Annual Report 2010

Northern Territory 
Chronic Conditions 
Prevention and Management 
     Strategy
  2010-2020

Acknowledgement

The Chronic Conditions Strategy Unit is grateful to the many people who have assisted in the production of this report including colleagues from within the Department of Health, other Government Departments, non-Government and Aboriginal community-controlled health services; without your support the task of writing, compiling and extrapolating data would be extremely challenging.  

Suggested citation:

NT Department of Health.  Annual Report 2010.  The Northern Territory Chronic Conditions Prevention and Management Strategy 2010-2020.  Darwin, 2011

ISBN: 

An electronic version is available at:
xxxx

General enquiries about this publication should be directed to:
Program Leader, Chronic Conditions Strategy Unit
Health Development Branch
Department of Health
PO Box 40596, Casuarina, NT 0811

Phone:  (08) 8985 8171
Fax:  	(08) 8985 8177
email:  	christine.connors@nt.gov.au

Contents
Acknowledgement
Executive Summary
Introduction
Section A: A Profile of Chronic Conditions in the NT
Health Status and Outcomes
Prevalence and incidence of in-scope chronic conditions
Life Expectancy
Mortality
Determinants of Health
Smoking
Physical Activity
Body Mass Index
Average cost of food basket
Education
Employment
Income
Housing
Section B: Chronic Disease Activities across the NT
Overall implementation of CCPMS
Progress against Key Action Areas
Key Action Area 1: Increase the focus on the Social Determinants of Health
Key Action Area 2: Increase the focus on primary prevention to prevent and reduce risk factors
Key Action Area 5: Care for people with chronic conditions
Key Action Area 6: Workforce planning and development
Key Action Area 7: Information, communication and disease management systems
Key Action Area 8: Continuous Quality Improvement

Abbreviations……………………………………………………………………………………………………………………………………….. 98

Appendix

Appendix 1 - Table of data sources used for the profile of chronic disease in the NT……………………………………………………………………………… 99
Appendix 2 - Kessler 10 (K10) … ……………………………………………………………. …………………………………………………………………………. 101 
Appendix 3 - Partnership between the health sector and other government departments………………………………………………………………………… 102
Appendix 4 - Supplementary Data and Tables ………………………………………………………………………………………………………………………… 106
i)	Number and proportion of Aboriginal staff employed within the Department of Health……………………………………………….. 106
ii)	NT Aboriginal babies with low birth weight 2006 – 2010………………………………………………………………………...............  107
iii)	Chronic Disease Management……………………………………………………………………………………………………...............  108
iv)	Medical Specialist Outreach Assistance Program (MSOAP)……………………………………………………………………………... 110
v)	Access to General Practice and Primary Health Care Professionals ……………………………………………………………………..111
vi)	Electronic Care Planning and Recall System………………………………………………………………………………………………. 112
Appendix 5: - Number of community education/health promotion/social marketing activities to promote quitting 
                       and smoke free environments …………………………………………………………………………………………………………………….........  113

LIST OF FIGURES

Figure 1   - Prevalence of CVD, Aboriginal, non-Aboriginal   ……………..………………………………………………………………………………	……. 22
Figure 2   - Prevalence of hypertension, Aboriginal and non-Aboriginal……………………………………………………………….………………...	……. 22
Figure 3   - Incidence of acute myocardial infarction in population aged 40 years and over in the NT 
                   (1992-2004), and in Australia (1993-1999) ………….……………..…………………………………………………………………………	……..	24
Figure 4   - Prevalence of diabetes, Aboriginal, non-Aboriginal and Australia ……………………………………………………….…………………	……..	25
Figure 5   - Prevalence of COPD, Aboriginal, non-Aboriginal and Australia…………………………………………………………..…………………	……..	26
Figure 6   - Prevalence of asthma, Aboriginal, non-Aboriginal and Australia ……………….………………………………………..…………………	……..	26
Figure 7   - Prevalence of ESKD NT and Australia 2000-2010 (ADD 2010 DATA) …………………………………………............………………………..	28
Figure 8   - Number of new dialysis patient in the NT, 1986 – 2010 …………………………………………………………………..…………………	……..	29
Figure 9   - Incidence of ESKD patients on dialysis or transplant NT 2000-2010 ………………………………………………………………………	……..	29
Figure 10 - Prevalence of Rheumatic Heart Disease in the NT……..………………………………………………………………….…………………	……..	30
Figure 11 - Age-standardised incidence for all cancers, by sex and Indigenous status, NT and Australia Data 
                   are for 1991-2005 for NT; 1991-2001 for Australian ………………………………………………………………….......…………………	……..	32
Figure 12 - Trend in age-standardised incidence rates per 100,000 for all cancer, by sex and Aboriginal 
                   status, in NT and Australia ……………………………………………………………………………………………........…………………..	……..	33
Figure 13 - Life expectancy at birth, NT and Australia, 1967-2006 ………………………………………………………………………………………	……..	34
Figure 14 - Leading causes of death, Aboriginal and non-Aboriginal populations, NT 1985-2006 ………………………………..………………………...	35
Figure 15 - Age adjusted mortality rates for selected chronic disease by sex, Aboriginal status,
                   NT and Australia, 1997-2004 ………………………………………………………………………………………………..………………………...	36
Figure 16 - Trend in age-standardised mortality rates per 100,000 for all cancers, by sex and Indigenous 
                   status, NT and Australia ……………………………………………………………………………………………………..………………………...	38
Figure 17 - Trends in smoking prevalence in the NT non- Aboriginal population, by sex ………………………………………….…………………………	39
Figure 18 - Trends in smoking prevalence in the NT Aboriginal population, by sex ………………………………………………..…………………………	39
Figure 19 - Per Capita pure Alcohol Consumption (PCAC) in the NT and Australia…………………………………………………………………………..	41
Figure 20 - Cost of basket of foods in remote stores compared with Darwin Supermarket 1998-2008 …………………………..…………………. …….	45
Figure 21 - Average number of varieties of fresh fruit and vegetables in remote stores 1998-2008 ………………………………………………………..	45
Figure 22 - Mean gross weekly equivalised household income, by Indigenous status and state/territory,
                   persons aged 18 years and over, 2006 …………………………………………………………………………………….………………………...	47
Figure 23 - Proportion of persons aged 18 years and over living in overcrowded households, by Indigenous 
                   status and state/territory, 2006 ………………………………………………………………………………………………………………………..	48
Figure 24 - Classification levels of Aboriginal staff in the Department of Health (DoH) and the 
                   Department of Children and Families (DCF) in 2010 …………………………………………………………………….………………….	……..	106
Figure 25 - Trend in the proportion of liveborn low birth weight babies by Indigenous status ……………………………………..…………………...........107
Figure 26 - Number and Proportion of clients with Type 2 Diabetes who have a chronic disease 
                   management plan in 2010………………………………………………………………………………………………………………………	……..	108
Figure 27 - Proportion of clients with Type 2 Diabetes who have had an HbA1c test in the last 6 months in 2010……………..…………………………	109
Figure 28 - Proportion of clients with Diabetec clients with proteinuria treated with ACEi and/or ARB…………………………..………………… ………	109

