% 20.7% 24.9% Indigenous clients 4.2% 3.8% 2.6% Non-English speaking clients 2.5% 11.2% 9.5% Source: PHIDU, PHN data, Home and Community Care Program

11 MENTAL HEALTH SERVICES

GPs are the gatekeepers for a range of primary mental health services such as the Better Outcomes, Better Access, and the Mental Health Nurse Incentive Program (MHNIP). More importantly, the GP role in these programs is intended to extend beyond that of a referrer, and instead, lead to the creation of a mental healthcare team with continuing involvement of the GP. Murrumbidgee PHN undertook a community survey focused on mental health, suicide and AOD needs and experiences of services. The survey received 799 responses and of those respondents who had accessed a mental health service, 23.6% had identified “a GP” as their primary service provider. (Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016)

The Murrumbidgee PHN has a good ratio of GPs who have completed Mental Health Skills Training: to population when compared with the NSW ratio (Table 11-2).

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Table 11-1 Medical Benefits Schedule Item 2700 Mental Health Treatment Plan (minimum 20 mins) undertaken by a GP who has not had Mental Health Skills Training, 2014-15 MPHN NSW Population 241,487 7,467,976 Number of Providers 87 3,084 Population: GP ratio 2,776 2,422 Number of Item 2700 claims 927 51,197 Item 2700 claims per 1,000 population 3.84 6.86 Source: Murrumbidgee Primary Health Needs Assessment; November 2016- derived from Department of Health – Primary Health Network Dataset

Table 11-2Medical Benefits Schedule Item 2715 Mental Health Treatment Plan (minimum 20 mins) undertaken by a GP who has had Mental Health Skills Training, 2014-15 MPHN NSW Population 241,487 7,467,976 Number of Providers 203 5,957 Population: GP ratio 1,190 1,254 Number of Item 2715 claims 4,415 173,051 Item 2715 claims per 1,000 population 18.3 23.2 Source: Murrumbidgee Primary Health Needs Assessment; November 2016- derived from Department of Health – Primary Health Network Dataset

However, the Mental Health Treatment Plan is under-utilised in the Murrumbidgee when compared with the NSW average (Table 11-1and Table 11-2). This indicates that whilst uptake of Mental Health Skills Training amongst Murrumbidgee GPs is high, subsequent use of this training in practice is limited.

11.1.1 Mental Health Nurse Incentive Program

The Mental Health Nurse Incentive Program (MHNIP) provides a non-MBS incentive payment to community based general practices, private psychiatrist services and other appropriate organisations to engage mental health nurses to assist in the provision of coordinated clinical care for people with severe mental illness. In 2011/12 to 2014/15 there were two MHNIP providers within MPHN. Table 11-3 shows MHNIP providers visited an average of 539 patients and conducted an average of 2864 sessions per year, which equates to around five sessions per patient. Since 2014/15, MPHN has put in place strategies to develop to MHNIP workforce.

Table 11-3 Use of Mental Health Nurse Incentive Program, MPHN (2011/12 to 2014/15) Ave number of patients Ave number of services No of services per patient 0-11 years 3 15 5 12-24 years 78 313 4 25-64 years 412 2256 5 65+ years 45 280 6 Total 539 2864 5 Source: Department of Health, PHN, secure data

Note, In 2016 the Commonwealth redirected the MHNIP to an activity to provide directed care and coordination for people with complex mental illness.

KBC Australia P a g e | 124 11.1.2 Psychological Strategies (formerly known as ATAPS)3

ATAPS is an Australian Government program that was developed to provide services to those people who are unable to, or experience difficulty accessing MBS funded mental healthcare. In the Murrumbidgee, ATAPS is prioritised for children, young people, Aboriginal and Torres Strait Islander People, people at risk of suicide, and those in rural and remote areas. Due to only recent conversion of the ATAPS program into the Psychological Strategies program; the data analysis in this report refers only to the previous ATAPS program.

Services are provided by mental health clinicians (psychologists, mental health accredited social workers, mental health nurses and occupational therapists), for those people with emerging or mild- moderate mental health conditions who would benefit from short-term therapeutic interventions (12 sessions per calendar year, and up to 18 sessions in exceptional circumstances).

In the Murrumbidgee, child ATAPS (Mighty Minds for Children aged 0-11) is provided in Deniliquin, Wagga Wagga, Young, Griffith and Leeton.

Aboriginal ATAPS is provided in Wagga Wagga (integrated with the Riverina Aboriginal Medical and Dental Corp) and Lake Cargelligo (integrated with the Community Health Centre).

General ATAPS is available in Corowa, Cowra, Cootamundra, Leeton, Griffith, Narrandera, Urana, Henty, Howlong, Lockhart, Tumbarumba, Tumut, West Wyalong, and Young.

The number of ATAPS clients and services reached a high point in 2012/13 and has declined by 9% and 14% respectively since. This is in part due to funding caps for the ATAPs program.

Over the 4 years from 2011/12 to 2014/15, between 23.1% and 33.6% of all ATAPS clients were young people aged 12-24 years. These are typically a hard to reach demographic for mental healthcare.

This, again, highlights the importance of planning and commissioning services in a way that improves the equitable distribution of services and maximises digital-mental healthcare options for rural communities in the Murrumbidgee PHN, particularly given the increased risk of higher than average psychological distress and suicide in rural communities.

