Response to the Green Paper on Developing Northern Australia

Policy directions to capitalise on the Region’s strengths

The socio-economic conditions of Northern Australia and high proportion of vulnerable population sub-groups make the area especially amenable to the transmission of endemic communicable diseases. The international border with Papua New Guinea and close proximity of other nations such as Indonesia and East Timor increase the likelihood for incursion of exotic communicable diseases.

Diseases of poverty and tropical diseases relevant to Northern Australia include:

1. 
   Rheumatic Heart disease;
   
2. 
   Mosquito-borne disease / illnesses (Dengue and various genus of flavivirus);
   
3. 
   Tuberculosis; and
   
4. 
   Sexually transmitted diseases such as syphilis and HIV
   

A coordinated approach to detecting and responding to outbreaks of relevant tropical diseases is required across Northern Australia. The need for such a function is exemplified by the response mounted to the current outbreak of syphilis across Indigenous communities in Northern and Central Queensland and the Northern Territory. This outbreak started in the Mount Isa region in 2010 and attempts were made to manage it at a local level. The response had limited success in controlling the outbreak which has now spread to areas of the Northern Territory and Cape York, with two further outbreaks declared in 2014. It is of significant concern that there have been 18 cases of syphilis in pregnant Indigenous women in Northern Queensland since 2009 and approximately five cases of congenital syphilis in infants in the same time period including some deaths⁵.

Response to this syphilis outbreak has been hampered by the following cross-regional issues:

1. 
   Differing case definitions in different states;
   
2. 
   Lack of communication of risk across adjacent geographic areas;
   
3. 
   Differing levels of access to expertise in some areas;
   
4. 
   Lack of laboratory and pathology resources in some areas.
   
5. 
   Lack of co-ordination in response to the outbreak, leading to delays in notification and duplication of resources.
   

Northern Australia is vulnerable to several different types of natural and man-made disasters. The level of disaster preparedness, resilience and ability to respond to local and regional disasters would be significantly enhanced through the establishment of an institute specifically responsible for providing the health expertise necessary to prepare and respond to disasters. Establishing a Northern Australia Disaster Health Institute in Cairns would significantly enhance regional capability and reduce the impact of future disaster events.

Cairns is ideally placed for such an institute due to its geographical location, international airport and disaster experience. The region has arguably the most vulnerable population in the country and recently experienced Cyclones Larry (2006); Yasi (2011); and Ita (2014). Natural disasters are a feature of the climate and landscape and this threat will continue^6,7. Also, 88% of all deaths from natural disasters in Australia are related to cyclones, storms and flooding⁸.

The infrastructure, research capacity and mitigation strategies developed through a Northern Australia Disaster Health Institute would allow the risks to the region to be mitigated. The Institute could be formed in collaboration with the Cairns and Hinterland Hospital and Health Service and other key stakeholders such as the National Critical Care and Trauma Centre in Darwin and academic institutions. It would include disaster health professionals and academics, researchers and a purpose-built training facility for healthcare (including a field hospital). The purpose-built training facility may also be used in the event of a severe cyclone or natural disaster. The field hospital would be deployable across the region during times of need.

This initiative will significantly reduce replacement and redevelopment costs from a disaster. For every dollar invested in disaster preparedness there is an estimated seven dollar reduction in disaster-related economic losses¹⁵. This initiative will also provide a disaster health tourism opportunity for northern Australia.

Recommendation: Establish a Northern Australia Disaster Health Institute in Cairns.


Figure - Storm Surge Mapping at Cairns Hospital

Case-study – Cairns Hospital Campus Storm Tide Risk
Cairns Hospital is the only public hospital and emergency department in Cairns. It is situated 120 metres from the high water mark of Trinity Bay (the Coral Sea). The floor level of most buildings on the hospital campus is approximately 4.05 m Australian Height Datum (AHD).

Research suggests that “Analysis of the prehistoric record near Cairns, Queensland show that during the period 1800-1870, three cyclone events occurred producing storm tides between 2.52 m and 4.51 m AHD.” (Nott, J (2006). Extreme Events A Physical Reconstruction and Risk Assessment. Cambridge University Press ).

