Inquiry into Chronic Disease Prevention and Management in Primary Health Care

Transcription

1 NSW HEALTH SUBMISSION to the Australian House of Representative Standing Committee on Health Inquiry into Chronic Disease Prevention and Management in Primary Health Care Page 1 of 31

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3 Table of Contents Executive Summary... 5 Introduction Examples of best practice in chronic disease prevention and management, both in Australia and internationally NSW Health directions Opportunities for the Medicare payment system to reward and encourage best practice and quality improvement in chronic disease prevention and management Opportunities for the Primary Health Networks to coordinate and support chronic disease prevention and management in primary health care GP leadership Partnerships Performance frameworks Models of care The role of private health insurers in chronic disease prevention and management The role of State and Territory Governments in chronic disease prevention and management Innovative models which incentivise access, quality and efficiency in chronic disease prevention and management Best practice of multidisciplinary team chronic disease management in primary health care and hospitals NSW Health best practice team-based care Models of chronic disease prevention and management in primary health care which improve outcomes for high end frequent users of medical and health services Further Comments Appendix Preventive and Public Health Services National Health Policies and Strategies Cancer Screening Programs NSW Healthy Lifestyle Programs NSW Health Programs for Aboriginal People Mental Illness as a chronic condition Physical Health of People with a Mental Illness Page 3 of 31

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5 Inquiry into Chronic Disease Prevention and Management in Primary Health Care Executive Summary NSW Health has prepared a comprehensive response to the House of Representatives Standing Committee on Health Inquiry into Chronic Disease Prevention and Management in Primary Health Care. This response demonstrates NSW Health s commitment and contribution to the prevention and effective management of chronic disease, while also recognising the central and critical role of primary health care providers in the prevention and treatment of chronic disease, and the need for health care to remain in the community. NSW Health has implemented a range of strategies and initiatives to minimise the incidence, prevalence and progression of chronic disease, including: the NSW State Health Plan: Towards 2021; the NSW Chronic Disease Management Program; the NSW Integrated Care Strategy; HealthOne NSW; and the Whole of Hospital Program. Additionally, NSW Health delivers and promotes cancer screening, health coaching, healthy lifestyle programs, mental health programs, and programs that address the needs of Aboriginal people. NSW Health remains committed to delivering public health initiatives to address lifestyle risk factors, and to working collaboratively with the primary care sector to minimise preventable hospitalisations. To this end, NSW Health is reviewing its approach to chronic disease management. The Chronic Disease Management Program is being redesigned to better link with broader integrated care initiatives and community based health care, and to foster new partnerships between Local Health Districts (LHDs), general practice and hospital specialty teams. The primary health care sector is best placed to lead the care of people with chronic disease, however, the need to build additional capacity and capability is recognised. NSW Health advocates community-based, multidisciplinary management of chronic disease, supported, as appropriate, by secondary and tertiary health care. NSW Health supports the establishment of Primary Health Networks (PHNs) and their role in increasing the efficiency and effectiveness of medical services, and improving the coordination of chronic disease prevention and management. NSW Health will work collaboratively with PHNs to establish and maintain connections with LHDs and will continue to support the development of clinical pathways between primary and hospital care. Digital technology offers a range of mechanisms to help keep people healthy and out of hospital. The capacity and potential of Healthdirect Australia should be explored to procure services, for example telephone coaching, as a means of helping consumers better manage their own health. NSW Health also supports private health insurers participation in health coaching and in other preventive health care initiatives. NSW Health favours a stronger population health approach to chronic disease management together with a funding system that promotes clinically and cost effective interventions. Individualised care packages and blended payment models that reward integrated and coordinated care warrant further consideration. International models of care such as Patient-Centred Medical Home can improve access to care and health outcomes and should be considered. So too should the use of financial and nonfinancial incentives to reduce avoidable hospitalisations, particularly for high end frequent users of medical and health services. NSW Health welcomes the work being done by the Primary Health Care Advisory Group (PHCAG) to improve the management of people with chronic and complex conditions and recommends the Steering Group consults the PHCAG during this inquiry. Page 5 of 31

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7 Introduction Australians are developing long-term, lifestyle-related diseases at increasing rates, placing a substantial burden on the health system. While chronic conditions are more prevalent, proportionally and in number in people over 65 years, they affect people of all ages; 17 per cent of people aged 15 to 24 years report having one chronic condition, as do 21 per cent of people aged and 32 per cent of people aged 45 years and over. Co-morbidities are more common in older people. Half of those aged 65 years and over report having two or more chronic conditions, which is significantly more than people aged years (21 per cent) or years (5 per cent) 1. This increase in chronic disease has a significant personal and social impact, and also places a substantial economic burden on Australia. In cardiovascular diseases, oral health, mental disorders, and musculoskeletal conditions incurred direct health-care costs of $27 billion, equating to 36 per cent of all allocated health expenditure 2. While chronic diseases are the leading cause of illness, disability and death in Australia they are largely preventable. NSW Health is committed to keeping people healthy and out of hospital by supporting the prevention and better management of chronic disease through system integration and working in partnership with primary care and other stakeholders. Effective prevention and management of chronic disease is essential to reduce the demands on the health system and the related personal and social impact of these conditions on Australians. 1. Examples of best practice in chronic disease prevention and management, both in Australia and internationally. NSW Health directions The NSW State Health Plan: Towards 2021 prioritises the delivery of truly integrated care across community and hospital services, mental and physical health, physical and social care and from prevention to palliative care. Work is underway to design and test more integrated service delivery models in NSW through investments in the Integrated Care Strategy, one-stop shop integrated community health centres (HealthOne NSW), and the redesign of the NSW Chronic Disease Management Program. NSW Health is responding to the challenges of an ageing population and a growing number of people living with chronic or complex health conditions by investing in new, innovative models of integrated care. The aim is to transform the health system to routinely deliver person-centred, seamless, efficient and effective care, particularly for people with complex, long term conditions. The NSW Integrated Care Strategy has been developed to deliver more coordinated and connected care across primary, acute and community settings, and focus on individual consumer needs. Locally led integration is at the heart of the strategy. Local Health Districts work in partnership with PHNs, government and non-government organisations, hospitals, primary care and community health services to develop and progress locally appropriate approaches to integrated care. 1 Australian Institute of Health and Welfare Australia s health Australia s health series no. 14. Cat. no. AUS 178. Canberra: AIHW. 2 ibid Page 7 of 31

8 NSW Health Response to the Australian House of Representative Standing Committee on Health The strategy s objectives are to transform care delivery across both hospital and primary care services to improve health outcomes for consumers and reduce costs derived from inappropriate and fragmented care. NSW Health is developing new ways of working with State government agencies and Commonwealth funded programs to deliver better outcomes for identified communities (more information is provided in Items 2 and 3 and under Further Comments). The $180 million strategy includes investment into three integrated care demonstrators in Western NSW, Central Coast and Western Sydney LHDs. For example, Western Sydney LHD and the WentWest PHN are delivering a joint program, building on previous work in chronic disease management and integrated care established through the Chronic Disease Management Program and HealthOne NSW (further information is provided later in this Item and in Item 6). Targeted patients are enrolled into a Patient Centred Medical Home in general practice and supported to better self-manage their chronic disease. Care coordination and care navigation are features of the program. Care facilitators located within both LHD community health and primary care services monitor patients and refer them to health coaching, selfmanagement strategies, and specialist and other health care services. Specialists and hospital acute clinicians provide care to the most complex patients and support capacity building within the community transition and primary care teams, working across the whole of District and in partnership with the PHN and General Practitioners (GPs). All other LHDs and Specialty Health Networks (SHNs) have received funding through a Planning and Innovation Fund to develop innovative approaches to integrating care in their region. For example, the CHESS Initiative: Chronic/Complex Healthcare: Engaged with all Stakeholders and Services is a collaboration of Murrumbidgee LHD with Murrumbidgee PHN, NSW Ambulance, Family and Community Services (FACS), BaptistCare and GPs. The CHESS integrated care model places the GP at the heart of care coordination for people with chronic and complex diseases. This model delivers both clinical and social support services to enable people to stay at home and avoid hospitalisation or exacerbation of their disease. The CHESS model provides alternatives to hospital care, with GPs overseeing a coordinated multidisciplinary team, and delivering clinical and social services tailored to suit the health needs of each individual. Patient Reported Measures (PRMs) and shared care plans are the important new components of the healthcare interaction between providers and patients within the Integrated Care Strategy. People who are engaged in their health care tend to experience better outcomes, and choose less costly interventions. The systematic collection of PRM data is shown to be more reflective of underlying health status than clinical reporting whilst also predicting survival and other meaningful clinical outcomes. PRMs enable patients to provide direct, timely feedback about their health related outcomes and experiences to drive health care improvement across NSW. Measuring PRM outcomes allows for better communication and shared decision making between patients and providers, and is as important as traditionally measured biomarkers. PRMs are soon to be tested in four NSW LHDs. Key pieces of state-wide infrastructure are funded to support and enable better connectivity and integration across all levels of the healthcare system. These include risk stratification tools to identify early intervention opportunities for people likely to need healthcare services frequently, and a fully linked-up ehealth record, HealtheNet, which is now operational in all NSW LHDs. Page 8 of 31