Murrumbidgee PHN has contracted with North Melbourne PHN, who engages 25 mental health clinicians to provide tele-ATAPS to Murrumbidgee community members through a locally led initiative called Connect. The model has been running since October 2015 and has been very successful, owing to inbuilt levels of flexibility (e.g., after hours’ service availability) and no waiting periods. Connect has successfully targeted areas in the Murrumbidgee PHN where limited Better Access or ATAPS services are available. Since the inception of the program in October 2015, 130 people have been referred to the programs (by local GPs). Progress Reports are provided by North Melbourne PHN on a quarterly basis and data to date indicates that the majority of referrals are for depressive and anxiety disorders (94%). As identified earlier, this uptake demonstrates a growing acceptance of digital mental healthcare in the region.

3 Source: Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016

KBC Australia P a g e | 125 Table 11-4 Number of ATAPS patients and number of ATAPS services over five years in MPHN Number of patients Number of services No of services per patient 2011/12 1139 3361 3.0 2012/13 1443 4716 3.3 2013/14 1307 4377 3.3 2014/15 1235 4311 3.5 2015/16 1364 5550 4.1 Source: Department of Health, PHN, secure data

Table 11-4 shows, over the past five years the average number of ATAPS services per patient has increased from 3 services per patient to 4 services per patient.

Table 11-5 Number of ATAPS patients and number of ATAPS services by age group in MPHN, 2015/16. Number of patients Number of services No of services per patient 0-11 years 300 1587 5.3 12-24 years 355 1479 4.2 25- 64 years 591 2091 3.5 65+ years 117 391 3.3 Total 1363 5548 4.1 Source: Department of Health, PHN, secure data

Table 11-5 shows 55% of ATAPS services are provided to those aged 24 years or less (3066 out of 5548 services). Persons aged 24 years or less have an average of 4 to 5 services per patient, which is higher compared to adults and older persons of around 3 services per person.

11.1.3 Better Access and Better Outcomes Services

Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access) was established in 2006 to improve access to evidence based treatment for Australians with mental disorders. Better Access allows patients with a mental disorder to receive a capped number of Medicare Benefits Schedule (MBS)-subsidised psychological services per calendar year, provided by eligible psychologists, social workers and occupational therapists or by general practitioners, upon referral from a GP, paediatrician or psychiatrist. Better Access psychological services are currently capped at 10 individual and or 10 group services.

KBC Australia P a g e | 126 Table 11-6 Murrumbidgee communities with no Better Access Clinicians, including distance to nearest provider. Community Distance to nearest Better Access Clinician (round-trip) Barham Deniliquin (176km) Jerilderie Deniliquin (170km) Finley Deniliquin (114km) Tocumwal Deniliquin (158km) Henty Wagga Wagga (120km) Holbrook Albury (122km) Urana Wagga Wagga (216km) Lockhart Wagga Wagga (128km) Hay Griffith (304km) Hillston Griffith (220km) Lake Cargelligo Griffith (268km) Source: Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016

Table 11-7 shows the pattern of Better Access utilisation differs considerably to Australia. MBS data collected over four years shows there is a lower rate of patients (44.1 vs 60.2) and a lower rate of services (281.3 vs 562.8) delivered to MPHN in comparison to Australia. Out of the 31 PHNs in Australia, MPHN has some of the lowest rates of service use (rank 26 and rank 28). There is also considerable variability within regions of MPHN. Wagga Wagga has a similar rate of patients utilising Better Access to Australia (56.9 vs 60.2), whereas the Lower Murray has a very low rate of patients in comparison to Australia (28.6 vs 60.2).

Table 11-7 Long term frequency of Better Access utilisation, MPHN and Australia (2007 to 2010) Australia MPHN PHN rank Lowest SA3 in Highest SA3 * MPHN in MPHN Patients (per 1,000 population) 60.2 44.1 26 Lower Murray Wagga Wagga (28.6) (56.9) Services (per 1,000 population) 562.8 281.3 28 Griffith- Wagga Wagga Murrumbidgee (365.3) (160.4) Source: Harris et al, 2017: * Highest to lowest, out of 31 PHNs in Australia;

KBC Australia P a g e | 127 Figure 11-1 depicts the percentage of patients using each type of Better Access psychological service, in ascending order of patients using Psychological Therapy Services.

KBC Australia P a g e | 128 Figure 11-1 shows that in 2013;

 MPHN had the lowest percentage of patients using Psychological Therapy Services for a PHN i.e. Perth North was 3.1 times higher than MPHN (63.0% vs 20.4%)  MPHN had the highest percentage of patients using Allied Health Focused Psychological Services for a PHN, i.e. MPHN was 2.0 times higher than Perth North (81.3% vs 40.1%).

KBC Australia P a g e | 129 Figure 11-1 Patients using Better Access psychological services, by type of Better Access psychological service used and PHN, 2013

Source: Harris et al, 2017

Table 11-8 shows, out of the 31 PHNs in Australia, MPHN had the highest percentage of patients who used an average of 1-2 services per year and the lowest percentage of patients who used an average of 10+ services per year. The frequency of use is linked with the type of Better Access psychological service. PHNs with a high number of Allied Health Focused Psychological Strategies had significantly more low frequency/short term service users and significantly fewer high frequency/long term users. Whereas PHNs with a high number of Psychological Therapy Services had significantly fewer low frequency/short term service users and significantly more high frequency/long term service users.