Several cyclones in the past 100 years have had the potential to produce a similar impact if they crossed the coast closer to and/or north of Cairns. These include the 1920 Port Douglas cyclone, Cyclone Winifred in 1986 and Cyclone Joy in 1990.

If the 4.51 m AHD event referred to by Nott (2006) were to be replicated today, the floor level of the hospital would be inundated by approximately 450 mm of salt water, with significant loss of assets.

Given past occurrences and the potential effects of climate change it would not be unrealistic to suggest that it is a matter of when, not if, such an event will reoccur.

The vulnerability of Cairns Hospital to storm tide inundation also raises concerns of substantial financial loss and the diminution of health services to the broader community via the loss of essential medical equipment. Hospital-style care would not be available for a significant period of time. For example, hospitals without mitigation strategies in New York were still recovering one year after Hurricane Sandy.

The Queensland Fire and Emergency Services operational mapping system provides indicative storm surge mapping. The graphics in Figure do not include the latest additions to the hospital buildings, but still effectively serve as an indication of the magnitude of the problem.



Figure - Magnitude of Storm Surge on the Cairns Hospital Campus
Population Health

The World Health Organisation has documented the clear link between health and economic development.⁹ A healthy community, in addition to reducing the requirements for medical treatment costs, is better able to make a productive contribution to the economy in which they live. Poor health outcomes hinder the individual’s capacity and motivation to participate in the economy of the local community.

Long-term health outcomes will play a significant role in the economic development of the North.

In general, the non-Indigenous population of northern Queensland experience health outcomes that are comparable with their southern counterparts. ^{10 11}

In northern Queensland, the median age of death for Aboriginal and Torres Strait Islander people has been reported as being more than 20 years earlier than non-Indigenous people.¹² As much of this burden of excess mortality has been due to chronic conditions, this suggests that the productive adult life of many citizens of northern Queensland is significantly reduced.

Poor health outcomes among Aboriginal and Torres Strait Islanders have been reported as being largely due to a range of factors that have been globally demonstrated to be associated with social and economic disadvantage, being ¹³:

• 
  High rates of tobacco smoking;
  
• 
  Excessive alcohol consumption;
  
• 
  High overweight/obese; and
  
• 
  Poor nutrition.
  

This, of course, does not mean that this group lives a healthy and balanced lifestyle. Anecdotal evidence is that alcohol and tobacco use amongst remote workers is higher than the national average, and tailored prevention and support programs are needed.

Policy directions to provide the best regulatory and economic environment for business

Lack of Aged Care Beds

Residential aged care facilities in Northern Australia are in critical shortage. Barriers to increasing the availability of facilities include:

1. 
   lack of investment from business for construction and ongoing operation of facilities;
   
2. 
   lack of an appropriately trained workforce to staff facilities; and
   
3. 
   lack of culturally appropriate facilities located close to where residents live.
   

It is recommended that residential aged care policies be developed to support measures to address these barriers by providing incentives to business to invest capital into the construction of facilities in Northern Australia and providing incentives via funding packages to ensure such facilities are financially sustainable.

It is also essential to implement workforce policies that ensure sufficient incentives and supports are included to attract appropriately qualified staff and consult appropriately with local communities to ensure that facilities meet the cultural, social and spiritual needs of the population.

Case Study – Bed Block at Cairns Hospital

On Friday 18 July 2014 the Cairns Post ran a front page story on the impact that a lack of available aged care beds in the region was having on Cairns Hospital. As at August 2014, there are approximately 70 long stay patients who would be more appropriately accommodated in aged care or disability care facilities, taking up beds across the Cairns and Hinterland Hospital and Health Service

Cairns Hospital has limited ability to draw on nearby hospitals as the next nearest major regional hospital is four hours drive away at Townsville.
Recommendation: Ensure appropriate numbers of aged care beds are funded and provided by operators across Northern Australia