9 Inquiry into Chronic Disease Prevention and Management in Primary Health Care HealtheNet provides the platform to share clinical information electronically from NSW Health with My Health Record. This will be done via the NSW Clinical Portal and with general practice via secure messaging, leveraging the National Health Service Directory (NHSD). HealthOne NSW aims to create a stronger and more efficient health care system by bringing Commonwealth-subsidised general practice and state-funded community health services together. Other health and social care providers may also be involved in the HealthOne NSW model, for example pharmacists, public dental services, private allied health professionals, other government agencies and non-government organisations. The NSW Government has committed $100 million in Rebuilding NSW funds for 20 additional HealthOne NSW services across metropolitan, regional and rural NSW to improve consumer access to services and increase overall efficiency. A further $300 million has been reserved to accelerate delivery of the Regional Multipurpose Health Facilities program. This investment will secure the sustainability of smaller rural facilities by integrating healthcare services, with a focus on innovation and flexibility in service delivery. Locations prioritised for new investment will be those with smaller populations that may not be able to sustain separate hospital, residential care, community health, and home care services. Access to high quality, safe and timely health care is critical for patients, carers and providers. The Whole of Hospital Program was launched in 2013 to support LHDs in driving the strategic change needed to improve access to care and patient flow within NSW public hospitals. This program helps LHDs develop capability in designing and implementing sustainable patient flow improvement strategies, whilst sharing knowledge and experience across the sector. In 2015, the Whole of Hospital Program transitioned to the Whole of Health Program. The focus is still very much on patient care within NSW hospitals, but has expanded to include out of hospital solutions and partnerships that better connect the entire patient journey, integrate care and reduce demand on acute services. The Whole of Health Program provides a platform for connecting acute care, primary care and community health to enable discussion, planning and sharing of successful models of care across the whole care continuum. The Whole of Health Program Master Classes bring together representatives from NSW Health services with general practice, PHNs, mental health, community health and Integrated Care. For example, a recent statewide Master Class on the topic of Acute Mental Health responses for Children and Young People brought together representatives from emergency medicine, paediatric medicine and mental health disciplines across NSW hospitals, mental health children and young people s services, Justice Health and Forensic Mental Health Network, Sydney Children s Hospitals Network as well as nongovernment organisations to share best practice and models for providing safe and timely patient care for this group. The Whole of Health Program works with partners such as the Agency for Clinical Innovation (ACI) and the Clinical Excellence Commission (CEC) to facilitate opportunities for providers to share learnings across the sector, particularly from Districts with long standing relationships with general practice. These joint forums are held by teleconference. Local LHD and SHN implementation plans are developed from these interactions. The Whole of Health Program provides support through subject matter experts who assist with solution design and implementation. Page 9 of 31

10 NSW Health Response to the Australian House of Representative Standing Committee on Health The ACI Clinical Innovation Program (CIP) describes new models that have been developed by teams of local healthcare providers in NSW. Clinical innovators identify a need for change and address the need by designing and implementing new models. These models are not clinical practice guidelines, but instead are based on real life examples of local practices. For example, the CIP has been used successfully to develop the Service Access and Care Coordination Centre model in South Western Sydney LHD (SWSLHD). A central hub for Intake, Information and Intervention (Triple I) has been developed and implemented by SWSLHD building on previous work undertaken in Northern Sydney, Illawarra Shoalhaven and Hunter New England LHDs. The model is based on five key elements: initial contact/access; needs identification; assessment; care planning and coordination; and service planning and resource allocation. It reduces duplication by having co-located teams act as a single point of contact. This improves access for local service providers and consumers. Service Access and Care Coordination Centres aim to support clients self-management, increase informed and participative decision making and improve access to and coordination of existing services. The CIP has enabled this model to be developed and made available across the state, whilst also providing state-wide implementation support of this clinical innovation. The NSW Government funds the NSW Chronic Disease Management Program (CDMP) to provide health coaching and care coordination to better support people with specific chronic conditions: diabetes, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease and hypertension. The program, established in 2010, is operationalised by LHDs and SHNs across NSW. There are currently over 60,000 people in NSW enrolled in the program. Although the CDMP has not achieved a reduction in hospital utilisation among those enrolled, a finding consistent with emerging international research 3, the evaluation has shown that the program has increased skills and capabilities within NSW health services in areas such as risk selection and enrolment of patients, care navigation, health coaching and case management 4. These capabilities extend to the development of care pathways which better link community based and hospital services around the consumer. The issues highlighted by the evaluation of the CDMP are being addressed in the design and roll out of the NSW Integrated Care Strategy. The CDMP will become part of the broader Integrated Care Program and will link to other related initiatives such as cardiac and pulmonary rehabilitation programs and community based health care. Better integration with primary care will also be considered in its redesign (further information is provided in response to Items 7 and 8). NSW Health delivers a variety of best practice programs in partnership with stakeholders. The most relevant programs are described in Appendix 1. The programs are informed by national and state policy, and supported by the NSW Government to provide best practice chronic disease prevention and management. A number of these programs could be considered for promulgation across Australia. 3 Bardsley, M., Steventon, A., Smith, J., Dixon, J. (2013) Evaluating integrated and community based care: How do we know what works?, Nuffield Trust. Available at 4 Statewide evaluation NSW Chronic Disease Management Program Final Report. The George Institute for Global Health, The Centre for Primary Health Care and Equity, UNSW and The Centre for Health Economic Research and Evaluation, UTS, October Available at Report-2014.pdf Page 10 of 31

11 Inquiry into Chronic Disease Prevention and Management in Primary Health Care 2. Opportunities for the Medicare payment system to reward and encourage best practice and quality improvement in chronic disease prevention and management NSW Health supports a greater emphasis on the prevention and multidisciplinary management of chronic disease, led by GPs but effectively integrated with, and supported by, acute, specialist and allied health services. Changes to the Medicare payment system are required to reward and encourage best practice and quality improvement, across all sectors, in the prevention and multidisciplinary management of chronic disease. Medicare funds primary health care services primarily on a fee-for-service basis. The Productivity Commission has noted that the financial incentives for health care providers should promote clinically and cost effective health interventions, but to achieve this in practice is difficult 5. It also noted that while no payment model was perfect, the fee-for-service payment method had raised concerns about over servicing, reduced quality and safety standards, fragmented care, and cost-shifting. Funding for primary care cannot be considered in isolation from funding for public hospital services. People with chronic conditions frequently use public hospitals for episodic and specialist care. The success of chronic disease prevention and management therefore depends on a strong primary-acute interface. This was reinforced at the recent Australian Leaders Retreat by the priority First Ministers placed on primary care and keeping people out of hospital. At the Australian Leaders Retreat, the need to consider an efficient pricing approach to cover treatments in hospitals was recognised 6. This is a promising outcome and sets a foundation for building on the positive aspects of the activity-based funding system that has seen a flattening in the average cost of public hospital services in NSW and nationally since its introduction. Public hospital services face increased pressure as a result of the Commonwealth decision in its 2014 Budget to withdraw guaranteed growth funding, meaning there is the potential for a funding shortfall for NSW of up to $1.5 billion over and Funding reform under consideration as part of the Reform of the Federation process has the potential to address the funding shortfall as well as reward and encourage best practice and quality improvement in the secondary prevention of chronic disease. Given the interdependencies between Commonwealth-funded and State-funded health services for people with chronic conditions, NSW Health supports further efforts by the Commonwealth to strengthen primary health care services to reduce the overall anticipated burden of chronic disease on the health system. Consumers have to visit a number of different providers to access multidisciplinary team care, and this increases with each additional diagnosis. Consumers with chronic and complex conditions often require care coordination, provided in primary health care, to enable them to navigate between the primary and hospital sectors. 5 Australian Productivity Commission, Efficiency in Health, Commission Research Paper, Canberra, 2015, p.2. Available at 6 Australian Leader s Retreat Communiqué. Available at: Page 11 of 31