Note the definitions of service use are shown in Table 11-9.

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Table 11-8 Long term frequency of Better Access use, MPHN and Australia (2007 to 2010) Australia MPHN *PHN Lowest SA3 Highest SA3 rank in MPHN in MPHN Long term frequency of use (% of patients) Low frequency/short term 26.7 40.7 1 29.7 47.1 Low frequency/long term 0.6 1.0 1 1.1 1.1 Medium frequency/short term 46.2 43.0 31 39.8 51.3 Medium frequency/long term 5.9 5.3 26 4.0 5.9 High frequency/ short term 19.0 9.6 31 6.1 13.9 High frequency/long term 1.5 0.4 31 n.a. n.a. Source: Harris et al, 2017 * Highest to lowest, out of 31 PHNs in Australia;

Table 11-9 Definition of service use Low frequency/short term An average of 1-2 services per year over < 3 consecutive years Low frequency/long term An average of 1-2 services per year over 3+ consecutive years Medium frequency/short term An average of >2 services per year over < 3 consecutive years Medium frequency/long term An average of >2 services per year over 3+ consecutive years High frequency/ short term An average of 10+ services per year over < 3 consecutive years High frequency/long term An average of 10+ services per year over 3+ consecutive years Source: Harris et al, 2017

11.1.4 Mental Health Hospitalisations

In the Murrumbidgee region, there is a 22-bed Mental Health Acute Unit and an eight bed High Dependency Unit based in Wagga. This service is available to those experiencing acute, severe clinical symptoms that pose a serious risk of harm to self or others. The unit does not service people less than 18 years and there are no designated child and adolescent mental health beds within the Murrumbidgee region. Children requiring inpatient mental healthcare in the Murrumbidgee have priority access to four of the ten Child and Adolescent beds based in Bloomfield Hospital, Orange. Local consultation indicates that this is not the case in reality and access to the beds is limited.

Table 11-10 shows mental health related admissions dominated the top 10 total bed days in MLHD for all age groups except older persons (65+ years).

KBC Australia P a g e | 131 Table 11-10 Top 10 hospital bed days, by condition and age [Number of separations (-)], 2013/14 Rank Age group 10-24 years 25-39 years 40-64 years 65+ years 1 Vaginal Delivery, Vaginal Delivery, Rehabilitation (303) Rehabilitation Single Single (1,210) Uncomplicated Uncomplicated (562) (1,329) 2 Major Affective Caesarean Delivery Major Affective Other Factors Disorders Age <70 * * (675) Disorders Age <70 * Influencing Health (68) (166) Status (468) 3 Eating and Schizophrenia Schizophrenia Chronic Obstructive Obsessive Disorders, Disorders, Airways Disease * Compulsive Involuntary Involuntary (1,133) Disorders (32) Admission (81) Admission (113) 4 Caesarean Delivery Rehabilitation (54) Colonoscopy, Other Follow Up * (198) Sameday (1,861) After Surgery or Medical Care * (648) 5 Rehabilitation (28) Major Affective Complex Heart Failure and Disorders Age <70 * Endoscopy, Shock * (634) (86) Sameday (1,388) 6 Dental Extractions Caesarean Delivery Chronic Obstructive Other Follow Up and Restorations with Severe CC Airways Disease * After Surgery or (623) (168) (331) Medical Care with Catastrophic CC (288) 7 Personality Personality Other Contacts with Lens Procedures Disorders and Disorders and Health Services with (2,995) Acute Reactions Acute Reactions Endoscopy, (141) (175) Sameday (1,226) 8 Antenatal and Other Vaginal Delivery * Personality Respiratory Obstetric (252) Disorders and Infections/Inflamma Admissions * (335) Acute Reactions tions with (149) Catastrophic CC (281) 9 Appendicectomy Antenatal and Other Knee Replacement * Respiratory W/O Malignancy or Obstetric (229) Infections/Inflamma Peritonitis * (269) Admissions * (503) tions with Severe or Moderate CC (467) 10 Schizophrenia Schizophrenia Other Follow Up Heart Failure and Disorders, Disorders (68) After Surgery or Shock with Involuntary Medical Care * Catastrophic CC Admission (12) (187) (218) Source: Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016: * Without Catastrophic or Severe CC

KBC Australia P a g e | 132

Table 11-11 Mental Health related presentations to Emergency Departments in Murrumbidgee, 2015 to 2016 Wagga Wagga Riverina Border Western MPHN Anxiety/Stress-related 107 96 77 83 363 Uncategorised disorders 118 77 33 47 275 Suicide risk/thoughts 104 38 21 43 206 Depressive disorder 78 27 18 38 161 Schizo disorders 39 8 2 18 67 Mixed anxiety & depression 20 16 11 8 55 Hallucinations/Delusions 18 2 8 6 34 Personality disorders 20 4 3 1 28 Bipolar 9 4 4 4 21 Eating disorder 1 0 0 0 1 TOTAL 514 272 177 248 1211 Source: Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016

Table 11-11 shows anxiety and stress related conditions are the main reason patients present to Emergency in the Murrumbidgee region (30%). Suicide risk/ thoughts is also a common reason (17%).

11.2 Non- Government providers4

11.2.1 Headspace

In the Murrumbidgee PHN region, headspace is located at Wagga Wagga and Griffith. Headspace Wagga provides outreach to West Wyalong, Tumut, Temora and Cootamundra. Headspace Griffith will provide outreach to Hay, Hillston and Lake Cargelligo.