LIST OF TABLES

Table 1   - Prevalence of kidney disease in remote Indigenous population in the NT in 2005 ………………………………………………………. 	……..	27 
Table 2   - NT data on the number of RHD and Acute Rheumatic Fever (ARF) ………………………………………………………………………. ……..	30
Table 3   - Annual changes in NT Aboriginal and Australian mortality rates and confidence intervals for 
                  selected chronic diseases, by sex, 1997-2004 …………………………………………………………………………….…………………………	37
Table 4   - Age-adjusted smoking prevalence by sex and Indigenous status, NT and Australia in 2007/08 ………………………..……………………...	39
Table 5   - Crude smoking prevalence of pregnant women in the NT, 1996 to 2005 ………………………………………………..………………………..	40
Table 6   - Alcohol Prevalence and consumption behaviour, by Indigenous status and Australia …………………………………………………………..	41
Table 7   - Proportion of pregnant women reporting alcohol consumption at first antenatal visit, 
                  Northern Territory (2003-2006) ………………………………………………………………………………………….…………………. …...........	42
Table 8   - The intake of Fruits and Vegetables in NT Aboriginal, NT non-Aboriginal and Australia ……………………………..…………………………	43
Table 9   - Physical Activity Levels in NT Aboriginal, NT non-Aboriginal and Australia ……………………………………………………………. ………..	43
Table 10 - Prevalence of overweight and obesity in NT Aboriginal, NT non-Aboriginal and Australia ………………………………………………..........	44 
Table 11 - Proportion of youths with year 12 attainment, by Indigenous status, sex and state/territory, 2007 …………………….………………………	46
Table 12 - Kessler 10 Level of psychological distress ……………………………………………………………………………….…………………. ……….	101
Table 13 - Trend in public hospital liveborn low birth weight (LBW) babies, by financial year and Aboriginal status ……………………………………..	107
Table 14 - Number of clinic sessions of specialist outreach program for people with chronic conditions in 2010 …………………………………………	110
Table 15 – Ratio of Medicare claims by Allied Health Professionals to General Practice services, and
 	     breakdown by service items ……………………………………………………………………………………………………………………………	111
Table 16 - The number and proportion of general practices within the Division using practice register/ recall/ reminder systems
     to identify patients with a chronic disease for review and appropriate action 2009/10…………………………………………………………..	112

 Executive Summary

In 2009, the Northern Territory Department of Health (then the NT Department of Health and Families) together with partners from non-Government and Aboriginal community-controlled health services developed a 10 year strategy – the Northern Territory Chronic Conditions Prevention and Management Strategy 2010-2020 (the CCMPS).  The Strategy or the CCPMS was launched in November 2009 and the CCPMS Implementation Plan 2010-2012 in May 2010.

The CCPMS was developed to encourage a consistent approach across all NT health services to reducing the incidence and impact of chronic conditions, in both planning and implementation of services.  The CCPMS Implementation Plan was developed to support services to strategically plan evidence-based activities and integrate these activities into the business plan of the organizations.

This first Annual Report 2010 provides readers with a snap shot of the Northern Territory profile of chronic conditions and the progress against each of the eight key action areas outlined in the CCPMS Implementation Plan.   In section A of this Report, various data sources have been utilized to describe the prevalence and incidence of chronic conditions. This has included self reported data from surveys as well as available epidemiological data from clinical systems and research. In section B of this Report, qualitative and quantitative data have been utilized to report against each of the eight key action areas.

Summary of Chronic Conditions Profile

•	In the NT, the life expectancy for Aboriginal and non-Aboriginal population has improved significantly over the past forty years. The gap between Aboriginal and non-Aboriginal women is closing due to rapid improvements in life expectancy observed in Aboriginal females. However, the gap has widened for Aboriginal men in comparison to non-Aboriginal men due to limited improvement in life expectancy.  During 1967-2006 there was an improvement in life expectancy of 16 years in Aboriginal females and 8 years in Aboriginal males compared to 16.5 years in non-Aboriginal females and 12.4 years in non-Aboriginal males. 

•	During 1991-2005, there has been a 25% reduction in cancer mortality rates for Aboriginal women (mainly cervical cancer) and an increase by 25% in cancer mortality rates for Aboriginal men.

•	The leading causes of death from 1985 to 2006 for all population groups were due to chronic conditions from cardiovascular disease, cancer and respiratory disease.  The Aboriginal population has much higher mortality rates than the non-Aboriginal population.

•	There is an observed decline in death rates from stroke (by 11.7% for males and 7.1% for females) and COPD (by 1% for males and 6.1% for females) in NT Aboriginal people, but increased deaths from ischemic heart disease (IHD) for both Aboriginal males (by1.3%) and females (2.9%), and renal failure for Aboriginal females (by 4.4%).  Amongst the NT non-Aboriginal population, there is an observed decline in death rates for all of these five diseases. 

•	Disease prevalence and incidence:
o	Cardiovascular disease: Between 1992 and 2004, the incidence of Acute Myocardial Infarction has declined by 23% for NT non-Aboriginal population, however for Aboriginal population it has increased by 60%. 
o	Diabetes: Prevalence is high for the Aboriginal population (7.9% in Aboriginal compared to 4.4% in NT non-Aboriginal).  Higher rates are seen in Central Australia (13.4%) than the Top End (6.3%), and in Aboriginal females (11.5%) than males (7.5%). This is consistent with the higher rates of obesity observed in Central Australia. 
o	Chronic Kidney Disease: In 2005, prevalence is much higher in Central Australia (25.2%) than the Top End (15.8%) and in Aboriginal females (23.1%) than males (17%). This is consistent with the higher prevalence of diabetes and hypertension in Central Australia region and amongst the female population. These two conditions were the leading causes of End Stage Kidney Disease in the NT in 2010. The number of new dialysis patients has increased from 57 clients in 1997 to 89 clients in 2008; figures in 2009 (72 clients) and 2010 (57 clients) have shown decreasing numbers.
o	Chronic Airway Disease: In 2008, the prevalence of Chronic Obstructive Pulmonary Disease (COPD) is higher in the Top End (8.1%) than Central Australia (5.4%), consistent with higher prevalence of smoking in the Top End, with highest rates in Arnhem Land
o	Chronic Mental Illness: Population data are available from self reported surveys. In 2008, 28% of NT Aboriginal people reported having high to very high levels of psychological distress. For NT non-Aboriginal people, the detailed CATI survey in 2000 showed 22% of people reported anxiety and depression.
o	Cancer: Overall during 1991-2005, NT population has a lower aged standardised cancer incidence rate (426 per 100,000 population) than the Australian population (456 per 100,000 population). Tobacco-related cancers were among the top most common cancers for all NT Aboriginal and non-Aboriginal people.