12 NSW Health Response to the Australian House of Representative Standing Committee on Health Individualised care packages for people with or at risk of chronic disease, as proposed in the Reform of the Federation Discussion Paper 7, also warrant serious consideration. Funding would be provided for all services received by the patient, including GP visits, specialist appointments, hospital care, and care from allied health professionals. Individualised packages would be flexible and could be tailored to the consumer s particular condition and treatment needs. The ageing population, and the strong correlations between health and aged care, suggest that financial and health benefits could be realised with an integrated health and aged care package for those eligible to receive an aged care package. In any case, health dollars need to follow the consumer to achieve the best health outcomes. Multi-Purpose Services are integrated health and aged care services (some of which incorporate the HealthOne NSW services described in response to Item 1) that provide flexible and sustainable service options for small rural and remote communities. Commonwealth aged care funding is combined with State and Territory-government funding for health services and infrastructure. This is an effective model of blended payments that achieves a flexible mix and range of aged care and health services under one management structure. Aboriginal Community Controlled Health Organisations (ACCHOs) are another example of a successful blended payment model. With 19(2) exemptions ACCHOS are able to deliver holistic, comprehensive, and culturally appropriate health care in their local community. It may also be appropriate for the Commonwealth to consider exemptions from Section 19(2) of the Health Insurance Act (1973) for HealthOne NSW facilities. This would recognise the role that NSW Health plays in the delivery of primary health care in small communities that cannot attract or sustain private GPs. The salaried doctors would assign the Medicare benefit to the HealthOne NSW service to fund additional primary health services and quality improvement activities in chronic disease prevention and management. Looking beyond Medicare, other payment or funding mechanisms warrant consideration. Other funding models are proposed in responses to Items 4 and 6 below. 3. Opportunities for the Primary Health Networks to coordinate and support chronic disease prevention and management in primary health care GP leadership NSW Health recognises the central role of GPs in chronic disease prevention and management and supports the establishment of PHNs as coordinating bodies for primary health care in Australia. The literature consistently shows that increasing access to GPs, even after correction for socioeconomic factors, results in better health outcomes and reduced costs 8. Equally, the 7 Draft Reform of the Federation Discussion Paper, Commonwealth Government, 2015 p.38. Available at 8 Caley M, Remember Barbara Starfield: primary care is the health system s bedrock. British Medical Journal, 2013;347:f4627. Available at Page 12 of 31

13 Inquiry into Chronic Disease Prevention and Management in Primary Health Care evidence shows that an emphasis on medical specialists compared to GPs results in greater costs and a trend towards an increased or neutral effect on overall mortality 9. Clinical leadership from GPs is essential to the uptake and long-term success of any initiatives to prevent and improve the management of chronic disease. Primary Health Networks will therefore have a critical role in chronic disease prevention and management, and supporting GPs in the coordination of care. In particular, PHNs are well positioned to engage general practice in: Systematic approaches to identifying and screening high risk patients the primary care workforce has a role in identifying lifestyle chronic disease risk factors, and in delivering opportunistic screening for people at higher risk; Brief interventions providing opportunistic advice and encouraging and motivating patients to reduce lifestyle risks e.g. smoking cessation. Discussions typically take between five and 10 minutes. Referrals to relevant programs PHNs have an opportunity to embed referral pathways into primary care services e.g. Practice Nurses and GPs referring overweight patients to the Get Healthy Information and Coaching Service. There is the potential for enrolment targets for health coaching programs to be included as Key Performance Indicators for PHNs, with funding linked to performance against these targets. Partnerships NSW Health will work collaboratively with PHNs to establish and maintain connections with LHDs. Primary Health Networks are expected to develop collaborative working relationships with LHDs to progress areas of common interest such as population health planning, reducing avoidable hospitalisations, developing clinical pathways, improving primary health care system performance, improving patient outcomes, improving management of patients with severe and persistent mental illness, and improving target rates of national immunisation and cancer screening. Many of these areas of common interest relate to the prevention and management of chronic disease. The renewed focus on GP engagement through the establishment of Clinical Councils within PHNs represents opportunities to support better chronic disease prevention and management in primary health care. The alignment of PHN and LHD boundaries is particularly positive, increasing opportunities and potential for integration and collaboration. Maintaining strong relationships with peak organisations such as the Royal Australian College of General Practitioners (RACGP), the Australian College or Rural and Remote Medicine (ACRRM) and the Australian Medical Association (AMA) will further enhance PHN s capacity to improve the delivery of primary health care services to the people of NSW. Performance frameworks The Commonwealth has identified that PHNs will be commissioners of care, taking an active and strategic approach to purchasing to meet the health needs of their populations. A robust performance framework will be needed for PHNs to be able to assess their performance in coordinating and supporting chronic disease prevention and management in 9 ibid Page 13 of 31

14 NSW Health Response to the Australian House of Representative Standing Committee on Health primary health care. Low acuity Emergency Department presentations and access to urgent care in the after-hours may reflect suboptimal management of chronic conditions. NSW Health supports exploring opportunities for PHNs and LHDs to have a shared performance management framework including Key Performance Indicators related to Triage 4 and 5 presentations to hospitals. Consideration should also be given to linking PHNs performance to funding, particularly in relation to enabling access to after-hours GP services. Models of care NSW Health continues to work with PHNs to support the development of clinical pathways between primary and hospital care using applications such as HealthPathways and Map of Medicine. HealthPathways is an online health information portal that provides information to GPs on appropriate assessment and management of medical conditions, and local referral pathways. The Map of Medicine is a similar tool from the UK. The development of these local pathways is a collaborative process enabling primary and specialist providers to work together to improve patient access to the right care at the right time in the right place. Additionally, PHNs are well positioned to support consumer engagement with their My Health Record, to enable coordinated, integrated care. Early detection of cancer can lead to significantly improved outcomes for consumers. Primary Health Networks are well placed to support and promote best practice cancer screening activities, including identification of suitable patients for screening and follow-up of recently screened patients. Primary Health Networks could promote to GPs the importance of endorsing screening invitation letters to encourage wider participation in cancer screening programs. The National Mental Health Commission s Review of Mental Health Programmes and Services recommended that the scope of PHNs be extended to also act as key organisations in the planning and purchasing of mental health programs, services and integrated care pathways. A key aspect of PHN involvement in the delivery of mental health programs will be supporting the central role of general practice in developing person-centred approaches to mental health treatment. Primary Health Networks could improve the management of people with chronic and complex needs including those with severe and persistent mental illness through their role as strategic purchasers to address service gaps. Purchasing would occur in collaboration with LHDs following joint service planning. 4. The role of private health insurers in chronic disease prevention and management. The private sector plays a major role in the Australian health system. By collaborating with the public sector on service integration, chronic disease prevention and management programs, and sharing information to avoid service duplication (e.g. test results), the private sector can play a significant role in helping to improve efficiencies and health outcomes. The Commonwealth encourages people to take out private health insurance by offering a rebate on premiums to those who do, and a Medicare levy surcharge for those who could potentially Page 14 of 31