Above and right: Newspaper clippings from The Cairns Post on 18 July 2014
Faster, more efficient registration for International Medical Graduates

The accreditation of overseas-trained medical specialists has been problematic for the Health Service and these issues are common to the health services across Northern Australia. This issue has been investigated at length and a report entitled “Lost in the Labyrinth: Report on the inquiry into registration processes and support for overseas trained doctors” was submitted to the House of Representatives Standing Committee on Health and Ageing in March 2012. This report suggests ways to remove impediments and promote pathways for Overseas Trained Doctors to achieve full Australian qualification, particularly in regional areas, without lowering the necessary standards required by Colleges and Regulatory Bodies.

Recommendation: Evaluate and implement the recommendations of the Report on the Inquiry into Registration Processes and Support for Overseas Trained Doctors submitted to parliament in March 2012.Diversification of Funding Models for Health Services

The Commonwealth can assist the health sector to better meet the needs of Northern Australia by enacting policies that diversify or otherwise enhance Health Service funding models. This includes:

• 
  Implementing an Activity Based Funding (ABF) model for the provision of primary healthcare.
  

Case Study: Cairns Hospital Emergency Presentations

A recent study conducted jointly by the Health Service, James Cook University and Far North Queensland Medicare Local has shown that 22% of patients who present to the Cairns Hospital Emergency Department could be appropriately treated by a General Practitioner.

Diverting these patients in an appropriate manner would significantly reduce the burden on regional hospital Emergency Departments and result in improved outcomes and satisfaction for patients.
Providing incentives for universities across Northern Australia to sustain and grow the local health workforce. This would ideally focus on the delivery of flexible training designed to extend the scope of practice for all elements of the workforce (medical, nursing, midwifery, allied health professionals and Indigenous health workers).

• 
  Expanding the Medicare Benefits Schedule (MBS) to include items delivered by care coordinators and relevant primary care team staff. This would enhance the flexibility of both private and public sector health workforces and enable increased use of telehealth services.
  
• 
  Considering incentive co-payments to health services who demonstrably reduce Emergency Department admissions.
  
• 
  Ensuring that a portion of all health and medical research grant money is directed towards investigating appropriate models of care and funding incentives for Northern Australia.
  

Recommendation: Diversify the funding models for provision of health services across Northern Australia.Enhancing control and surveillance programs targeting Tuberculosis in PNG

Tuberculosis (TB) is one of the world’s most prevalent infectious killers. High rates of TB, including strains of Multi-Drug Resistant TB (MDR-TB) and Extensively Drug-Resistant TB (XDR-TB) exist in nearby countries such as Papua New Guinea (PNG).

Although Australia’s rate of TB infection is low by international standards, quarantine challenges exist in Northern Australia because of cultural linkages between Indigenous population groups in Papua New Guinea and Torres Strait. Traditional people are permitted to conduct visit and trade in traditional goods between our nations in accordance with the Torres Strait Treaty. Therefore, the failure to control TB in PNG poses a public health threat to Australia, Transmission of MDR-TB has been recognised among PNG nationals accessing health care in the Torres Strait Islands. From 2004 to 2007, 24 cases of MDR-TB were diagnosed among these visitors¹⁴, imposing a substantial demand on health resources.

There is a need for significant investment in public health physicians and TB control officers to assist with the control and eradication of TB in PNG.

Recommendation:

1. 
   Investigate, resource and coordinate a TB control program in the western province of PNG;
   
2. 
   Fund healthcare costs incurred by PNG nationals within Australia’s primary and referral healthcare services; and
   
3. 
   Fund a public health physician and support team to provide ongoing detection, response and coordination of treatment across northern Australia.
   