•	Chronic condition risk factors:
o	Compared to the total Australian population, the NT has a higher prevalence of tobacco smoking (33.4% NT, 21% Australia).  In Aboriginal males, the trend from 1994-2008 appeared stable (approximately 60%) and increasing for Aboriginal females (from 35.5% in 1994 to 48.6% in 2008).  During 1998-2007, in non-Aboriginal population, the trend appeared declining for both males and females from 32.8% to 31.1% in males (1998) and from 39.3%% to 24.1% in females (2007).
o	Consumption of alcohol in the NT is higher than the national average.  The NT non-Aboriginal population is more likely to consume alcohol than Aboriginal population (88.7% compared to 49.2%); however, among Aboriginal population who consume alcohol, 30.1% reported drinking alcohol at risky levels (compared to 17.2% of non-Aboriginal). Alcohol consumption and consequent alcohol-attributable deaths and hospitalisation for both Aboriginal and non-Aboriginal population in the NT have occurred at levels far higher than elsewhere in Australia. 
o	Various surveys on nutrition and physical activity utilised different indicators, which makes comparison across surveys difficult.  Overall, for all population groups, the prevalence of consuming adequate fruits and vegetables and having adequate physical activity is low.  Almost 50% of all NT adults are found to be overweight or obese. 
o	The socio-economic findings affirm the degree of social disadvantage observed in the NT Aboriginal population.

Progress against the CCPMS Implementation Plan

Key Action Area 1 – Increase the focus on the Social Determinants of Health
•	Raising awareness of the Social Determinants of Health (SDoH) – There are various activities by health sector to raise awareness of SDoH for health professionals but there is a current lack of a strategic and systematic approach to raising awareness of SDoH. The incorporation of SDoH teachings into tertiary education in the NT is essential to develop the future health workforce who will understand the impact of SDoH and who are expected to act on the wider determinants of health.  Better coordination of efforts are needed across sectors to address this gap. 
•	Inter-sectoral collaboration – There are a number of existing partnerships between Department of Health (DoH) and other government departments on a wide range of projects related to addressing social determinants of health.  Some of these partnerships are stronger than the others in terms of real collaborations resulting in tangible outcomes.  These types of partnerships can and should be utilised to progress the health sector’s agenda on social determinants of health.  For example an inter-Government partnership involving DET, DoH, DCF, NTPFES, DHLGRS, DCM was formed to guide the development and implementation of an NT wide Early Childhood Development Plan that will seek to improve early childhood development outcomes by identifying priority strategies for more coordinated cross-agency activities, and by delivering high quality services and programs for young children and their families.
•	Increasing health care access through improving health literacy – The 2010 Chronic Disease Network (CDN) Conference provided the forum for sharing of information, experience and lessons between health workers.  The majority of activities undertaken to improve health literacy driven from operational levels and have taken on a reactive rather than strategic approach.  Planning for health literacy activities at the systems level will yield significant benefits as this will include the development of benchmark measures.
•	Aboriginal employment – The proportion of Aboriginal employment in DoH (6%) does not reflect the demographic profile of Aboriginal people in the NT (approx. 30%).  The majority of Aboriginal people are employed in lower job classifications with very small numbers in executive or professional levels.  Whilst there are efforts to increase Aboriginal workforce, the development and implementation of better strategies to improve the recruitment and retention of Aboriginal staff are imperative.

Key action area 2 - Increase the focus on primary prevention to prevent and reduce risk factors
•	There were a number of tobacco control activities happening across the NT.  Some of the key highlights were: (a) regulatory changes related to smoke free areas, an effective population-based approach to reduce smoking rates and safeguard against environmental tobacco smoke, (b) implementation of Smoke Free Policy in DoH, (c) increased taxation on the price of cigarettes (Federal’s initiative) (d)  mandatory reporting of tobacco wholesales data that will enable the monitoring of tobacco consumption in the NT and provide timely data for policy planning, (e) development of a tobacco control framework, and (f) expansion of the tobacco workforce, especially in remote communities, and (g) increased research effort.  The area that requires further effort is good coordination of tobacco control programs, especially at community levels to prevent duplication of efforts and promote sharing of ideas and resources.
•	There are a number of activities to tackle high obesity rates including key initiatives to improve the availability and affordability of food in remote settings and the implementation of healthy school canteen policies, for example ongoing partnership with outback stores to facilitate the supply and demand for healthy food choices in remote communities.  The majority of physical activity and nutrition programs are limited to urban areas.
•	The use of Health Impact Assessments (HIA) is very limited in the NT with a lack of initiatives/partnerships that support the creation of healthy environments, especially in remote settings. There are however, opportunities through the Territory Growth Towns to initiate partnerships with other government departments.

There are a number of well-established programs in place for the early years and good partnerships established to improve the delivery and integration of early childhood services.  In 2010, the prevalence of Aboriginal low birth weight babies is 14.4% (compared to non-Aboriginal 7.7%), highlighting that further work needs to be done during antenatal care to reduce the prevalence of smoking during pregnancy.

Key action area 3 – Early detection and secondary prevention
•	The new edition of CARPA was released in 2010 and contained changes to several sections in chronic conditions, including a section on cardiovascular risk assessment. The cardiovascular risk assessment (CVR) tool was incorporated into electronic primary care systems.
•	The rates for health checks (adults and children) are low at national and state/territory levels.  In 2009-10, only 12% of eligible Australian Aboriginal population received a check.  National data also showed that 80% of health checks showed health problems that needed follow-up service; however the delivery of such follow-up service has legged.  In 2009-10, an average of 8.4% of eligible Australian Aboriginal children received a check; the NT had the highest proportion (12.4%) of its eligible NT Aboriginal children (<15 years) received a health check.  Within non-Aboriginal population, in 2010 a total of 197 people received a health check; this is a decline from 2009 figure of 594.  
•	GPNNT have continued measures to improve the uptake of this item number, such as promoting at conferences, forums and in face-to-face visits, supporting practices to identify clients for health assessments through motivational interviewing workshops and installation of the Pen Cat data collection tools and ongoing promotion of lifescripts to support the Item number.
•	There are various strategies in place in both primary and tertiary settings to improve the assessment and recording of risk factors but this is an area that still needs ongoing improvements.
•	Greater utilization of the PHC clinical data available on electronic systems would enable the provision of timely data to inform clinical practice and policy planning.