15 Inquiry into Chronic Disease Prevention and Management in Primary Health Care afford it but are uninsured. In there were 9.7 million people in Australia with private health insurance (57.1 per cent of all people 18 years and over) 10. Since 2007, private health funds are able to cover a wide variety of clinically appropriate alternatives to hospital treatment under the Broader Health Cover reforms. These alternatives include treatment provided at home or in community healthcare clinics (known as hospital substitute treatment), as well as programs to manage or prevent chronic disease (known nationally as chronic disease management programs). Private health insurers are innovating in chronic disease prevention and management, in partnership with governments. The CarePoint integrated care trial is a joint project between the Victorian government and Medibank Health Solutions that aims to reduce hospital admissions by 25 per cent in its target groups. The two-year trial involving 2,200 patients with multiple chronic conditions and a history of multiple hospitalisations will provide GP-led care planning, dedicated nurse care navigators and an electronic care plan shared across primary and acute care settings. NSW is exploring similar partnerships in Northern Sydney LHD. HCF provides health coaching to its members through Healthways Australia Pty Ltd. Over a four year period, participation in health coaching by HCF members resulted in significant reductions in hospital admissions (11.4 per cent) and readmissions (36.7per cent), with improvements in admissions and bed days increasing over time 11. Cumulative program savings from reduced hospital claims was estimated at $3,549 per participant over the four years. The Private Health Insurance Administration Council recently reported industry concerns in relation to Broader Health Cover and risk equalisation. It noted that while the cost of providing chronic disease management programs is borne by the individual health insurer, risk equalisation arrangements mean that any savings stemming from a future reduction in claims due to Broader Health Cover are potentially being lost to the individual insurer. The Council stated that one of the financial incentives for offering chronic disease management programs is at risk of being diminished 12. Private health insurers should be supported to continue to provide chronic disease management programs to members and the Commonwealth should consider funding similar programs for people without private health insurance. The exclusion of GP services from private health insurance coverage was cited by the Council as another concern as it compromised the realisation of the full potential of chronic disease management programs 13. The Commonwealth should consider including some GP services for private health insurance coverage to enable the full potential of chronic disease management programs to be realised. The Commonwealth has responsibility for incentivising and regulating private health insurers role in chronic disease management. Continuing to support private health insurers to provide healthy lifestyle programs will assist in reducing the burden on the public health system. Private 10 Australian Bureau of Statistics, Australian Health Survey: Health Service Usage and Health Related Actions, Available at 11 Hamar GB, Rula EY, Coberley C, Pope JE, Larkin S, (2015) Long-term impact of a chronic disease management program on hospital utilization and cost in an Australian population with heart disease or diabetes. BMC Health Services Research, 15: 174. Available at 12 Australian Prudential Regulation Authority, Private Health Insurance Administration Council, The operations of private health insurers: annual report , PHIAC, Canberra, 2012, p. 8. Available at 13 Ibid, p. 34. Page 15 of 31

16 NSW Health Response to the Australian House of Representative Standing Committee on Health health insurers have an important role to play in incentivising members to participate in chronic disease prevention and management programs. Incentives could include reduced premiums. The Reform of the Federation process offers opportunities to re-evaluate the role of the private health sector, including private health insurers, in the Australian public health system. 5. The role of State and Territory Governments in chronic disease prevention and management NSW Health recognises and reinforces the central role of GPs in chronic disease prevention and management, and the responsibility of the Commonwealth to predominately fund primary health care. States and Territories operate public hospitals, and deliver community health services as well as population and public health services. State and Territory Governments therefore need to partner with the Commonwealth in the prevention and management of chronic disease. Although States and Territories share responsibility with the Commonwealth for policy and funding for chronic disease prevention and management, the planning and delivery of services is often poorly coordinated, making it hard for people with chronic and complex conditions to get the care they need, when and where they need it. A population health approach to chronic disease management would target consumers before they need hospital care. NSW Health has adopted a population health approach to the prevention of chronic disease by promoting healthy eating, healthy weight and physical activity through a variety of programs (see Appendix 1). To maximise the benefits of this approach, however, healthy public policy is needed. That is, public policy must support individuals to adopt healthy behaviours and sustain them in the longer term; for example, through infrastructure, food security and education. Healthy public policy is a cost-effective way to support large scale population change and promote equitable access to good health. Chronic conditions affect people of all ages but are more prevalent in people over 65 years 14 The prevalence of chronic disease not only increases with age but so does its impact on an individual s capacity to function independently in the community. Consumers with chronic and complex conditions, especially older people, often require assistance in coordinating their care to enable them to navigate between the primary and hospital sectors. This is a role best provided by the primary health care team. A large percentage of health (and aged care) funding is spent on a small proportion of the population. Evidence from the CDMP indicates that it is difficult to improve outcomes in frequent users of health care, but that focusing on particular risk factors or functional difficulties in people with two or more chronic conditions may be a more effective approach 15. Integrated care and support packages for targeted frequent users of health care have the potential to reduce avoidable hospital admissions and presentations to Emergency Departments in the longer term. 14 Australian Institute of Health and Welfare. Analysis of the National Health Survey. Available at 15 Smith SM, Soubhi H, Fortin M, Hudon C, O Dowd T. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.: CD DOI: / CD pub2. Available at 03AA6FE9CFF09.f02t04 Page 16 of 31

17 Inquiry into Chronic Disease Prevention and Management in Primary Health Care A recent study (based on a Western Sydney population) confirms this approach and recommends that care coordination programs target those living with a high level of dependency and their carers 16. Work in relation to risk stratification should therefore consider incorporating functional measures. Clarifying the roles of each level of government in chronic disease management will help to target current health spending by both levels of government to improve health outcomes. Shared roles between the Commonwealth and States and Territories for policy and funding of coordinated and or integrated care services warrants further consideration. Similarly, collaborative efforts between the Commonwealth and States and Territories to share data to better understand the consumer s journey through the health and aged care systems will better support the delivery of truly integrated care. The use of digital technology by Governments will be fundamental to delivering chronic disease prevention and management more equitably, efficiently and effectively. This is discussed further in Item 6 below. 6. Innovative models which incentivise access, quality and efficiency in chronic disease prevention and management Many people live with multiple chronic conditions. Successful prevention and management of chronic conditions requires people to be equal partners in decisions about their care and treatment to be active, engaged and empowered, rather than passive recipients of care. Increasingly, innovative models which incentivise access, quality and efficiency of chronic disease prevention and management are leveraging digital technology. Digital innovation puts the consumer at the centre of service delivery with solutions developed using user-based design. Opportunities to better utilise digital technologies range from the web through to smart phones and other rapidly developing technologies that present opportunities to better prevent and manage chronic disease. The telephone and internet provides a more equitable, efficient and effective way of delivering services, particularly when the target group for an intervention is of working age. Technologyenabled services encourage best practice and quality improvement in chronic disease prevention and management using decision support and call audits. Services leveraging the telephone and internet should be rewarded and encouraged through the Medicare payment system or other payment or funding mechanisms. Increasingly, consumers are using smart phone apps and other devices to access information and track their health. These technologies enable consumers to monitor their vital signs and communicate these to their GP, specialist or other provider. Consumers are also able to make medical appointments, request repeat scripts and obtain medical certificates from their GP via the internet. 16 Mallitt K-A, Kelly P, Plant N, Usherwood T, Gillespie J, Boyages S, Jan S, Leeder S (2015) Demographic and clinical predictors of unplanned hospital utilisation among chronically ill patients: a prospective cohort study. BMC Health Services Research, 15: 136. Available at Page 17 of 31