To be suitable for headspace services, the young person must be willing to engage in services, and experiencing emerging, mild or moderate mental health conditions. The service is generally not suitable for those young people with longstanding, complex mental health and/or alcohol and other drug issues who are unlikely to benefit from short-term therapeutic interventions (e.g., 10 visits be calendar year). Headspace Wagga and Griffith have access to MBS funded tele-psychiatry services, dietetics services and general practice services.

11.2.2 Royal Far West (RFW)

RFW engages 50 specialist clinicians and support staff on site at Manly providing a multidisciplinary model to assess, diagnose, and tackle complex health and development issues, using a range of services, programs and tools that are designed to optimise health and wellbeing outcomes and fill the gaps in local services. RFW works with children and families to improve attention and concentration, behaviour, emotional regulation, communication, parenting, self-care skills and social skills.

4 Source: Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016

KBC Australia P a g e | 133 In 2014/15, 187 children from the Murrumbidgee LHD catchment across 23 LGAs were seen by RFW. There were 322 visits in total and of these 191 were under the Paediatric Development Program.

Clients who have accessed psychiatry and/or clinical psychology services (i.e. for developmental, behavioural, or emotional assessment) at RFW between April 2015 and March 2016: over 75% were males; the highest number of clients were aged 9; and around one in seven children were Aboriginal.

General Practitioners and Paediatricians refer to RFW and the most common reason for referral is to seek diagnostic clarity.

11.2.3 Centacare

Centacare Southwest NSW, works with the Catholic Schools Office Wagga Wagga to provide a School Wellbeing Program for Catholic school students and their families. School Wellbeing Practitioners work alongside teaching staff to provide social and emotional support, and counselling services to primary and secondary students.

During 2015, 647 students in the Murrumbidgee region received school counselling services under the School Wellbeing Program. The most commonly identified issues were support for anxiety (18.7%), parental separation or divorce (13.4%) and support with peer relationships (10.2%). Of the children engaging in the School Wellbeing Program, the majority attend schools in Wagga Wagga (42.8%). Based on total enrolment numbers, the Local Government Areas with the highest utilisation rate of the program were Berrigan (31.0%), Tumbarumba (22.4%) and Jerilderie (20.5%).

11.2.4 Kurrajong Early Intervention Service

Kurrajong Early Intervention Service is based in Wagga Wagga and provides a service to children and young people throughout the Murrumbidgee PHN region. Kurrajong Early Intervention Service conducts an Autism Clinic in partnership with a local paediatrician. 15% of the children supported by KEIS have a diagnosis of Autism, which represents a 100% increase in the last 9 years.

11.2.5 Intereach ROAR Program

The ROAR (Reach Out and Relax) program will be launched in the Murrumbidgee in April 2016. The program aims to improve the emotional health and well-being of children and young people, up to 18 years of age, who may be showing early signs of, or are at risk of developing a mental health issue.

The free program offers early intervention support for children and their families by providing short- term immediate assistance; intensive, long-term early intervention case management support; and, community outreach, mental health education and community development activities.

ROAR provides support across 21 of the 29 Local Government Areas within the Murrumbidgee PHN region, and referrals outside these areas are subject to workforce availability.

11.2.6 Domestic Violence Program

Murrumbidgee PHN in collaboration with Wagga Women’s Health Centre has established a program to increase access and provide expanded services to women from priority populations who are and/or have experienced domestic violence. Women and children subject to domestic violence have poorer

KBC Australia P a g e | 134 mental health outcomes. Nearly one third of the clients in the program have a diagnosed mental illness. Access to a trauma specialist counsellor is provided through the program.

11.3 Community Mental Health5

The District has a comprehensive span of community based health services including generalist counselling services and six community Specialist Mental Health and Drug and Alcohol teams across the District. These are located at: Wagga Wagga, Young, Tumut, Temora, Griffith and Deniliquin and comprise of a number of sub-specialities. Sub-specialities include: Specialist Child and Adolescent Mental Health Services (CAMHS); Specialist Adult Mental Health Services; Youth Mental Health Services, Perinatal Mental Health Services and Specialist Mental Health Service for Older People (SMHSOP). Specialist Mental Health Services offer a range of interventions based upon individual, family and group evidenced based models of care.

11.3.1 Specialist Child and Adolescent Mental Health Services

Specialist Child and Adolescent Mental Health services (CAMHS) provide community based assessment, evidence-based therapy and treatment services to children and adolescents with psychological difficulties. This includes behavioural disturbances and prodromal syndromes requiring early intervention. The service targets individuals aged 0-17 years, although this may vary depending on developmental factors. CAMHS are co-located with, and managed by, adult mental health services. CAMHS clinicians offer a range of interventions based upon individual, family and group evidenced based models of care.

CAMHS function within an integrated framework working collaboratively with or offering secondary consultation to other primary healthcare providers. There are close ties to NSW mental health promotion and early intervention initiatives such as Youth Mental Health, School-Link and SAFE START (Integrated Perinatal care initiative). CAMHS also provide psychosocial assessments as part of the Comprehensive Health Assessments for children living in Out of Home Care.