Key action area 4 – Self Management
•	A NT Chronic Conditions Self Management Framework is currently being developed.  The Framework will identify key principles which are fundamental for the implementation of self management.  The Framework will guide and inform: (a) service providers across a range of health settings about how a self-management approach can be promoted and integrated into current practice, (b) health staff to deliver evidence based self management initiatives including to ensure clients are prepared and empowered to manage their chronic conditions, and (c) policy makers on how to better structure the health services in order to support health staff to provide self-management initiatives to clients, and to create an appropriate environment conducive to clients participating in self management.
•	There are a number of self management programs in the NT, the majority of which are disease specific and are mostly held in urban areas. Further work needs to be done to expand programs to remote areas and program evaluation needs to be included as part of the whole program.
•	There were a number of training opportunities about self management for health professionals organised by various health services.

Key action area 5 - Care for people with chronic conditions
•	Evidence based clinical care: During 2008-2010, there has been a steady increase in the proportion of management plans prepared by GPs for clients with Type 2 Diabetes. In 2008, approximately 39% of clients have management plans prepared by their GPs.  In 2009 and 2010, this figure has increased to 74% and 81% respectively. Similarly, for the same period, there has been a steady increase in the proportion of clients with Type 2 Diabetes who have had an HbA1c test in the last 6 months.  In 2008, 54.4% of clients had an HbA1c check in the last 6 months. This figure increased to 76.5% in 2009 and 76.7% in 2010.
•	Specialist outreach services have been extended to include more medical specialties and allied health through Medical Specialist Outreach Assistance Program-Indigenous Chronic Disease and increase coverage of geographical areas. NT Renal Services have established regular telephone case conferencing with remote PHC centres for over 2 years; other chronic conditions are interested to explore this type of service. 
•	There are several care coordination models of service in place for renal, cardiac and respiratory disease. Renal care coordination is the most established of the three and provides a good model of care for other conditions to replicate.  There are also initiatives in place to improve care coordination at the PHC / Community Health level.  
•	One of the identified gaps is linking mental health services with other services and introducing screening for co-morbidities of chronic mental and physical illness.
•	There are limited cardiac, pulmonary and other rehabilitation services in the NT, in particular for clients in remote areas.  Further work needs to be done to increase these services.
•	In the area of palliative care, 25% of referrals to palliative care were due to chronic conditions.  Of this, over half were referrals from end stage CKD patients, where a model of referral pathways has been developed.  Work needs to be progressed to translate this model for other conditions.

Key action area 6 – Workforce planning and development
•	The collaborative work between DoH and CDU has resulted in the establishment of the new Bachelor of Health Sciences degree through CDU.
•	Flinders University and CDU have established a fulltime medical school with an emphasis on training Aboriginal doctors.
•	There are a range of educational programs organised by key education/research organisations, DoH and NGOs in the form of professional development courses, lectures/seminars, symposium or group sessions.  A number of accredited chronic conditions professional development courses can be utilised towards gaining Continuing Professional Development points.  However, coordinated approaches to the planning and delivery of education sessions in the NT are required to maximise the use of the limited current resources.

Key action area 7 – Information, communication and disease management systems
•	With the exception of four DoH remote health clinics that are still paper-based, all of the other Aboriginal PHC centres in the NT have electronic patient information and recall systems, and plans are underway to connect the four paper-based centres. This helps facilitate chronic disease management activities by having a uniform, effective and efficient system that will support the work of PHC and other multidisciplinary teams. 
•	There are existing collaborations in place between the information communication technology teams on a variety of projects relating to chronic conditions care. These collaborations should be strengthened and progressed further to enhance the system and incorporate the needs of chronic conditions prevention and management into systems. 
•	The development of a system to generate routine electronic reports relating to chronic conditions care in PHC should be made a priority. The development of these could be undertaken in a coordinated and structured approach to include both government and the Aboriginal community-controlled health services.  This will enable a NT-wide reporting system similar to the approach that is being implemented for the NT AHKPI data system. 
•	The continuing expansion of the e-health initiative to enable the sharing of electronic health records and other added features further support the integration and coordination of care for patients. 
•	The activities of the Chronic Disease Network (CDN) continued to facilitate networking and information sharing between a wide range of stakeholders working across the health sectors in the NT. The main activities of CDN include the annual CDN conference, quarterly newsletters, fortnightly e-CDN news and the sharing of information through CDN website.

Key action area 8 – Continuous quality improvement
Remote:
•	There is a wide range of CQI activity / programs being implemented across the NT. This included the Quality Assurance for Aboriginal and Torres Strait Islander Medical Services (QAAMS) monitoring quality of Point of Care testing, Audit and Best Practice in Chronic Disease (ABCD - now One21Seventy, the National Centre for Quality Improvement in Indigenous Health) an action research project led by Menzies School of Health Research, Healthy for Life,  Australian Primary Care Collaboratives (APCC) and GP accreditation through Australian General Practice Accreditation Limited (AGPAL). 
•	A wide range of CQI tools and techniques were used. The common tools that were used were ABCD audits, ABCD Systems Assessment Tools, file auditing, clinical case reviews and action planning, followed by client feedback, charts and process mapping.
•	Ongoing development of the NT AHKPI collection covering the Government and Non-Government sectors to improve the quality and robustness of data collection in PHC service planning and management through CQI.
•	The Audit and Best Practice in Chronic Disease action research, has been a collaboration between MSHR, NT Department of Health and more recently AMSANT. The project has extended its national reach in 2010 with the successful awarding of an NHMRC partnership grant, collaboration between Health Departments, research institutes and community controlled peak bodies in NT, Queensland, SA and WA.
•	Point of care testing and electrocardiograms (ECGs) with electronic transmission to specialist centres enable primary health care staff to initiate best practice treatment for heart attacks in remote settings which reduces heart damage and risk of heart failure.

Urban:	

Oral Health – The Oral Health Service NT (OHS-NT) of the Department of Health is focused on organisational wide quality improvement. As part of the ongoing accreditation process, in 2010, the OHS-NT undertook a number of activities in order to prepare themselves for a full accreditation in 2011. Activities in 2010 included: 
•	Providing training for staff on the use of Quality Improvement Program Planning System (QIPPS), and 
•	Developing a comprehensive work instruction for staff (including clinical guidelines) to ensure the provision of timely dental care for Rheumatic Heart Disease clients in particular all priority one (most severe) clients.