18 NSW Health Response to the Australian House of Representative Standing Committee on Health Digital technology can improve the quality of public services by transforming the experience of people delivering and receiving these services 17. It also enables those most in need to access services, including Aboriginal people, and those living in rural and remote areas. This is most effective when developers work with the eventual users of a product from the very start in an iterative cycle that involves repeated testing. Researchers have identified three key benefits of increasing the role of technology in public services: saving time, boosting user participation, and encouraging users to take responsibility for their own wellbeing 18. The Commonwealth has the potential to foster digital innovation to incentivise access, quality and efficiency in chronic disease prevention and management by bringing together developers and end-users. In 2006, the Council of Australian Governments established Healthdirect Australia (HDA) to provide people with access to trusted health information and advice without time or geographic restriction. The company is owned by the Governments of Australia (except Victoria and Queensland) and aims to help consumers manage their own health and access needed services using digital technology. Healthdirect Australia provides a range of online and telephone services including healthdirect (website, symptom checkers and telephone nurse triage), mindhealthconnect, and the After Hours GP Helpline to enhance health literacy and support consumers to prevent and manage chronic disease as well as acute exacerbations. The company also manages the NHSD on behalf of all Governments of Australia to help consumers navigate the system and find the services they need. Given the existing investment by the Commonwealth and the States in HDA, any proposed expansion of online and telephone services should leverage their existing services and capabilities in order to provide coordinated and cost effective solutions. A number of international models incentivise access, quality and efficiency in chronic disease prevention and management. The work of the PHCAG and the review of Medicare Benefits Schedule (MBS) items provide an opportunity to consider the adoption of successful international models and extending effective Australian models. A key feature of the models outlined below is the central role of general practice in driving innovation. Care needs to be taken, however, in the direct adoption of overseas models in Australia, given the different health systems in place; although there is benefit in adopting successful elements that translate well to the Australian context. Patient Centred Medical Homes place a person at the centre of a home, where partnerships are established with a particular primary care provider and their team. Additional services are added to this partnership as required. This model places the primary care provider as the first point of contact, allowing the coordination of care between providers and across healthcare settings. This model has been in place in the USA for a number of years, and is being established in a number of centres in NSW, including Western Sydney and the North Coast of NSW. A recent systematic review of evidence supporting the Patient Centred Medical Home concept found that the model can improve access to care, clinical parameters and outcomes, 17 Bickerstaffe S. (2013) Building Tech-powered Public Services, Institute for Public Policy Research. Available at 18 Ibid p. 4 Page 18 of 31

19 Inquiry into Chronic Disease Prevention and Management in Primary Health Care management of chronic and complex disease, preventive care services, and provide improved condition-specific quality of care and palliative care services. Patient Centred Medical Homes can also decrease the use of inappropriate medications, and significantly reduce avoidable hospital admissions and readmissions, Emergency Department use and overall care costs 19. Another model in place in the USA is Iora Health, a series of practices which utilise peersupport workers to achieve cost-effective management of chronic disease. Practices team with employers, who pay for their workers health care costs, health insurers, or a private Medicare plan. The practices are paid a flat fee for each patient. A private health insurer in South Africa, Discovery, offers a rewards program (Vitality) to its members to encourage primary self-managed prevention and healthy lifestyle habits, for an annual fee. Rewards include discounts on healthy food items in supermarkets and discounts on healthy lifestyle products from pharmacies. The Knockout Health Challenge (described in Appendix 1) is an innovative Australian model which incentivises access to chronic disease prevention and management through competition, with financial and non-financial incentives building on links with the community, health organisations and rugby league. Enrolment targets for health coaching programs could be established for PHNs to encourage them to promote chronic disease prevention and management to consumers (see response to Item 3 for further information). Consumers with private health insurance could be encouraged to access the service provided by their insurer to maximise availability of the publicly funded service to the uninsured (see Item 4 for further information). A better health system should not only improve incentives for health care providers to focus on prevention and early intervention it should also provide incentives for consumers. Effective use of technology and e-health is one means of incentivising access, quality and efficiency in chronic disease prevention and management and reducing future costs of delivering quality care. Given the current fiscal circumstances faced by all governments, consumers want services to be delivered as efficiently as possible, so that taxes and user-charges are not higher than they need to be. 7. Best practice of multidisciplinary team chronic disease management in primary health care and hospitals Multidisciplinary care is well recognised as best practice management of chronic and complex diseases. Outlined below are a number of examples of best practice multidisciplinary chronic disease management provided in NSW hospitals and at the interface between acute hospitals and primary health care. These programs specifically target cardiovascular disease, mental health conditions and musculoskeletal conditions. These are three of the most expensive conditions to treat 20 and in , almost $20 billion was spent by government and non-government sources on 19 Janamian T, Jackson CL, Glasson N, Nicholson C (2014) A systematic review of the challenges to implementation of the patient-centred medical home: lessons for Australia. Medical Journal of Australia, 201 (3 Supp); S69 S73. Available at 20 Australian Institute of Health and Welfare Australia's health Australia's health series no. 14. Cat. no. AUS 178. Canberra: AIHW., p 96. Available at Page 19 of 31

20 NSW Health Response to the Australian House of Representative Standing Committee on Health treatments. They are therefore a focus of effort at both a national and state level, in primary health care and in hospitals. NSW Health best practice team-based care There is ongoing work to enhance multidisciplinary models for chronic disease management for Aboriginal people including the Better Cardiac Care for Aboriginal and Torres Strait Islander People project and cardiac rehabilitation. Close collaboration and coordination with ACCHOs, PHNs and other key stakeholders is ongoing to improve care for Aboriginal people with chronic disease. The NSW Better Cardiac Care Project, includes state-wide audits of care for people presenting with chest pain, and a collaborative Medicare data linkage project involving NSW, ACT and QLD to examine cross-sector patient flows, patterns of care and access to primary and acute care services. The Chronic Care for Aboriginal People Program develops and implements initiatives to optimise access to appropriate chronic disease services for Aboriginal people across NSW. The 48 Hour Follow Up for Aboriginal people discharged from hospital ensures a referral pathway from acute to primary care, which strengthens the capacity to provide health literacy and education support. The LikeMind pilot, developed and implemented by NSW Health, provides an integrated mental health service by co-locating a range of mental health care professionals, drug and alcohol services, primary care and social services, including vocational and employment support. The pilot aims to ensure people s mental health needs are addressed in one space. The ACI s Osteoporotic Re-fracture Prevention Model of Care focuses on patient case management. Fracture Liaison Coordinators in hospitals provide individuals with disease management education, support for self-management and initiate specific treatment to reduce the risk of further fractures. The model has identified linkages with chronic care and falls prevention services, primary care, community-based lifestyle services and homecare services as imperative. The evaluation conducted in multiple sites across NSW indicated that at least 10 per cent of re-fracture presentations can be avoided within two years of implementation of the model of care. An analysis completed by John Hunter Hospital in Newcastle, where the model of care has been in place for five years, showed a reduction of 30 per cent in osteoporotic refracture presentations compared to a similar hospital which had not implemented the model. The Osteoarthritis Chronic Care Program (OACCP) is based upon the National Health and Medical Research Council (NH&MRC) and RACGP Guideline for the non-surgical management of hip and knee osteoarthritis. It has been externally evaluated and shown to improve options for care for people awaiting elective hip or knee replacement. The evaluation found that up to 11 per cent of people with knee arthritis participating in the program were able to come off elective joint replacement waiting lists when supported to self-manage their arthritis. Modelling by the ACI has suggested over $113 million in potential costs could be avoided in NSW over a ten year period, in addition to nearly 38,000 bed days. A follow-up of a sample of participants found over 90 per cent remained off the waiting list, or had not had surgery in the months since coming off the waiting list. Approximately four per cent of those with hip arthritis gained earlier access to surgery through the OACCP team working closely with orthopaedic surgeons. Initial evidence has shown that these people have a shorter length of stay, have fewer last minute cancellations (as their co- Page 20 of 31