11.3.2 Specialist Youth Mental Health Services

The Specialist Youth Mental Health Service is targeted at young people aged 14 to 24 years with complex or high needs who may be difficult to engage in effective treatment and support. Youth Mental Health Clinicians aim to develop strategic partnerships with primary care providers, consumer and carers to deliver an improved service response to early identification and treatment of young people who may be exhibiting behaviour indicative of a serious mental illness including psychosis. The aim is to guide the future management of these young people in primary health settings or facilitate referral to specialist settings, where required.

There are currently two Youth Clinical positions in MLHD both of which are based in Wagga Wagga. The positions involve consultation and liaison, capacity building among a range of service providers, providing assessment and interventions for young people accessing the service and working in collaboration with Drug and Alcohol Services, as well as families of individuals referred to the service.

5 Source: Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016

KBC Australia P a g e | 135 A redistribution of clinical positions to provide more equitable allocation of resources will enable the District to better meet the needs of the youth target population in the future.

11.3.3 Specialist Adult Mental Health Services

There are six Specialist Adult Community Mental Health services across MLHD staffed by multidisciplinary workers. Each team has a team manager who oversights the operational functioning of the team and in turn reports to the MHDA Community Manager.

Specialist Adult Mental Health Services provide community-based assessment, evidence-based therapy and treatment services to adults with a diverse range of mental illnesses that result in significant impairment of an individual’s cognitive and emotional functioning. These conditions include: post-traumatic stress symptoms, mood disorders, anxiety disorders, eating disorders, personality disorders and psychotic disorders. Specialist Adult Mental Health Services also provide care for individuals under the NSW Mental Health Act 2007 and those who are at risk of harm to self or others. Under the NSW Mental Health Act 2007, risk is defined as risk of physical harm, risk to reputation, finances and relationships.

Referrals are prioritised according to risk and clinical need rather than diagnoses. Priority for urgent care is given to consumers with: rapid escalation of symptoms; acute distress; suicidal ideation or suicidal attempt; symptoms of psychosis; and those experiencing significant disability as a result of their mental illness. Services are provided whether or not the mental illness is in the context of an additional problem such as substance misuse or intellectual disability. Where additional difficulties are identified, consumers are co-managed with other relevant agencies.

Following a mental health assessment, clinicians are able to offer a range of interventions based upon individual, family and group evidenced based models of care. Ongoing support is offered only to those individuals with a major mental illness who are experiencing persistent lifestyle difficulties as a result of mental illness or where there is a potential for at-risk behaviour.

11.3.4 Specialist Mental Health Services for Older People

Older people are at considerable risk of multiple complex comorbid physical health, mental health and substance use disorders which increase the risk of suicide and the need for greater utilisation of services (NSW Health 2012). Clinicians working within Specialist Mental Health Services for Older People (SMHOPs) within MLHD are co-located with and managed by adult mental health services. The target population for SMHSOP is outlined in the NSW Service Plan for SMHSOP 2005/15 (NSW Health 2006) and includes older people who:

• Develop or are at high risk of developing a mental health disorder at the age of 65 years and over, such as depression, psychosis, anxiety or a severe adjustment disorder; • Have a lifelong or recurring mental illness, and now experience age-related problems causing significant functional disability; • Have had a prior mental health problem but have not recently seen a specialist mental health service and now have a recurrence of their illness or disorder that can be optimally managed by SMHSOP, or • Present with severe behavioural or psychiatric symptoms associated with dementia or other long-standing organic brain disorder.

KBC Australia P a g e | 136 • The families and carers of older people are also included in the broader target group for SMHSOP.

In certain circumstances, younger people who are deemed to be “functionally old” are considered for inclusion in the service. These individuals may have complex problems, including dementia, acquired cognitive impairment or poor health status. People of Aboriginal descent are eligible for SMHSOP from the age of 50 years as the life expectancy for Aboriginal people in NSW is, on average, 20 years below that of the general population (NSW Health 2006).

11.4 Acute Mental Health

MLHD residents have access to mental health inpatient facilities at Wagga Wagga and Albury. Wagga Wagga facilities include an acute unit, a high dependency unit, a sub-acute/recovery unit and a T- BASIS unit for consumers with dementia and challenging behaviours. All units in Wagga Wagga accept admissions from across the District. The mental health acute inpatient unit located at Albury accepts admissions from sites located on the border between NSW and Victoria including Deniliquin.

Table 11-12 Number of adults accessing MLHD Community Mental Health services by diagnosis, 2015-2016. Category of Diagnosis Deniliquin Griffith Temora Tumut Wagga Young Total Wagga* Acute stress reaction 41 82 80 39 137 79 458 and PTSD Anxiety, dissociative, 98 73 68 72 142 108 561 stress-related, somatoform, and other nonpsychotic mental disorders AOD related mental 29 79 81 50 160 60 459 health conditions Autism 0 4 0 1 7 1 13 Bipolar disorders 63 40 41 27 137 32 340 Dementia 10 37 5 20 15 3 90 Depressive disorders 181 199 188 145 381 173 1267 Disorders of personality 30 39 46 41 245 41 442 and behaviour Eating disorders 0 1 4 5 8 6 24 Psychotic disorders 92 183 117 77 493 101 1063 Suicide and self-harm 14 46 47 34 75 19 235 Source: Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016 *Includes Mental Health Acute and Sub-Acute Units, Community Residential Services and Mental Health Emergency Care Support (MHECS)

Table 11-12 shows depressive disorders (1267), followed by psychotic disorders (1063) and anxiety related conditions (561) are the main reasons people are accessing MLHD specialist mental health services.