Community Health – The accreditation of the Department of Health Community Health Branch including: its six clinics in cities and towns across the Northern Territory, the home visiting services in those towns and cities, the school health services, immunisation services, and, the family and child health services, is undertaken by the Institute for Healthy Communities Australia Ltd using the Quality Improvement Council (QIC) standards and review process (corporate and clinical reviews).  

The QIC review cycle emphasises population (community) and individual client outcomes and is a cycle of continuous quality improvement utilising an organisational development model of quality management.  It has a strong consumer focus that encourages adoption of primary health philosophy and therefore it enhances the capacity of individuals and communities to take control of their own healthcare.  

In 2010, QIC released its 6th Edition Standards and replace the 5th Edition, published in 2004, upgrading their requirements for governance, safety and quality integration, assessment & planning, and consumer rights.

In 2009-2010, the Community Health Branch, as part of its continuous quality improvement cycle, underwent an annual Staff, Clients and Stakeholders Satisfaction Survey. A review of its policies and procedure documents were also undertaken.  Recommendations out of these activities were included in the Community Health six monthly quality work plan to improve and strengthen service delivery.  The Branch was accredited in December 2009 by the Quality Improvement Council for a period of 3 years.

Hospital – Five of the NT public hospitals have current accreditation.  In 2009-2010, the Royal Darwin, Alice Springs, Gove District and Tennant Creek Hospitals underwent accreditation surveys and have been granted full accreditation by the Australian Council and Healthcare Standards (ACHS) through their Evaluation and Quality Improvement Program (EQuIP).

Hospital accreditation addresses clinical, support and corporate functions through assessment against with the following standards:,

•	Clinical function: Continuity of care, Access, Appropriateness, Effectiveness, Safety, Consumer focus.
•	Support function:  Quality improvement and risk management, Human resources management, Information management, Population health, Research.
•	Corporate function:  Leadership and management, Safe practice and environment.
Introduction

Overview of the Northern Territory Chronic Conditions Prevention and Management Strategy 2010- 2020

The Northern Territory Chronic Conditions Prevention and Management Strategy 2010-2020 (CCPMS) is a ten year strategy that provides a framework and key evidence-based strategies for building and strengthening system-wide approach to prevention and management of chronic conditions in the NT.  A three year implementation plan was developed to guide the implementation of the strategy.  An evaluation process has been included within the plan.

The CCPMS was developed in 2009 through a collaborative effort of the NT Department of Health (previously known as the Department of Health and Families), non-government agencies and Aboriginal Health sectors as well as through consultation with a wide range of other stakeholders. It builds on previous achievements and aims to guide the development of a consistent and integrated approach to chronic disease across all sectors, including government departments, public and private health service providers, non-government/community organisations and education and research organisations.  

The key players involved in the implementation of the CCPMS are:
•	Communities, Schools, Workplaces
•	Non-government Services
•	Primary Health Care Services (DoH and Aboriginal community-controlled health centres)
•	Hospitals and Other Acute Care Services
•	Researchers and Educators
•	Other non-health Government Department

The CCPMS focuses on seven chronic conditions:
•	Cardiovascular disease
•	Rheumatic heart disease
•	Type 2 diabetes
•	Chronic airways disease
•	Chronic kidney disease
•	Chronic mental illness
•	Cancers that are associated with shared risk factors for other chronic conditions;
The eight key action areas are:
•	Social Determinants of Health
•	Primary Prevention
•	Early Detection and Secondary Prevention
•	Self Management
•	Care for People with Chronic Conditions
•	Workforce Planning and Development
•	Information, Communication and Disease Management Systems
•	Continuous Quality Improvements

What is this Annual Report

This is the first annual report of the CCPMS Implementation Plan to assess how we are going against implementing the activities stated in the plan and to identify key gaps in implementation as well as to identify areas for improvements.  This Progress Report aims to provide a snap shot on NT activities on chronic conditions.

Methodology

A variety of methods were used to collate data from a wide range of sources and stakeholders who play key roles in implementing the strategy:
•	Desktop review of a range of documents including reports, activity logs, surveys, epidemiological studies.
•	Collation of existing quantitative indicators.
•	Consultation with key stakeholders 

Limitations of report

•	It is not possible to obtain a comprehensive picture of all chronic conditions activities across the NT due to the breadth of activities carried out by various stakeholders.  This report aims to provide a snapshot of a number of the main programs happening across the NT.  
•	Data availability and quality varies among urban private General Practices (GP) and is generally inconsistent.  There is only a small sub-set of GP practice indicators that can be utilised.
•	Data for urban non-Indigenous population on a number of chronic disease indicators is also difficult to obtain. Data from the National Health Surveys for the NT are generally not representative of the population due to small sample sizes.
•	The quality and robustness of data from the primary health care (PHC) sector, both Government and Aboriginal community controlled services, is continuously improving through substantial investment in Continuous Quality Improvement (CQI) activities in the remote Primary Health Care (PHC) sector. 

A large proportion of the monitoring of key action areas in this report consists of descriptive qualitative data. The quantitative indicators used are sourced from the administrative data-sets, a range of chronic disease indicators (national, regional and local data) and data from the Division of General Practice (DGPP) indicators.

It is anticipated that there will be new potential sources of regular, quantitative data that can be used for routine reporting. These include, but not limited to:
•	One-21-Seventy audit data (when uptake across the NT is sufficient enough to provide robust data).
•	Expansion of use of routine data from the electronic Patient Information Recall Systems (PIRS). 
•	The NT Aboriginal Health Key Performance Indicators 

Structure of report

This report presents its findings in two sections:

Section A contains a profile of a selected list of chronic disease indicators in the NT. These are:
•	Prevalence of chronic conditions
•	Incidence of a selected number of chronic conditions 
•	Mortality from chronic conditions
•	Life expectancy
•	Prevalence of the main risk factors and a number of socio-economic indicators

Section B contains a snapshot of some of the chronic disease activities happening across the NT. It will be structured against the eight key action areas listed on the Implementation Plan and will predominantly focus on the listed Year 1 indicators. 

Section A: A Profile of Chronic Conditions in the NT

The section of this report does not provide any new information about profile of chronic conditions.  It is a compilation of data from a wide variety of sources to paint a picture of chronic conditions in the NT. 

Data origin

Data on a number of chronic disease indicators in this section is collated from a variety of surveys, surveillance data and epidemiological studies available in the NT and Australia. The details of the data sources used in this section are presented in Appendix 1. The appendix will also include information on the new Australian Health Survey planned for 2011 that will assess a comprehensive set of chronic disease indicators, including objective measurements for risk factors.  