Case Study: Media clip from The Courier-Mail 15 March 2015





Case Study: Media clip from The Courier-Mail 15 March 2015


Policy directions in critical infrastructure for long-term growth

Availability of broadband internet

• 
  
  Case Study: Chemotherapy in Atherton

  The drugs that combat cancers are, by their very nature, substances that are highly toxic to human tissue, as cancers are rapidly growing bundles of what would ordinarily be normal human cells. The ordering, preparation and administration of cytotoxic chemotherapy agents is a complex and dangerous process, and is performed up to three times per week per patient. Traditionally, this would have meant that people who live outside of a major regional setting who require chemotherapy would need to leave their homes, families and support structures during treatment courses. With the use of videoconferencing, patients on the Atherton Tablelands are able to receive services in Atherton. The process is as follows:

  
  
  • 
    The specialist oncologist meets via videoconference with the patient on the day of treatment and, based on the information gained in this process, approves the administration of treatment.
    
  • 
    The pharmacist in Atherton prepares the chemotherapy medication under videoconference supervision from the specialist oncology pharmacist in Cairns.
    
  • 
    The administration of the chemotherapy to the patient is undertaken under videoconference supervision from the Nurse Practitioner based in Cairns.
    
  By comparison to the balance of Australia, the region defined as Northern Australia is sparsely populated, with islands of population dispersed across vast distances. The critical mass of population required to support many services is not achieved within reach of most of the land mass of the region. In addition, due to the low population numbers in many parts of the region, commercial scheduled air services are either not available or prohibitively expensive.
  

In order to provide access to services across this environment it is essential that health and other service providers maximise their use of videoconferencing and other technologies that allow connection with clients without the need for one to travel (at very high cost) to the other.

While this is not appropriate for all patient episodes, many reviews and other occasions of service are principally matters of information exchange.

In many cases, the ranges of services that may be offered in remote locations is limited by the skills, experience and qualifications of the staffing models that are reasonable to station within that locality.

By allowing senior clinicians to undertake remote supervision of local staff, services can be permitted to operate outside what would be their normal scope of practice and undertake more complex procedures or treatments. A case study of this is presented.

In the future, electronic medical records that can be remotely viewed and advances in telemetry and tele-monitoring will allow even greater capacity for health services to access the expertise of larger centres while providing more services close to patients’ homes.

Underpinning all of these advances is increased capacity to transmit data. High speed data connectivity in remote and very remote locations to major centres is a critical enabler of future innovation.

Recommendation: Ensure that reliable broadband internet is available to all communities across Northern Australia.Health research, education and training networks

Appropriate Commonwealth policy directions and support of existing capacity in health, education and research sectors can position Northern Australia as a leader in health systems innovation and health workforce training in the Tropics. This would result in significant health, social and economic benefit to both Australia and its neighbours. Such policy support may include:

• 
  Development of a collaborative Northern Australian Tropical Academic Health Centre. Such an institution would build research capacity and better inform health decision making;
  
• 
  Extension of the Northern Clinical Training Network;
  
• 
  Resourcing of the Greater Northern Australia Regional Training Network (GNARTN) to provide coordination, co-investment and productivity in health professional training;
  
• 
  Ensuring that grants issued to educational institutions and specialist colleges are conditional upon the implementation of strategies to address inconsistencies in workforce distribution.
  

Recommendation: Enhance health research, education and training networks across Northern Australia

Commonwealth directed community assistance programs

Commonwealth capability enhancement programs should be focused to deliver significant enhancements to health, training and community wellbeing outcomes in Northern Australia.

One such program, the Army Aboriginal Community Assistance Program, has been delivered annually since 1997 resulting in tangible benefits to the communities in which it has been conducted. Army provides soldiers and equipment to deliver construction, health care and training opportunities to remote Indigenous communities.

AACAPs are directed and coordinated in consultation with the Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA), the Australian Army, and other Government agencies.

Recommendation: Enhance and focus community assistance programs, including the Army Aboriginal Community Assistance Program, in areas of Northern Australia.


Case Study: About the Army Aboriginal Community Assistance Program

Text obtained directly from Defence.gov.au

The Army Aboriginal Community Assistance Program (AACAP) is a co-operative initiative between the Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA) and Army to improve environmental health conditions within remote Aboriginal communities.

A steering committee with representation from all key organisations runs the program, identifying appropriate locations for project delivery.