Table 11-13 shows schizophrenia disorders, followed by major affective disorders account for the highest number of bed days for mental health related conditions. The majority of schizophrenia

KBC Australia P a g e | 137 separations occur in the 25-39 year age group, whereas the majority of major affective disorders occur in the 40-64 age group.

Table 11-13 Number of mental health related bed days [and number of separations (-)], by condition and age group, MLHD 2013/14. Condition 10-24 years 25-39 years 40-64 years 65+ years Total Anxiety disorders 409 (180) 622 (248) 1,455 (508) 2,532 (656) 5,018 (1,592) Childhood mental 111 (58) 102 (11) 23 (4) 8 (4) 244 (77) disorders Eating and 1,332 (108) 139 (24) 372 (23) 39 (4) 1,882 (159) Obsessive- Compulsive Disorders Major Affective 3,712 (510) 8,876 (1,107) 16,985 2,073 (179) 31,646 (3,352) Disorders Age <70 (1,646) W/O Catastrophic or Severe CC Major Affective 181 (8) 410 (26) 2,492 (88) 7,264 (434) 10,347 (556) Disorders Age >=70 or W Catastrophic or Severe CC Mental health 1,433 2,053 (2,053) 2,209 497 (497) 6,192 (6,192) treatment, same (1,433) (2,209) day Other affective 2,410 (755) 3,938 (976) 5,894 6,566 (856) 18,808 (3,935) disorders (1,348) Personality 3,185 (952) 5,233 (1,132) 4,089 (906) 651 (122) 13,158 (3,112) disorders Schizophrenia 5,827 (353) 23,481 19,838 2,392 (113) 51,538 (3,112) disorders (1,383) (1,263) Total 18,600 44,854 53,357 22,022 138,833 (4,357) (6,870) (7,995) (2,865) (22,087) Source: Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016

11.5 Drug and Alcohol Services6

In the MLHD, Drug and Alcohol Services are located in Wagga Wagga, Young, Tumut, Temora, Griffith, Leeton and Deniliquin. With the exception of Leeton, Drug and Alcohol clinicians are co-located with Community Mental Health Teams. In Leeton, the Drug and Alcohol Clinician is managed remotely by the Griffith MHDA Team Manager.

Key programs offered by MLHD Drug and Alcohol services include: opioid treatment services; specialist addiction counselling; Hepatitis C treatment and support; consultation liaison services; inpatient and outpatient withdrawal management services; court diversion programs and treatment under the Drug and Alcohol Treatment Act 2007. These services are described below.

6 Source: Murrumbidgee Mental Health, Suicide Prevention, and Alcohol and Other Drugs Needs Assessment; November 2016

KBC Australia P a g e | 138 11.5.1 Opioid treatment services

The Opioid Treatment Program (OTP) provides opioid replacement therapies for consumers who are dependent on opioids including heroin, morphine and oxycodone. The three primary medications used include: Methadone, Buprenorphine and Buprenorphine and naloxone combination.

Within the Murrumbidgee PHN, the OTP was previously centralised in Wagga Wagga. To facilitate more equitable access for consumers, the program was devolved to local sites. Local Drug and Alcohol clinicians now have responsibility for OTP consumers in their local communities (wherever possible). Opioid replacement dispensing services are provided through outpatient clinics, community pharmacies, local hospitals (e.g. Banksia Clinic at Wagga Wagga Base Hospital) and private providers. Prescribing is performed by VMOs with the support from the Drug and Alcohol Clinical Director and a number of general practitioners within the District who prescribe privately.

11.5.2 Specialist addiction counselling

The MLHD offers Specialist Addiction Counselling services or brief interventions for a wide range of alcohol and other drug problems. The service aims to reduce harm caused by substance use and promote recovery. The service responds to consumers with varying patterns of use – it is not restricted to those with substance dependence. Specialist Addiction Counselling is offered at all sites where MHDA teams are located. Brief interventions provided by Drug and Alcohol clinicians include a wide variety of strategies that aim to change behaviour. These include advice, referral, motivational interviewing and brief counselling interventions.

11.5.3 Consultation liaison services

Drug and Alcohol Consultation Liaison (CL) services aim to: provide direct access to specialist services for support; provide treatment advice and assistance with the management of alcohol and other drug issues; improve the knowledge and expertise of generalist health staff to identify and refer consumers with substance use issues; reduce the health burden and associated costs that alcohol and other drug problems place on the health system; and improve consumer outcomes.

In the Murrumbidgee PHN, the Drug and Alcohol consultation liaison positions are located at Wagga Wagga and Griffith.

11.5.4 Withdrawal management

Withdrawal occurs in drug-dependent people who stop or considerably reduce their drug use. The diagnosis of dependence is generally required to understand and manage drug withdrawal. Consumers may: present for elective withdrawal; present when in withdrawal (crisis presentation); or commence withdrawal incidentally when being treated for another illness. Withdrawal can be managed in a variety of settings including the consumer’s residence, as an outpatient or in hospital. Calvary Drug and Alcohol Centre provides both inpatient and outpatient withdrawal services in Wagga Wagga for the MLHD population. The Drug and Alcohol Centre offers inpatient detoxification for alcohol and cannabis and a medium to long term (3-6 months) residential illicit drug rehabilitation program based on a ‘therapeutic community’ model of care. There is capacity (albeit limited) for Drug and Alcohol clinicians to negotiate for consumers to undergo withdrawal in their local hospitals. These admissions are negotiated at the site level and, where possible, organised in advance.