Summary of findings

•	In the NT, the life expectancy for Aboriginal and non-Aboriginal population has improved significantly over the past forty years. The gap between Aboriginal and non-Aboriginal women is closing due to rapid improvements in life expectancy observed in Aboriginal females. However, the gap has widened for Aboriginal men in comparison to non-Aboriginal men due to limited improvement in life expectancy.  During 1967-2006 there was an improvement in life expectancy of 16 years in Aboriginal females and 8 years in Aboriginal males compared to 16.5 years in non-Aboriginal females and 12.4 years in non-Aboriginal males.

•	The leading causes of death from 1985 to 2006 for all population groups were due to chronic conditions from cardiovascular disease, cancer and respiratory disease.  Aboriginal population have much higher mortality rates for the three conditions than the non-Aboriginal population.

•	There is a decline in death rates from stroke and COPD for NT Aboriginal people, but increased deaths from Ischemic Heart Disease (IHD) for both males and females, and Renal Failure for Aboriginal females.  Amongst the NT non-Aboriginal population, there is a decline in death rates for all of these five diseases. 
•	In terms of disease prevalence and incidence:
o	Cardiovascular disease: Between 1992 and 2004, the incidence of Acute Myocardial Infarction has declined by 23% for NT non-Aboriginal population, however for Aboriginal population it has increased by 60%. 

o	Diabetes: Prevalence is very high for the Aboriginal population (7.9% in Aboriginal compared to 4.4% in NT non-Aboriginal).  Higher rates are seen in Central Australia (13.4%) than the Top End (6.3%), and in Aboriginal females (11.5%) than males (7.5%). This is consistent with the higher rates of obesity observed in Central Australia. 

o	Chronic Kidney Disease: In 2005, prevalence is much higher in Central Australia (25.2%) than the Top End (15.8%) and in Aboriginal females (23.1%) than males (17%). This is consistent with the higher prevalence of diabetes and hypertension in Central Australia region and amongst the female population. These two conditions were the leading causes of End Stage Kidney Disease in the NT in 2010. The number of new dialysis patients has increased from 57 clients in 1997 to 89 clients in 2008; figures in 2009 (72 clients) and 2010 (57 clients) have showed decreasing numbers.

o	Chronic Airway Disease: In 2008, the prevalence of Chronic Obstructive Pulmonary Disease (COPD) is higher in the Top End (8.1%) than Central Australia (5.4%), consistent with higher prevalence of smoking in the Top End, with highest rates in Arnhem Land.

o	Chronic Mental Illness: Population data available from self reported surveys. In 2008, 28% of NT Aboriginal people reported having high to very high levels of psychological distress. For NT non-Aboriginal people, the detailed CATI survey in 2000 showed 22% of people reported anxiety and depression.

o	Cancer: Overall during 1991-2005, NT population has a lower aged standardised cancer incidence rate (426 per 100,000 population) than the Australian population (456 per 100,000 population). Tobacco-related cancers were among the top most common cancers for all NT Aboriginal and non-Aboriginal people.

•	Chronic condition risk factors:
o	Compared to the total Australian population, the NT has a higher prevalence of tobacco smoking (33.4% NT, 21% Australia).  In Aboriginal males, the trend (from 1994-2008) appeared stable (approximately 60%) and increasing for Aboriginal females (from 35.5% in 1994 to 48.6% in 2008). During 1998-2007, in non-Aboriginal population, the trend appeared declining for both males and females from 32.8% to 31.1% in males (1998) and from 39.3%% to 24.1% in females (2007).

o	Consumption of alcohol in the NT is higher than the national average. The NT non-Aboriginal population is more likely to consume alcohol than Aboriginal population (88.7% compared to 49.2%); however, among Aboriginal population who consume alcohol, 30.1% reported drinking alcohol at risky levels (compared to 17.2% of non-Aboriginal). Alcohol consumption and consequent alcohol-attributable deaths and hospitalisation for both Aboriginal and non-Aboriginal population in the NT have occurred at levels far higher than elsewhere in Australia. 

o	Various surveys on nutrition and physical activity utilised different indicators, which makes comparison across surveys difficult.  Overall, for all population groups, the prevalence of consuming adequate fruits and vegetables and having adequate physical activity is low.  Almost 50% of all NT adults are found to be overweight or obese. 

o	The socio-economic findings affirm the degree of social disadvantage observed in the NT Aboriginal population.
Health Status and Outcomes
Prevalence and incidence of in-scope chronic conditions

The prevalence of chronic conditions is difficult to determine accurately. Most measurements from surveys used self-reported data which may lead to an underestimation of prevalence as they are dependent on recall, patient’s understanding of their diagnosis and undiagnosed disease. The last point is especially relevant in conditions such as chronic kidney disease and diabetes. Another factor leading to the underestimation of prevalence is the incompleteness of case definition in major clinical data-sets, as demonstrated in a study in the NT.   

There is limited opportunity for trend analysis as comparisons across time and population groups.  It is also difficult due to multiple data sources, differences between studies in relation to disease definition and measurement and different use of age structures.  Broad comparisons can only be made across the three populations – NT Aboriginal, NT non-Aboriginal and total Australian population.  Caution is advised in making direct comparison of results. 

Incidence of chronic conditions is available for a limited set of chronic conditions that have an acute onset with symptoms and have a more definitive diagnostic date, for example: acute myocardial infarction, stroke and cancer. 

Prevalence of Cardiovascular Disease

The scope of cardiovascular disease in CCPMS covers Ischaemic Heart Disease, Heart Failure, Stroke and Hypertension. 

Figure 1 – Prevalence of CVD, Aboriginal, non-Aboriginal-(Self reported data)
Data source: 
- NATSIHS 2004/05 (National Aboriginal and Torres Strait Islander Health Survey) for NT Aboriginal; 
- NT CATI 2000 (NT Computer Assisted Telephone Interview) for NT Non-Aboriginal; and 
- NHS 2007/08 (National Health Survey) for Australia.

Figure 2 – Prevalence of hypertension, Aboriginal and non-Aboriginal- self reported (blue) clinical data (red)
Note: SR (Self Reported); 
Data from Zhao 2008 were sourced from the NT Chronic Disease Register and Hospital 
Morbidity Data. AusDiab surveys conducted across Australia.

The two figures above outline the prevalence of cardiovascular disease in the three population groups, presented together for broad comparison.
Incidence of Acute Myocardial Infarction

Figure 3 – Incidence of acute myocardial infarction (AMI) in population aged 40 years and over in the NT (1992-2004), 
                  and in Australia (1993-1999) 

•	Overall, the incidence rate of AMI was higher for Aboriginal than the non-Aboriginal population, and higher for men than women. 

•	The figure above showed a declining AMI incidence rate in NT non-Aboriginal population by 23%. This group had similar incidence rates and rate of decline in AMI as the rest of Australia. In contrast, for NT Aboriginal men and women, we observe that the incidence rates for AMI started off to be the same in 1992, but diverged towards the opposite direction thereafter.  For this group, the incidence rates increased between 1992 and 2004 to about twice the rate of non-Aboriginal people and Australia.    