Each project has a construction component, a health component and a training component. The construction component focuses on the provision of environmental health infrastructure such as housing, water, sewerage and electrical services as well as improving access to primary health care facilities by constructing or upgrading roads and airfields. The health component focuses on augmenting existing community medical, dental and veterinary programs. The training component focuses on specific skills required within the community and includes courses on construction and building maintenance, vehicle and small engine maintenance, welding, concreting and cooking.

Army is involved with AACAP at the direction of the Australian Government. Army involvement is based on its suitability to meet priorities and works proposals as determined by the steering committee. Army undertakes projects only after close, culturally sensitive consultation with the indigenous communities concerned. Works are not undertaken without the approval of the communities involved and the steering committee. Army coordinates support from across the ADF and participation from other nations.

The AACAP objectives are consistent with those of the National Aboriginal Health Strategy (NAHS) program.

The AACAP seeks to maximise benefit to Indigenous communities by focusing on projects that allow Army to make best use of its construction expertise and capability, by capitalising on Army’s ability to holistically deliver a range of services to remote Indigenous communities, that would not normally be available in a single project.

Conclusion

Northern Australia requires access to effective health services in order to develop sustainable and financially stable communities.

By implementing appropriate health policy at the national level and delivering appropriate health services now and into the future we can ensure that the residents of Northern Australia are able to fully participate in the workforce without a disparate burden of disease.

The final White Paper on Developing Northern Australia will be better able to achieve its objectives if it incorporates and prioritises the opportunities and initiatives discussed in this response.

1^ Queensland Health. Health Indicators 2009 – North Queensland. Tropical Population Health Service. Cairns 2009.

2^ QLD Department of Health 2012-13 Annual Report

3^ NT Department of Health Annual Report 2012-13

4^ WA Department of Health Annual Report 2012-13

5^ Data provided by Tropical Public Health Service (Cairns), Pers. Comm. 04 August 2014.

6^ McMichael, A. J., R. E. Woodruff, et al. (2006). Climate change and human health: present and future risks The Lancet
367(9513): 859-869.

7
^ COAG (2011). National Strategy for Disaster Resilience – Building the resilience of our nation to disasters. Barton, ACT,
Commonwealth of Australia.

8

^ Blong, R. (2005). Natural hazards risk assessment: An Australian perspective. Issues in risk science series, Benfield
Hazard Research Centre, London.

9

 World Health Organisation. Macroeconomics and Health. http://www.who.int/macrohealth/en/. Accessed 15/07/2014

10

 Queensland Health. Health Indicators 2009 – North Queensland. Tropical Population Health Service. Cairns 2009.

11

 Australian Institute of Health and Welfare. Rural, regional and remote health. A study on mortality (2^nd ed). 2007. http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442459836

12

 Queensland Health. Health Indicators 2009 – North Queensland. Tropical Population Health Service. Cairns 2009.

13

 Australian Institute of Health and Welfare. Life expectancy and mortality of Aboriginal and Torres Strait Islander people. 2011. http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737418955

14

 Lumb R, Bastian I, Carter R, Jelfs P, Keehner T, Sievers A. Tuberculosis in Australia: Bacteriologically confirmed cases and drug resistance, 2007. Commun Dis Intell. 2009;33(3)298–303.

Directory: sites -> prod.office-northern-australia.gov.au -> files -> files
sites -> 587 Return function, r i(X) r i(0) r i(1) r i(2) r i(3) 1 0 2 4 6 Thermal Station, I 2 0 1 5 6 3 0 3 5 6 10
sites -> Glossary for Chapter 1 Algorithm
sites -> North Carolina Inclusion Initiative Mapping Where Children with ieps are Being Served Purpose
sites -> Northern England’s set-jetting locations
sites -> Physical custody of 1033 program property accountibility form statement of Physical Custody: By signing for the below 1033 property I am a Law Enforcement Officer of the aforementioned Law Enforcement Agency
sites -> Nstructions for Acquiring Excess Equipment online, through the 1033 Program
sites -> Memorandum of agreement
files -> Green Paper on Developing Northern Australia

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