KBC Australia P a g e | 139 11.6 Non-Government AOD services

There is a considerable absence of services in the Murrumbidgee PHN region for people seeking treatment for alcohol and other drug addiction. There is a range of services provided in Wagga intended to service the Murrumbidgee PHN region, however this requires that consumers are willing and able to travel significant distances to access support. There are no non-government treatment options located in any communities outside of Wagga.

11.6.1.1 Coordinated Regional Alcohol & other Drug Program- Griffith Aboriginal Medical Service

Continuation and expansion of regional AOD program consortium currently being delivered by Griffith AMS, Riverina Medical and Dental Aboriginal Corp, Albury Wodonga AMS and Viney Morgan AMS (Cummeragunja).

11.6.1.2 Calvary Healthcare Riverina, Alcohol and Other Drugs Services

Calvary Healthcare Riverina is the major non-government provider of AOD services in the Murrumbidgee PHN. The services available include:

O'Connor House Alcohol Detoxification and Rehabilitation Service O’Connor House is a 10 bed alcohol detoxification and motivation unit provided by Calvary Healthcare Riverina and funded by the NSW Health Department through the Murrumbidgee Local Health District. The unit provides care for clients from a wide geographical area of country New South Wales and north-east Victoria.

Peppers Illicit Drug Program This program is provided by Calvary Healthcare Riverina in a therapeutic community residential setting for those recovering from drug abuse. Funding has been provided through the Commonwealth National Illicit Drug Program for this essential service.

11.6.1.3 Home Detoxification and Transitional Support Service

This service is provided by a Registered Nurse, delivering alcohol and other drug services to facilitate detoxification in the most appropriate setting. This service is provided by Calvary Healthcare Riverina and funded through MLHD.

COPE Day Program and Transition Care Homes Situated in Wagga Wagga and provided by Calvary Healthcare Riverina, COPE is an intensive drug education, support and counselling program designed to help clients deal with stress through developing coping strategies and a care plan clearly outlining achievable goals. COPE is an 8-week program.

11.6.1.4 Calvary Comorbidity Treatment and Capacity Building Project

The project will provide capacity building and clinical support for clients of Calvary Alcohol and Other Drug Services (CAODS) who present with comorbid issues. The project aims to develop and integrate clinical services for clients with comorbid mental health and alcohol and other drug conditions to address current gaps in services and improve outcomes for this client group. This will include

KBC Australia P a g e | 140 frontline service delivery, staff development/training, Quality Assurance, partnership development, consumer involvement and data collection.

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KBC Australia P a g e | 144 APPENDIX 1

Raw PENCAT data by Indigenous status and disease type A B C D E F G non- non- Indigenous Indigenous not-stated Total Indigenous Indigenous not stated Category n n n n % (A/D) % (B/D) % (C/D) Active patients 6746 104182 33230 144158 5% 72% 23% Chronic disease CKD 116 1823 346 2285 5% 80% 15% Diabetes 554 7620 2056 10230 5% 74% 20% COPD 306 4080 656 5042 6% 81% 13% Asthma 1336 13619 0 14955 9% 91% 0% Cardiovascular disease 284 6503 0 6787 4% 96% 0% Hypertension 792 22457 0 23249 3% 97% 0% Heart failure 57 1434 0 1491 4% 96% 0% Mental health Anxiety 666 7852 0 8518 8% 92% 0% Depression 1183 12712 0 13895 9% 91% 0% Schizophrenia 117 522 0 639 18% 82% 0% Bipolar 126 1054 0 1180 11% 89% 0% Dementia 9 531 0 540 2% 98% 0% ADHD 182 799 0 981 19% 81% 0% Autism 33 409 0 442 7% 93% 0% Post-natal depression 46 422 0 468 10% 90% 0% Source: MPHN, PENCAT (unpublished)

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Sum of Potentially Preventable Hospitalisations divided by Sum of all hospitalisations over 4 years (2013/14 to 2016/17) by Health Facility in MLHD A B C D E F G Total Chronic Total Acute Total Total PPH Chronic PPH Acute PPH Health facility Total PPH PPH PPH hospitalisations % (A/D) % (B/D) % (C/D) Wagga Wagga Health Service 9394 4555 4430 92518 10.2% 4.9% 4.8% Griffith Health Service 3961 2073 1821 32578 12.2% 6.4% 5.6% Young Health Service 1200 629 544 10937 11.0% 5.8% 5.0% Deniliquin Health Service 1239 780 434 10667 11.6% 7.3% 4.1% Cootamundra Health Service 1125 617 490 7707 14.6% 8.0% 6.4% Tumut Health Service 1040 614 401 7239 14.4% 8.5% 5.5% Leeton Health Service 1095 734 352 6573 16.7% 11.2% 5.4% Temora Health Service 799 568 215 5560 14.4% 10.2% 3.9% Corowa Health Service 819 556 240 5407 15.1% 10.3% 4.4% Narrandera Health Service 738 512 221 5117 14.4% 10.0% 4.3% Gundagai Health Service 649 338 280 3862 16.8% 8.8% 7.3% West Wyalong Health Service 698 455 231 3244 21.5% 14.0% 7.1% Finley Health Service 480 295 178 2787 17.2% 10.6% 6.4% Junee Health Service 379 237 142 2251 16.8% 10.5% 6.3% Harden-Murrumburah Health Service 416 282 132 1995 20.9% 14.1% 6.6% Hay Health Service 257 157 98 1687 15.2% 9.3% 5.8% Tocumwal Health Service 239 154 85 1608 14.9% 9.6% 5.3% Barham Health Service 276 181 91 1506 18.3% 12.0% 6.0% Coolamon Health Service 217 111 92 1450 15.0% 7.7% 6.3% Tumbarumba Health Service 237 135 100 1417 16.7% 9.5% 7.1% Lake Cargelligo 311 170 138 1282 24.3% 13.3% 10.8% Boorowa Health Service 204 113 87 972 21.0% 11.6% 9.0% Hillston Health Service 180 102 75 878 20.5% 11.6% 8.5%