Prevalence of Diabetes

Figure 4 – Prevalence of diabetes, Aboriginal, non-Aboriginal and Australia (self reported blue, clinical and survey (red)

Figure 4 outlines the prevalence of diabetes in the three population groups, presented together for a broad comparison.
•	Overall in the NT, the prevalence of diabetes is high. There are variations observed between self reported data and objective measures which may reflect the degree of under-diagnosis that is commonly observed in diabetes. 

Regional, sex and age variations:
•	For the NT non-Aboriginal population, diabetes is higher in males (9.1% versus 4.7% in females). 
•	A different picture is observed for the NT Aboriginal population.  Diabetes is more common in females (11.5% versus 7.5% in males).  Central Australia has higher proportion than the Top End (13.4% and 6.3% respectively), consistent with the high rates of obesity observed in Central Australia.  The prevalence increases with increasing age, around 33% in those aged 50+ years old.
•	A similar picture is showed in another study (DRUID study) on urban-Indigenous population in Darwin.  The prevalence of diabetes was higher amongst females than males (around 33% for females aged 35+ and 29% for males aged 35+).
Prevalence of Chronic Airway Disease

Figure 5 -  Prevalence of COPD, Aboriginal, non-Aboriginal and Australia-(self reported blue, clinical data (red)
Figure 6 – Prevalence of asthma, Aboriginal, non-Aboriginal and Australia

Figures 5 and 6 outline the prevalence of Chronic Airway Disease (CAD) in the three population groups presented for broad comparison.
•	There may be considerable overlap in self reporting between Chronic Obstructive Pulmonary Disease (COPD) and Asthma, making it difficult to delineate both conditions, in particular in the Aboriginal population. 
•	Prevalence is approximately 9% for asthma and we observe a range of figures were reported for COPD. 

Regional, sex and age variations (clinical data and available for remote NT Aboriginal population only):
•	Using clinical data, the prevalence of COPD higher in the Top End compared to Central Australia, consistent with higher prevalence of smoking, particularly in the East Arnhem region. It was also slightly higher for females (4.3%) than males (3.4%).  Prevalence increases with increasing age, over 18% for those aged 50+ years old. 

Prevalence of Chronic Kidney Disease

a)    Non end-stage disease

It is difficult to measure prevalence of non-end stage disease in Australia and the NT due to the insidious onset and progression of disease, resulting in under-diagnosis. 

Table 1 - Prevalence of kidney disease in remote Indigenous population in the NT in 2005. 

Definition	Survey	Year	Remote Indigenous in NT
Observed Prevalence (Expected prevalence)b	
			Region	Gender	Age	
			TE	CA	Male	Female	 15-49	>50	
Chronic Kidney Disease	Zhao 2008 ANZPHa	2005	9.0 
(15.8)  	13.7
(25.2) 	9.3
(17.0)    	12.9
(23.1)	11.9
(21.1)	29.8
(52.6)	
a)	Data Source: Chronic Disease Register, NT Hospital Morbidity Data.
b)	The observed prevalence of disease represents the proportion of patients actually recorded by both the data sources.  Expected true prevalence includes the observed cases as well as an estimate of the unrecorded cases that was estimated statistically.  	

The best available data for the NT is an epidemiological study by Zhao 2008 in the NT Remote Indigenous population using recorded cases from the NT Chronic Disease Register and NT Hospital Morbidity Data. 

The study indicated very high prevalence of Chronic Kidney Disease (CKD) in the NT, as summarised in Table 1.  Prevalence was much higher in Central Australia and amongst females. This is consistent with the higher prevalence in diabetes and hypertension observed in these groups, which are some of the leading causes of CKD in the NT. 

b)   Prevalence and Incidence End Stage Kidney Disease 

The data is predominantly sourced from the ANZDATA which collects information on End Stage Kidney Disease (ESKD) patients commencing renal replacement therapy such as dialysis or transplantation.  Therefore, the reported incidence and prevalence of ESKD is an underestimate as some people choose not to commence renal replacement therapy or are unsuitable for treatment. 

Figure 7 – Prevalence of ESKD NT and Australia 2000-2009

There is increasing prevalence of ESKD patients on renal replacement therapy, due to a combination of increasing incidence secondary to increased diabetes incidence and improved management for people on dialysis, resulting in improved survival. 

Figure 8 – Number of new dialysis patients NT 1986-2010

Figure 9 – Incidence of ESKD patients on dialysis or transplant NT 2000-2009

Whilst an increasing trend in incidence is observed from 2000 to 2008, with much higher rates than Australia, there appears to be a decrease in incidence since 2008. There has been work in care coordination to improve management of people with late stage chronic kidney disease, which may contribute to this reduction, although this will be monitored over the next few years to determine if this trend persists.

Leading causes of ESKD

Diabetes is the main co morbidity with ESKD in the NT. Across Australia, from 2006 to 2009, diabetes nephropathy is the leading cause of ESKD.  Together with hypertensive kidney disease, these two conditions contributed to approximately 48% of the causes for ESKD. 

Rheumatic Heart Disease

Data on Rheumatic Heart Disease (RHD) is obtained from the NT Rheumatic Heart Disease Register. 

Figure 10 - Prevalence of Rheumatic Heart Disease in the NT

The prevalence of chronic RHD in the NT is showing an overall increasing trend, although the rate of increase appears to have slowed over the last few years. This may be due to a combination of decreasing incidence of ARF and improved management of the disease. 

Number of Rheumatic Heart Disease

Table 2 - NT data on the number of people with RHD and Acute Rheumatic Fever (ARF) 

Year	RHD	ARF	
2006	6	54	
2007	3	84	
2008	4	49	
2009	6	56	
2010	9	58	

Chronic Mental Illness

The scope of chronic mental illness covered in CCPMS covers anxiety, depression and co-morbidity with chronic physical conditions.  The main indicator is the prevalence of psychological distress using the Kessler 10 (K10) that has been used in population surveys to determine rates of depression and anxiety.(Appendix 2).  There are four levels of psychological distress using K10 – low, moderate, high and very high. 

a)	NT Aboriginal 

The National Aboriginal and Torres Strait Islander Social Survey (NATSISS) 2008 showed that 28.1% of the NT Aboriginal population aged 15 years and older reported having high to very high levels of psychological distress. This level of distress was slightly lower than the national Aboriginal and Torres Strait Islander population (30.7%).  

b)	NT non-Aboriginal 

The NT CATI survey in 2004 showed that approximately 8.4% of NT non-Aboriginal adults reported having high to very high levels of psychological distress. This survey showed the gradient of psychological distress related to income levels; the highest prevalence of psychological distress (14.5%) was seen in the lowest socio-economic group compared to 7.6% in the highest socio-economic group.

