1. The Power of Primary Care
6 November, 2017
Stephen Mann, Director of System and Service Integration, NCPHN

2. North Coast Primary Health Network
Better health for North Coast communities
North Coast Primary Health Network (NCPHN) is one of 31 Primary Health Networks funded by the Australian Government since July 2015.
We work alongside communities and health professionals to ensure access to coordinated and high-quality healthcare.
Our vision is to achieve better health outcomes for North Coast communities through a person-centred health system.
A key PHN focus is working with our primary health partners to assist all people in our community maximise their quality of life and experience a more caring and well organised health system. This is especially critical for complex situations and for individuals more at risk of poor health outcomes and requires a neighbourhood of carers and professionals who communicate and work well together as one team in the one system
1. Australian Bureau of Statistics, Census of Population and Housing: Quick Stats, [Online] Available at [Accessed March 2016].

3. North Coast Primary Health Network
Integration:
Helping the health system to work ‘as one’
Commissioning new services:
Identifying and addressing health service gaps
Health reform:
Improving and designing new local solutions
Some key functions of the PHN
Help The Health System Work ‘As One’
We partner with the hospital system, plus health and social services, to improve patient andclinician experience through better coordination of care.
Identify And Address Health Service Gaps
We listen to our communities, health professionals and other service providers to make sure we are meeting the health needs of our region.
Improve And Design New Local Solutions
We work with local stakeholders to achieve targeted health reform across our region, including the development of new programs and initiatives.

4. Person – centred care
In a person-centred health system each North Coast resident will:
– have an ongoing relationship with a general practice or Aboriginal Medical Service that connects and coordinates their care from community, public and private services – otherwise known as a Patient Centred Medical Home.
– actively manage their own health and be able to make informed decisions about their healthcare needs.
– be able to get the type of healthcare they need, where and when they need it.

5. What will an integrated health system look like?
Patients and clinicians time is not wasted
Patients get the care they need because practitioners work together as a team
Patient information is shared and there is less duplication
Patients are actively involved in their own care
The importance of integration to the work of the PHN in plain language…
What is health system improvement?
Health system improvement involves working closely with general practices, allied health providers and hospitals so that all services work ‘as one’.
Strong partnerships have been established with Aboriginal Medical Services, Local Health Districts, Not for Profit Organisations and Government agencies to support this. Integration activities with hospitals include joint Board and Executive meetings, formal agreements and joint planning.
NCPHN is also working to build the capacity of general practices and allied health providers.
Initiatives include:
- Supporting general practices to transition into Patient Centred Medical Homes.
- Providing education and training to GPs, nurses and allied health professionals.
- Trialling innovative projects to test different models of care e.g. Chronic Pain Management.
- Sharing national and international experience locally.

6. Improving Cancer Screening Rates: The Power Of Primary Care
Suggested intro from Sara (would be delivered by Monika or Steve):
With the support of the Cancer Institute NSW, NCPHN has been delivering the Women's Cancer Screening Collaborative.  25 General Practices and 2 Aboriginal Medical Services have enrolled in this initiative across the footprint from Port Macquarie to Tweed. 
Cancer screening saves lives and improving cancer screening participation is a priority for both the Department of Health, the Cancer Institute NSW and NCPHN.  The Cancer Institute NSW Primary Care Strategy for the bowel, breast and cervical screening programs recognises the critical importance of General Practice and Aboriginal Medical Services in lifting screening rates. The Women's Cancer Screening Collaborative aim to support and drive primary care led improvements to cancer screening. 
The program held its first workshops in March this years, as the program moves towards completing its first year, there is clear evidence emerging that primary care service providers taking action does lift screening rates.  We are looking carefully at what we can learn form the collaborative about what needs to be done to make managing cancer screening time efficient for clinicians and patients, to ensure all patients get the care they need when they need it and to actively engage patients in the screening journey.  I'd now like to hand over to Sara Gloede, Program Manger Women's Cancer Screening Collaborative for a short presentation on this program.
Healthy North Coast Ltd (ABN: ), trading as North Coast Primary Health Network