21 Inquiry into Chronic Disease Prevention and Management in Primary Health Care morbidities are better managed), have their home needs addressed early and have a more realistic understanding of the procedure and potential outcomes. Multidisciplinary case conferencing is an example of best practice care in a hospital setting. For example, oncology services in NSW have over 200 teams which include specialists, nurses and allied health professionals. These teams deliver multidisciplinary care and advice through presenting case conferences, and facilitate best practice multidisciplinary care for people diagnosed with cancer. Many rural cancer centres use telehealth to link into larger cancer centres, ensuring access to specialist multidisciplinary team discussion. Inter-professional education and training is a positive development in undergraduate and prevocational medical, nursing and allied health education and is widely adopted in NSW. A New Graduate Interprofessional Educational Framework has been designed to support new graduate doctors, nurses, midwives and allied health providers during their transition to work in NSW Health. An interprofessional learning program has also been developed for students in rural practice using clinical case studies provided by health consumers, clinical supervisors, students and expert clinicians. In addition, a 'ClinTeach' website was created to support clinical educators working with students involved in interprofessional learning placements. NSW Health supports and encourages interprofessional training as the best preparation for effective and efficient multidisciplinary team-based health care. 8. Models of chronic disease prevention and management in primary health care which improve outcomes for high end frequent users of medical and health services The Reform of Federation discussion to date recognises that care coordination could play a central role in the effective management of chronic conditions, and that a solution would need involvement of the primary care system. NSW Health recognises that chronic disease management delivered in the community by primary health care professionals is central in avoiding unnecessary hospital admissions for frequent health system users. A number of examples of primary-led initiatives are already included in this submission (see Items 2 and 3). One of the programs previously described is the CDMP. This program was implemented on recommendation of the NSW Independent Pricing and Regulatory Tribunal (IPART). In its 2008 Framework for Performance Improvement in Health Final Report IPART suggested that in the absence of an imminent, national coordinated chronic care model, that NSW Health pursue its proposed State-based coordinated care arrangement (the CDMP) for people with serious chronic diseases. 21 IPART also recommended that NSW Health continue to pursue the option of a Commonwealth-driven arrangement that strengthened the role of GPs. The CDMP evaluation has shown that the program did not reduce hospital use amongst those enrolled, however, it improved skills and capabilities within our health services and enhanced skills in the development of care pathways to better connect community and hospital services. 21 NSW Independent Pricing and Regulatory Tribunal Framework for performance improvement in health. Other industries final report., September Available at lth/09_oct_2008_-_release_final_report/framework_for_performance_improvement_in_health_-_final_report Page 21 of 31

22 NSW Health Response to the Australian House of Representative Standing Committee on Health A consistent feature of the evaluation was that, for most outcomes, people were enrolled in the program around the time that their acute service utilisation peaked. This finding suggests that the acute sector, by its nature, responds to realised risk not latent risk. The primary health care sector is better placed to proactively manage future health crisis risk a fundamental premise of chronic disease management 22. A recent randomised controlled trial (based on a Western Sydney population) also demonstrated that hospital-based care coordination (for an expanded CDMP cohort) did not improve quality of life or reduce unplanned admissions despite community health service utilisation almost doubling 23. This finding reinforces that the primary health care sector, rather than the acute sector, is best positioned to provide care coordination. Telephone health coaching is another tool that has been demonstrated to improve health behaviour, self-efficacy and health status, particularly for vulnerable populations who have difficulty accessing health services 24 and are often frequent users of medical services. The Commonwealth should consider adopting a population health approach to chronic disease management and providing national health coaching programs like the successful Get Healthy Information and Coaching Service (see Appendix 1) to help consumers better manage their own health and support decision making. These programs could be funded via a different mechanism from the Medicare payment system such as that used for HDA. NSW Health welcomes the work being done by the PHCAG to examine opportunities for the reform of primary health care in improving the management of people with complex and chronic disease. NSW Health recommends that the Inquiry consults with this Group. Further Comments NSW Health recognises that chronic disease prevention and management is required across the life span, and that the focus of management needs to encompass preventing and managing complications of chronic disease earlier in life through to enhancing independence and maintaining function towards the end of life. The NSW Government Plan to Increase Access to Palliative Care reported that only ten per cent of people who have a life-limiting illness that is not cancer receive access to specialist palliative care in their last year of life. In their Diagnostic Report to Inform the Model for Palliative and End of Life Care Service Provision, ACI has recommended that many people living with a chronic disease would benefit from, or require access to, palliative and end 22 Statewide evaluation NSW Chronic Disease Management Program Final Report. The George Institute for Global Health, The Centre for Primary Health Care and Equity, UNSW and The Centre for Health Economic Research and Evaluation, UTS, October Available at Report-2014.pdf 23 Plant NA, Kelly PJ, Leeder SR, D Souza M, Mallitt K-A, Usherwood T, Jan S, Boyages SC, Essue BM, McNab J, Gillespie JA (2015) Coordinated care versus standard care in hospital admissions of people with chronic illness: a randomised controlled trial. Medical Journal of Australia, 203 (1); Available at 24 O Hara BJ, Phongsavan P, McGill B, Maxwell M, Ahmed N, Raheb S, Bauman AE (2014) The NSW Get Healthy Information and Coaching Service: the first five years. NSW Ministry of Health & Prevention Research Collaboration: University of Sydney. Available at Report_WEB_version.pdf Page 22 of 31

23 Inquiry into Chronic Disease Prevention and Management in Primary Health Care of life care that takes account of their needs. The report also noted that the transition between active disease management and palliative care is not always clear. People with chronic disease often have multiple co-morbidities and may need treatment to manage disease, as well as palliative care. It can be difficult to plan for a palliative care approach for people with a chronic disease due to the potential for frequent, and often erratic, changes in condition. Notwithstanding, a concerted effort is required to increase the proportion of people with chronic or complex care needs, that are not cancer-related, accessing palliative and end of life care. Management of chronic life-limiting illness in primary health care should include Advance Care Planning early, when a person is still well. Advance Care Planning should consider and incorporate the person's wishes as they move towards the end of their life. The NSW Health Advance Planning for Quality Care at End of Life: Action Plan demonstrates NSW Health s commitment to normalising Advance Care Planning across the life cycle. Community pharmacy also plays a key role in primary health care through the delivery of Pharmaceutical Benefits Scheme medicines and related services. The role of pharmacists in assisting patients to better manage their own health and, in particular, medicines, is supported by NSW Health. The NSW Government invested $7.4M over four years (2011/ /15) to better utilise the 1,700 community pharmacies in NSW by enabling them to offer free Pharmacy Health Checks through the Pharmacy Health Check Know Your Numbers program. The checks were to identify people at risk of developing a chronic disease and provide a brief intervention. Interim results indicate that the program has developed important skills and capacities within community pharmacy in the delivery of primary care initiatives. The final evaluation findings will help guide future primary health care initiatives in community pharmacy. Pharmacists are also building new skills in preventing infectious diseases. From June 2015, registered pharmacists in NSW can initiate and administer influenza vaccine to healthy people aged 18 years and older in a retail pharmacy, in accordance with the NSW Pharmacist Vaccination Standards. Pharmacists in South Australia, Northern Territory and Western Australia are also able to administer influenza vaccine. Given the untapped potential of the community pharmacy workforce, particularly in small rural and remote communities, serious consideration should be given to better utilising community pharmacy as a primary health care destination. Pharmacists are well-positioned to improve medicine adherence and management and help people with mental health conditions. Finally, people in need of better chronic disease management are often the same people needing other forms of social assistance, such as help finding employment, disability support, social housing, and accessing training and education. There is widespread agreement on the need for better integration between the primary and acute sectors of the health system; equally, there must be better coordination of services across the health and social sectors, given the social determinants of health and wellbeing. The Reform of Federation White Paper recognises these interdependencies in its identification of health, education, housing and homelessness as key reform areas. The inquiry should consider exploring potential linkages between related reforms such as the National Disability Page 23 of 31

24 NSW Health Response to the Australian House of Representative Standing Committee on Health Insurance Scheme and My Aged Care to enhance the prevention and management of chronic disease. Page 24 of 31