KBC Australia P a g e | 146 Sum of Potentially Preventable Hospitalisations divided by Sum of all hospitalisations over 4 years (2013/14 to 2016/17) by Health Facility in MLHD A B C D E F G Total Chronic Total Acute Total Total PPH Chronic PPH Acute PPH Health facility Total PPH PPH PPH hospitalisations % (A/D) % (B/D) % (C/D) Berrigan Health Service 145 102 40 871 16.6% 11.7% 4.6% Lockhart Health Service 118 86 32 839 14.1% 10.3% 3.8% Holbrook Health Service 116 62 48 810 14.3% 7.7% 5.9% Culcairn Health Service 119 84 32 678 17.6% 12.4% 4.7% Henty Health Service 117 71 44 581 20.1% 12.2% 7.6% Jerilderie Health Service 141 99 42 567 24.9% 17.5% 7.4% Batlow Health Service 41 24 14 427 9.6% 5.6% 3.3% Urana Health Service 70 46 23 332 21.1% 13.9% 6.9% MLHD 26820 14942 11152 214347 12.5% 7.0% 5.2% NSW* 683917 321170 331038 11214367 6.1% 2.9% 3.0% Source: MLHD, hospitalisation data (unpublished): *Source: HealthStats NSW- (Note, NSW PPH data ranges from 2012/13 to 2015/16)

KBC Australia P a g e | 147 APPENDIX 3 FACILITIES AND SERVICE SUMMARY, BY SECTOR

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Remoteness classifications for LGAs within MPHN ASGS MMM Land area per Persons per Sector LGA ERP 2013 classification classification sq km sq km Corowa Shire Inner Regional 4 11,410 2,329 4.9 Deniliquin Inner Regional 4 7,376 143 51.5 Lockhart Outer Regional 5 3,021 2,896 1 Berrigan Outer Regional 5 8,365 2,066 4

Conargo Outer Regional 5 1,543 8,738 0.2 Greater Hume Outer Regional 5 10,176 5,749 1.8 Border Shire Jerilderie Outer Regional 5 1,504 3,373 0.4 Murray Outer Regional 5 7,418 4,344 1.7 Urana Outer Regional 5 1,157 3,356 0.3 Wakool Outer Regional 5 3,979 7,521 0.5 Cootamundra Inner Regional 4 7,625 1,524 5 Tumut Shire Inner Regional 4 11,316 4,567 2.5 Young Inner Regional 4 12,699 2,693 4.7 Boorowa Inner Regional 5 2,558 2,579 1

Coolamon Inner Regional 5 4,276 2,431 1.8 Harden Inner Regional 5 3,762 1,869 2

Riverina Bland Outer Regional 5 6,010 8,560 0.7 Gundagai Outer Regional 5 3,747 2,457 1.5 Inner/Outer Junee 5 6,227 2,030 3.1 Regional Temora Outer Regional 5 5,995 2,803 2.1 Tumbarumba Outer Regional 5 3,521 4,392 0.8 Wagga Wagga Wagga Inner Regional 3 62,149 4,826 12.9 Wagga Griffith Inner Regional 3 25,425 1,640 15.5 Lachlan (Part) Inner Regional 5 1,857* 14,973** 0.5 Leeton Outer Regional 4 11,539 1,167 9.9 Hay Outer Regional 5 2,962 11,329 0.3

Western Murrumbidgee Outer Regional 5 2,503 3,507 0.7 Narrandera Outer Regional 5 6,030 4,117 1.5 Carrathool Remote 5 2,792 18,940 0.1 MPHN 238,942 136,919 1.8 Source: Murrumbidgee Primary Health Needs Assessment; November 2016

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Acknowledgements

Acknowledgement of country

MPHN acknowledges the Traditional Custodians of the land in the Murrumbidgee region. We pay respect to past and present Elders of this land: the Wiradjuri, Yorta Yorta, Baraba Baraba, Wemba Wemba and Nari Nari peoples.

We would like to thank the MLHD team for their contribution to the 2017 HNA. We also acknowledge their assistance in the development of the Technical Paper. This document draws on the 2016 Murrumbidgee Primary Health Needs Assessment and the 2016 Murrumbidgee Mental health, Suicide Prevention and Alcohol and other Drugs Needs Assessment. These two previous documents have been consolidated and summarised into one plain English document. Where possible data has been updated to reflect the most current health needs of Murrumbidgee residents. We also recognise that MPHN is already commissioning work in response to the 2016 HNA and therefore this document acknowledges the activity that has already commenced.

This activity has been made possible through funding provided by the Australian Government under the PHN Program.

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