7. Because, we know screening works:
Many of you sitting here today may have had the experience of having a to give a patient the life altering news that they have cancer.
This experience may be worsened when a patient has a cancer that could have been prevented or detected early through cancer screening.
Because, we know screening works:
Breast cancer is one of the most survivable cancers when detected early, with survival as high as 97 per cent, and cervical cancer is one of the most preventable
Having a Pap test every two years can reduce the risk of cervical cancer by up to 96%, the incidence of cervical cancer has halved since our national screening program began in 1991 and changes to the cervical screening program, which we will hear more about later, are expected to further reduce the incidence of cervical cancer by 30%.
1 in 8 NSW women will develop breast cancer in their lifetime, with 9 out of 10 of these women NOT having a family history. A woman whose cancer is detected by a breast screen is almost half as likely to need a mastectomy and survival at five years is much higher for women who are diagnosed early (Cancer Institute NSW website)
References
97% survival breast: Cancer Institute NSW. Community-centred initiative encouraging Aboriginal women to screen. Available at:
Incidence cervical reduce by half/further 30% reduction:
Pap Reduce risk 96%
Need for mastectomy: (Reporting for Better Cancer Outcomes Report 2016, Cancer Institute NSW)
5 year survival:
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8. Close to 20% of eligible women have never attended breast screening.
So, screening works, but yet 4 out of 10 North Coast women are overdue for breast and cervical cancer screening.
Close to 20% of eligible women have never attended breast screening.
For our Indigenous patients, screening participation is even more problematic: Over half of Indigenous women in the North Coast are overdue for a mammogram, and Indigenous women are four times more likely to die from cervical cancer than non-Indigenous women, this is thought to be due to later detection.
It’s clear, screening works but we need to do better at engaging women in breast and cervical cancer screening, and doing better will reduce breast and cervical cancer morbidity and mortality.
(Reporting for Better Cancer Outcomes Report 2016 – BreastScreen participation 56.7% for non-Indig, 46.3 % Indig, Cervical participation rate 59.7%)
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9. What we do know is that General practice and Aboriginal Medical Services are critical to improving participation in cancer screening.
The Cancer Institute NSW found that women are up to 60% more likely to participate in screening when reminded by their primary care provider, compared to women reminded by the screening registry only.
Cancer Institute NSW’s Primary Care Strategy highlights how important working in partnership with General Practice and Aboriginal Medical Services is, which is why they have offered competitive grants to Primary Health Networks to pilot primary care led approaches to improving participation in cancer screening and have been working hard to build primary care cancer screening networks and information sharing.
With the support of a Cancer Institute NSW grant, NCPHN has been working closely with 25 General Practices and Aboriginal Medical Services across our footprint, including in Port Macquarie, Coffs Harbour, Wauchope, South West Rocks, Kempsey, Macksville, Grafton, Lismore, Casino, Ballina, Mullumbimby and Tweed Heads.
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10. Let’s hear from some of the practices themselves:
These practices have been working hard, and we believe that there are some key lessons that can be distilled from the experience of our Women’s Cancer Screening Practices that have demonstrated success in lifting cancer screening rates.
Let’s hear from some of the practices themselves:
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12. Common themes in relation to this step were that:
You will find in your conference pack a short overview of ‘top tips’ for primary care providers interested in lifting cancer screening rates, but I want to cover what we see as the essentials.
The first critical step is about knowing how you are performing in relation to cancer screening and being able to easily identifying who is overdue for cancer screening in your practice so that you can be systematic in reminding and engaging these patients.
Common themes in relation to this step were that:
practices were setting recalls when they received a result, and a woman’s screening history could be checked when she was in front of a clinician, but it was often difficult for a practice to identify at-risk women – that is women who had never screened or who were overdue for screening
As is the most common theme when practices dive into their data – most practices realised once they had tidied up their screening data, they were not performing quite as well as they thought in relation to cancer screening or there were specific co-horts who were being overlooked, for example one practice realised they were not engaging women with disabilities in screening
Paper based breast screen results were often not systematically handled, and there was a lot of work to do to ‘clean up’ breast screening data
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13. As we heard earlier, primary care reminding patients about cancer screening matters.
Often the perception is that “oh well the registry reminds women, us doing it is duplication” – but as we will hear later in the day from Cancer Institute NSW, and from what we have learnt through the Women’s Cancer Screening Collaborative – this simply isn’t the case! Registries can have limited capacity to reach women who have not screened for a long time or who have never screened, and a letter from a registry is simply not as powerful and contact from a patients primary care provider.
Practices experience of systematising their recall and reminders was very positive.
There was the example of single doctor practice who phoned their under-screened patients and as a result two women were diagnosed with early stage breast cancer. These are women who would simply not have detected their cancer otherwise.
We have some great case studies available of practices who have introduced or updated their reminder systems, such as Start Street Medical in Macksville who have seen great benefits in terms of business efficiency and patient responsiveness from introducing SMS based reminders.
The reminder system that is right for your practice and your patient cohort will vary – some practices use letters, others have introduced SMS, others phone. What is important is developing a systematic and sustainable approach to recall and reminders.
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14. Cleaning up your data will paint a powerful picture for your practice about which women in your practice are at risk of under-screening.
Reminding women is a critical first step, and will tip a significant proportion of women into screening, but there will also be cohorts of patients whose reasons for not screening are more complex and who need additional education or support.
And there are simple steps that can be taken to improve patient centredness.
Firstly, we know 60% of adult Australians do not have the health literacy skills they need to effectively act on information and to navigate the health system. At-risk populations such as those people low-socio economic backgrounds, smokers, Indigenous women are also more likely to have low health literacy.
In addition, it is estimated that 40-60% of health information is forgotten immediately!
We have Taya Prescott here today, she is NCPHN’s resident health literacy guru and can provide great tips, support and resources for how your practice can ensure you are taking the necessary steps to removing health literacy as a barrier to screening and other health barriers, this can include ensuring all information has a grade 6-8 reading age and building the ‘teach-back’ skills of clinicians in your practice, which is a simple method of ensuring patient comprehension.
Secondly is building an understanding of which women can be most at risk of under-screening, and we will hear more about that in this afternoon’s session, including some local level focus group research that NCPHN has undertaken. Knowing which cohorts are women who are often at risk of under-screening, and some of the reasons why can help not only your practice but the whole screening community which includes support organisations such as the LHD and NCPHN, services such as BreastScreen NSW and organisations such as LGBQTI health organisation ACON, who are here with us today, to work together to respond appropriately to patient needs.
Patient centred responses don’t need to be complicated, we have had several practices including AB Surgery and Tintenbar Medical make the decision to open after hours women’s health clinics because they asked women what got in the way of cervical screening and found it was finding the time during the day in the midst of work and child care – these evening clinics have been very successful and we have some case studies available.
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15. taking the time for cancer screening quality improvement can seem difficult against the day to day in a busy practice, but as we have heard, there are simple steps that WILL improve your patients participation in cancer screening.
But, the lesson learnt from the many years of primary care collaboratives is that change takes time, it is important to provide staff with some protected time and to allow your practice to make change over time and for change to be sustainable it is also important to think about the role and function of your whole team – doctors, nurses, and practice administrators – in achieving change.
The key components of lifting participation in cancer screening - data management, reminder systems and engaging the patient – depend on your whole team – doctors, nurses, Aboriginal Health Workers and practice administrators.
Screening does save lives, which is why I believe you are all cancer screening super heroes in disguise, and NCPHN would like to do whatever we can to get your cape out!