25 Appendix 1 Preventive and Public Health Services Chronic disease prevention is fundamental to keeping people healthy and out of hospital. To improve health and wellbeing in the population, NSW Health delivers a range of preventive and public health programs. The NSW Government has developed the NSW Tobacco Strategy to achieve ambitious tobacco control targets, including measures governing the sale, display and advertising of tobacco products, bans on smoking in public places, social marketing campaigns, cessation support and a focus on reducing smoking rates in key population groups including Aboriginal people and custodial populations. The Cancer Institute NSW delivers public education campaigns, projects to support priority populations, and the NSW Quitline and icanquit website. In partnership with the Aboriginal Health and Medical Research Council (AHMRC) of NSW, the NSW Government developed The ATRAC Framework: A Strategic Framework for Aboriginal Tobacco Resistance and Control in NSW. The framework aims to support the planning, integration and coordination of Aboriginal tobacco resistance and control efforts across NSW. The framework identifies relevant evidence and key principles to encourage best practice approaches to address smoking in Aboriginal communities. The NSW Healthy Eating and Active Living Strategy is a whole of government approach to address overweight and obesity by encouraging healthy lifestyle change at a personal level and creating environments that support healthy choices in the places where people work, live and play. A new social marketing campaign, Make Healthy Normal, is seeking to generate a community-wide conversation about how overweight and obesity became a problem, and the simple, easy and effective measures people can take to get their lives back on track. The NSW Skin Cancer Prevention Strategy aims to reduce overexposure to ultraviolet radiation (UVR) through a UVR protection policy, shade provision, UVR protection behaviours and strategic research. Australia has the highest rate of skin cancer in the world, and there have been increases in sun protective behaviour and decreases in pro-tan attitudes over the life of the strategy. The NSW Government developed the NSW HIV Strategy : A New Era which sets ambitious targets, including measures on testing, diagnosis and treatment uptake intended to prevent HIV in the first instance, or where diagnosed, support effective long term care management. The strategy s implementation has been delivered in collaboration and partnership with public sector services, primary care and non-government organisations, and involves innovative approaches to prevention, providing expert support to providers at the time they make an HIV diagnosis, and delivering models of care that effectively manage people with HIV over their lifespan. These models will support client linkage and retention in care, adherence to treatment, and a continuum of care. The NSW Hepatitis C Strategy aims to reduce hepatitis C infections and improve the outcomes of people living with hepatitis C in NSW. The targets of this strategy include reducing sharing of injecting equipment among people who inject drugs by 25 per cent; and increasing the number of people accessing hepatitis C treatment in NSW by 100 per cent. Page 25 of 31

26 NSW Health Response to the Australian House of Representative Standing Committee on Health This strategy focuses NSW Health s efforts on working with those groups of people that are most at risk or most affected by hepatitis C including: people living with hepatitis C; people who inject drugs, especially new initiates; people in or recently in custodial settings; Aboriginal people; and people from culturally and linguistically diverse backgrounds. The NSW Hepatitis B Strategy aims to reduce hepatitis B infections and improve the outcomes of people living with hepatitis B in NSW. It seeks to prevent this chronic disease by improving childhood vaccination coverage and screening of all pregnant women for the virus. For people living with hepatitis B, the strategy aims to improve their health outcomes by improving monitoring, care and treatment. National Health Policies and Strategies The NSW Government supports national efforts for prevention and management of chronic disease, including the Health Star Rating System and tobacco and alcohol control. NSW continues to support the national Health Star Rating System as a key initiative to help people make healthy food choices as part of an overall strategy to reduce overweight and obesity. NSW Health s support for this initiative includes contributing to the social marketing campaign and inclusion of information about the System in existing policies and programs where relevant. NSW Health supports the National Drug Strategy and the development of the National Drug Strategy to reduce harm from excessive alcohol consumption, and the use of tobacco and other drugs. Tobacco control activities in NSW undertaken in addition to the support for the National Tobacco Strategy , are developed by the Intergovernmental Committee on Drugs. Cancer Screening Programs To facilitate the early detection and treatment of cancer, NSW Health delivers a number of targeted cancer screening services. The Breast Screening Program targets the most common cancer in Australian women, with population based screening using mammography being the best early detection method. Evidence for the benefit is strongest for women aged years. A series of television and radio advertisements, including the Take You Away and Cherry and Pea television campaigns, and The Facts radio campaign, reminded women of the importance of early detection of breast cancer. The program is delivered by nine Screening and Assessment services, located and managed within LHDs, as well as a fleet of mobile van units servicing more than 150 towns across NSW. Between 1999 and 2008, the mortality rate for breast cancer fell by 11 per cent across the state. The Pink Sari Project is a community driven initiative in NSW that specifically targets Indian and Sri Lankan communities and seeks to understand and overcome the low breast cancer screening rates within this population. The project was conducted by NSW Multicultural Health Communications Service, with a grant provided by the Cancer Institute NSW as part of their Evidence to Practice Grants Program. The Bowel Screening Program seeks to address the second most common cause of cancer deaths in Australia. Modelling work done in Australia shows that biennial screening for those aged over 50 has the potential to save 500 lives annually. The national program will be Page 26 of 31

27 Inquiry into Chronic Disease Prevention and Management in Primary Health Care expanded until 2020, when a phased implementation of two-yearly screening will be in place. Once fully implemented, all Australians aged between 50 and 74 will be offered free screening every two years, consistent with recommendations from the NH&MRC. Survival from bowel cancer in NSW is better than for comparable countries, with a relative five-year survival rate of 66 per cent. Almost 90 per cent of people diagnosed with bowel cancer at an early stage in NSW will live for at least five years after diagnosis. Through the NSW Cervical Screening Program, regular cervical screening is currently recommended for all women aged 18 to 70 years who have ever been sexually active. Rates of cervical cancer in women of all ages in Australia remain at an historical low of seven new cases per 100,000 women, while deaths are also low, by historical and international standards, at two deaths per 100,000 women. The program has produced resources in a range of languages to encourage women to be screened for cervical cancer. Testimonials are also used to promote the use of Pap tests for screening. The NSW Pap Test Register ensures that women who return abnormal results receive the necessary follow-up. NSW Healthy Lifestyle Programs NSW Health supports the prevention and management of chronic disease through the following lifestyle and coaching services. The Get Healthy Information and Coaching Service (GHS) is a free, telephone-based service supporting NSW adults to make sustained improvements in healthy eating, physical activity and achieving or maintaining a healthy weight to prevent and manage chronic disease. A NSW initiative, the GHS is also available to residents of Queensland and South Australia. The GHS targets those most at risk of chronic disease and seeks population level reach to maximise its public health impact. The GHS includes two levels of service; information-only and a six month coaching program which includes up to ten individually-tailored calls provided by universityqualified health coaches. More than 32,000 NSW adults have accessed the GHS since it commenced in Further enhancements to the service include the introduction of an Aboriginal specific module and a type 2 diabetes prevention module for participants who are at an increased risk of type 2 diabetes. Participants who have completed the six month GHS coaching program report significant improvements including an average weight loss of 4 kg; an average loss of 5.1cm off their waist; an increase in the amount of fruit and vegetables consumed daily; a decrease in the amount of take away meals consumed per week; a decrease in the amount of sweetened drinks consumed daily, such as soft drinks, cordials and fruit juices; and an increase in physical activity levels. A six-month follow up study (six months after completing coaching and 12 months from baseline) showed that anthropometric improvements made at the completion of the coaching program were maintained. Get Healthy at Work is a NSW Government initiative, available to all NSW businesses, regardless of their size, location or industry, that aims to improve the health of working adults by giving businesses the tools to develop and implement an effective workplace health program. It is delivered in partnership by the NSW Ministry of Health, NSW Office of Preventive Health and WorkCover NSW. Workers in participating businesses are offered a free and confidential brief health check, which helps individual workers to understand their risk of developing type 2 diabetes and heart disease. Workers at elevated risk are offered referrals to the GHS, NSW Quitline, or a GP. Page 27 of 31