16. taking the time for cancer screening quality improvement can seem difficult against the day to day in a busy practice, but as we have heard, there are simple steps that WILL improve your patients participation in cancer screening.
But, the lesson learnt from the many years of primary care collaboratives is that change takes time, it is important to provide staff with some protected time and to allow your practice to make change over time and for change to be sustainable it is also important to think about the role and function of your whole team – doctors, nurses, and practice administrators – in achieving change.
The key components of lifting participation in cancer screening - data management, reminder systems and engaging the patient – depend on your whole team – doctors, nurses, Aboriginal Health Workers and practice administrators.
Screening does save lives, which is why I believe you are all cancer screening super heroes in disguise, and NCPHN would like to do whatever we can to get your cape out!

17. What is important to know there is a lot of support available in our cancer screening neighbourhood, which includes NCPHN, BreastScreen NSW, the LHD and Cancer Institute NSW, for your Practice or Aboriginal Medical Service to work towards improved cancer screening rates.
For example:
BreastScreen NSW can provide lists of your patients who have had a pap smear or who have attended BreastScreen available to support your data clean up processes.
NCPHN has been working in partnership to undertake focus group with under-screened women to build local evidence, and will be working with practices on what that means in terms of action.
The introduction of electronic breast screen results is on the immediate horizon!
NCPHN has a range of tools and resources available to support undertaking the steps we have talked about today, and are working to refine and improve these tools based on what we have learnt during the collaborative.
NCPHN is working with other PHN, BreastScreen NSW and CancerInstitute NSW on how we can make systems and information flow better between patients, primary care providers and the rest of the screening ‘neighbourhood’ to ensure doing the right thing is the easy thing

18. As many of you may be aware, there is a pipeline of change coming that includes a move away from existing practice incentive payments to a consolidated quality improvement practice incentive payment.
NCPHN is here to support practice in our footprint to make the most of this change, and we see cancer screening based quality improvement as a really important component of the quality improvement a practice can take on.
It is our priority to take the lessons learnt from the Women’s Cancer Screening Collaborative to shape up a really excellent, easy to use set of tools and resources to support cancer screening related quality improvement, and we look forward to making these available.
If your practice is interested in working on improving your patients participation in cancer screening, you can check out the ‘top tips’ sheet in your conference pack, and you can also contact your Practice Support Officer to flag your interest, so that as we roll out updated support tools we can ensure your practice is in engaged.
We have such a great range of speakers here, with expertise across the cancer screening and care continuum, I am sure you will all have a great day.
Thankyou
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