28 NSW Health Response to the Australian House of Representative Standing Committee on Health All Get Healthy at Work information and tools are available online and businesses can choose to work through the process themselves or request support from a service provider. The NSW Healthy Children s Initiative includes programs which have been scaled up to achieve population reach across NSW. These include: Live Life Well at School a primary prevention program offered to all primary schools in NSW to improve teachers skills and confidence around physical activity and nutrition as part of a whole of school approach. As at 30 June 2015, 84 per cent (2,039) of schools have participated in the program since its inception in Of those schools, 81 per cent had vegetable, fruit and water breaks in class time, and 84 per cent were encouraging physical activity during recess and lunch breaks. Munch and Move a primary prevention program offered to all centre-based early childhood services in NSW. The program offers training to services around physical activity and nutrition. As at 30 June 2015, 90 per cent (3,184) of services have participated in the program since its inception in per cent of services have adopted 70 per cent of practices, including 94 per cent of services providing fruit and vegetables daily, 97 per cent having a written nutrition policy and 93 per cent providing active play opportunities for at least 25 per cent of the day. Go4Fun a secondary prevention program for children aged 7 13 years. More detail is provided below. Go4Fun is a healthy lifestyle program for children aged 7 13 years who are above a healthy weight, and their families, managed by the NSW Office of Preventive Health and implemented by LHDs. The program consists of ten sessions run over ten weeks in the after school period, during school term. Families are supported by trained leaders to make lifestyle changes which support healthy behaviours to achieve and maintain a healthy weight. Since July 2011, there has been an average waist circumference reduction of 1.5cm, a 0.6kg/m 2 reduction in BMI, an increase of 3.5 hours per week in physical activity, a decrease of 2.7 hours per week in sedentary activity, and an increase in fitness and self-esteem. Further enhancements to Go4Fun include: The review and adaptation of Go4Fun for Aboriginal families; The development of a flexible delivery model to encourage participation from hard to reach families including those in rural and remote locations, and The development of a post program support model to support the maintenance of program effects in the 6-12 months post program. Currently a randomised controlled trial is being conducted in partnership with the Behavioural Insights Unit (Department of Premier and Cabinet) and the University of Sydney to investigate the effect of incentivising the achievement of behavioural goals on participant outcomes. With the Fast Choices legislation, NSW is the first jurisdiction in Australia to introduce mandatory kilojoule labelling in fast food chains, café and coffee chains and major supermarkets. Since 2012, these outlets have been required by law to display kilojoule information and the average adult daily kilojoule intake (8700kJ) on their menu boards. Page 28 of 31

29 Inquiry into Chronic Disease Prevention and Management in Primary Health Care A consumer education campaign targeted at the main consumers of fast foods (18 24 year olds) supports the legislation. The legislation and supporting 8700kJ campaign have resulted in a significant increase in consumer awareness of the average daily kilojoule intake and a 15 per cent reduction in fast food kilojoules purchased. NSW Health Programs for Aboriginal People Recognising the poorer health outcomes in Aboriginal people, NSW Health has implemented a number of programs to reduce the incidence and severity of chronic disease among Aboriginal people. One Deadly Step is a community event to promote screening, early detection and follow up of chronic disease in Aboriginal communities in NSW. The event involves screening for albumincreatinine ratio, HbA1c, cholesterol, blood pressure, blood glucose, body mass, waist circumference, risky drinking behaviours and smoking. Participants with abnormal results are followed up with their GP or another health provider. The program has a partnership with Country Rugby League to provide support with current and former players. The wide range of age groups, good engagement of males (an average of 42 per cent of participants), and the high proportion of Aboriginal participants (85 per cent on average) demonstrates the success of the program in engaging a broad spectrum of the community. A high proportion of participants across all sites were identified to be at risk of developing chronic disease, based on overweight and obesity (70 per cent of all participants), unhealthy waist circumference (76 per cent), current smoking (48 per cent) and high total cholesterol level (52 per cent). Most (94 per cent) participants agreed to be followed up following the events, with staff from Aboriginal Medical Services, LHDs and Medicare Locals undertaking follow up. The NSW Knockout Health Challenge is a primary prevention program aimed at motivating Aboriginal communities to reduce their risk of chronic disease through increasing physical activity, and improving nutrition and weight loss. The Challenge is a partnership between the NSW Ministry of Health and NSW Rugby League, involving a series of challenges including weight loss and fitness/sport competitions, for Aboriginal people 18 years and over living in NSW. The 2013 evaluation demonstrated a significant reduction in average weight (a mean reduction of 4.9kg), with 89 per cent of those who submitted final weights, losing weight. Critically, this weight loss was sustained over a nine month period. The majority of participants in the 2013 Challenge (91 per cent) reported improvements to their physical health, along with increased confidence to eat healthily and be physically active. Improved quality of life was reported by 76 per cent of participants. There were significant improvements in adequate levels of physical activity and fruit and vegetable consumption. Factors associated with successful implementation of the Challenge included: The competitive nature of the Challenge in driving engagement and motivation; Having structured support through team training, fitness coaching, team meetings, monthly weigh-ins, team t-shirts and incentives; Having a recognised community leader as team manager to build on existing connections; Forming linkages with local health organisations to facilitate access to health professionals, and Having links with local rugby league teams to foster team spirit. Page 29 of 31

30 NSW Health Response to the Australian House of Representative Standing Committee on Health NSW Health has established a Better Cardiac Care Implementation Committee to oversee implementation of the Australian Health Ministers Advisory Council (AHMAC) Better Cardiac Care for Aboriginal and Torres Strait Islander People 2014 project s national recommendations in NSW. NSW Health is also establishing an Aboriginal Advisory Group to ensure that Aboriginal people s perspectives are incorporated into the NSW Better Cardiac Care Project. In partnership with the NSW Ministry of Health, the AHMRC and Cancer Council NSW, the Cancer Institute NSW operates the Aboriginal Cancer Partnership Project to improve the cancer health outcomes of Aboriginal people in NSW. The project is working to build the skills, knowledge and capacity of the Aboriginal health workforce in cancer care, and to build partnerships between mainstream services and ACCHOs to enhance the cultural competence of health providers working in cancer care. The project has supported a diverse range of activities across the cancer control continuum, including community awareness raising workshops, community action workshops, clinical placements for Aboriginal Health Workers, and partnership building. Quit for New Life is a smoking cessation support initiative for women having an Aboriginal baby and their householder members who smoke. The program is currently being implemented across NSW and aims to reduce the high rate of smoking during pregnancy amongst women having an Aboriginal baby. Quit for New Life is a Ministry of Health-funded program delivered primarily through Aboriginal Maternal and Infant Health Services (AMIHS) and Building Strong Foundations (BSF) services located within LHDs. Women attending participating services for antenatal and postnatal care are offered culturally appropriate smoking cessation support including brief interventions, behavioural support, referral to NSW Quitline, free nicotine replacement therapy (also available for householders who smoke) and extended follow-up support. The sustainability of the program is achieved by focusing on practice change strategies in participating services (e.g. staff training, clinical redesign and policy change) that embed evidence-based smoking cessation support into routine care delivery. Mental Illness as a chronic condition Mental disorders are highly prevalent and distressing illnesses. NSW Health is working to improve mental health in the community through a range of interventions. Living Well: A Strategic Plan for Mental Health in NSW was developed by the Mental Health Commission of NSW following consultation with key stakeholders, including consumers and carers. The plan supports recovery-oriented care in the community wherever possible. The NSW Government has committed $115 million over three years to strengthen mental health care, with an initial focus on increasing community-based specialist services and psychological supports. Evidence-based programs to support people with a long-term mental illness to live independently in the community include the Housing and Accommodation Support Initiative (HASI), which has been independently evaluated 25. The Housing and Accommodation Support Initiative operates as a three-way partnership between LHDs (clinical service 25 University of NSW Social Policy Research Centre Evaluation of the Mental Health, Housing and Support Initiative (HASI) Second Report. Available at Page 30 of 31

31 Inquiry into Chronic Disease Prevention and Management in Primary Health Care delivery), non-government organisations (Psychosocial rehabilitation accommodation support) and housing providers (property and tenancy management). Consumer outcomes were positive for mental health hospital admissions (reduction in admissions and length of stay), mental health (clinically significant improvement in measures of psychological distress and life skills), stable tenancies, independence in daily living, social participation, community activities and involvement in education and voluntary or paid work. MH-Kids provides a range of programs to support the prevention, early identification and management of mental illness in children and young people, including Child and Adolescent Mental Health Services, NSW Children of Parents with a Mental Illness Program, Parenting Program for Mental Health and School-Link. These programs work closely with schools and families to support young people. Physical Health of People with a Mental Illness It is widely recognised that people with a mental illness are at higher risk of physical health problems, including heart disease and diabetes, than the general population, making this group an important focus area for the prevention and management of chronic disease. The Physical Health Care of Mental Health Consumers initiative was established by NSW Health to ensure that consumers who use a mental health service also have access to the physical health care they require. The initiative is supported by the Physical Health Care Within Mental Health Services Policy that provides a clear direction regarding the responsibilities of mental health services around physical health care for consumers, and the Physical Health Care of Mental Health Consumers Guidelines which gives practical advice to providers about how these responsibilities could be met. Page 31 of 31