In a previous CATI survey in 2000, a more in-depth analysis was performed on mental health status for NT non-Indigenous population. The results showed:

•	A prevalence of anxiety and depression of 22%, higher in females than males (27% versus 18%). 

•	A higher prevalence of depression observed in certain population groups:
o	Separated / divorced (35%) or single/widowed (25%); 
o	Lower educations levels (33%); 
o	Unemployed (37%) and 
o	Low income earners of <$20,000 per annum (34%).

•	Those with depression were more likely to be smokers, have high alcohol intake, low fruit and vegetable intake, low physical activity and are overweight. 

•	An association between those with chronic disease and depression. Those with respiratory disease, stroke, diabetes, heart disease and cancer were 2-3 times more likely to report being depressed.    

Incidence of Cancer

a)	All cancers combined 

Figure 11 - Age-standardised incidence for all cancers, by sex and Indigenous status, NT (1991-2005) and Australia (1991-2001)
Overall, relative to Australia, the NT had a lower cancer incidence rate than Australia partly due to a higher proportion of younger population in the NT compared to Australia. Incidence of cancer is more common among NT males than females. The average annual age-standardised cancer incidence rates were 487 cases per 100,000 population for males and 360 for females.   The NT Aboriginal population had lower incidence of cancer than than NT non-Aboriginals (356 cases per 100,000 population for NT Aboriginals and 451 for NT non-Aboriginals).

b)	Most common cancer sites 
In the NT, amongst Aboriginal males, the most common cancer site was lung cancer, followed by cancer of unspecified sites and lip and oral cancer.  Prostate cancer was more common among non-Aboriginal men followed by lung cancer and colorectal cancer.  

Amongst the NT Aboriginal women, the most common cancer diagnosed was breast cancer closely followed by lung cancer and cancer of unspecified sites. Breast cancer was by far the most common cancer amongst the NT non-Aboriginal women followed by colorectal and lung cancer. A high incidence of unspecified cancer sites in Aboriginal people could represent later diagnosis as a result of poor access to health services.

The cancer profile for NT non-Aboriginal people was similar to that of Australia; however this is not the case for NT Aboriginal peoples. Tobacco-related cancers occurred at a higher rate which is consistent with the higher prevalence of tobacco smoking in the NT compared to Australia and the even higher rates of tobacco smoking amongst the NT Aboriginal people. 

c)	Trends in Cancer Incidence
Figure 12 - Trend in age-standardised incidence rates per 100,000 for all cancer, by sex and Aboriginal status, in NT and Australia.

Overall, there was a declining trend in cancer incidence rates in NT non-Aboriginal population and increasing in the NT Aboriginal population. However, these trends were statistically insignificant. 

For NT Aboriginal males, there was an increasing trend in cancer incidence and the rate was stable for NT non-Aboriginal men. 

For NT Aboriginal females, there is a smaller increase in the overall cancer incidence compared to Aboriginal males.  NT non-Aboriginal females showed a greater decline in incidence compared with Aboriginal females.
Life Expectancy

Figure 13 - Life expectancy at birth, NT and Australia, 1967-2006

Life expectancy for all populations has improved significantly over the past forty years. 

The improvement of life expectancy in NT Aboriginal people is more evident among females than males (16 years females and 8 years males).   The life expectancy of NT non-Aboriginal males and females has increased by 16.5 years and 12.4 years respectively.

The gap between NT Aboriginal females and non-Aboriginal females has narrowed due to a rapid improvement in the life expectancy in NT Aboriginal females.  In contrast, the gap between NT Aboriginal males and non-Aboriginal males has widened due to the slow improvement in life expectancy in NT Aboriginal males.
Mortality

a)	Overall mortality rates

From 1985 to 2006, mortality rates have generally declined in NT Aboriginal men and women, as well as NT non-Aboriginal men.  The exception was for NT non-Aboriginal women whose rate remained stable since 1996. 

Similar to life expectancy, during the same period, the gap in mortality rates between NT Aboriginal men and non-Aboriginal men has widened due to the slower rate of decline in Aboriginal male mortality.  In contrast, we observed narrowing of gap in mortality rates for NT Aboriginal women.
    
Figure 14: Leading causes of deaths, Aboriginal and non-Aboriginal populations, NT 1985-2006

In 1985-2006, In NT, the leading causes of death for Aboriginal and non-Aboriginal population was predominantly due to chronic conditions.

b)	Mortality rates for specific chronic conditions

Figure 15 - Age adjusted mortality rates for selected chronic disease by sex, Aboriginal status, NT and Australia, 1997-2004,

The rates of age-adjusted mortality rates for the five chronic conditions were higher in the NT Aboriginal than NT non-Aboriginal and Australian population. Comparing NT Aboriginal males and females, mortality rates were similar except for IHD and COPD. 

c) Trends in mortality rates for five chronic conditions61

Table 3 - Annual changes in NT Aboriginal and Australian mortality rates and confidence intervals for selected chronic diseases, by sex, 1997-2004

Note: A negative value implies a decreasing trend and positive value represents an increasing trend.

•	Mortality rates from diabetes, stroke and COPD have all declined between 1997 and 2004 in the NT Aboriginal population. 

•	A different trend is observed for renal failure and IHD.  Whilst mortality rates from renal failure for NT Aboriginal males showed a declining trend, it is still increasing for NT Aboriginal females.  This picture is consistent with the previous findings of higher rates of renal failure and diabetes in NT Aboriginal females.  On the other hand, mortality rates from IHD are still climbing for both NT Aboriginal males and females. 

•	Although not statistically significant, the reduction in annual mortality rates in diabetes and stroke were higher in the NT Aboriginal population than Australia, indicating some early signs of improvement. 

c)	Trend in mortality rates for cancer

Figure 16 - Trend in age-standardised mortality rates per 100,000 for all cancers, by sex and Indigenous status, NT and Australia.

Cancer mortality rates have decreased for NT non-Aboriginal people and the change was highly significant. There has been a significant decrease (25%) in mortality rates for Aboriginal women, however over the same period the mortality rates for Aboriginal males has increased by 25%. Hence, there is no change in the overall cancer mortality rate for NT Aboriginal people.

The downward trends in mortality are attributed to the significant decrease in lung cancer mortality for non-Aboriginal people, declines in melanoma and pancreatic cancer among non-Aboriginal men and the marked decrease in cervical cancer death rates amongst all NT women, especially amongst Aboriginal women (92% reduction over this period).
Determinants of Health
Smoking

Age Adjusted Smoking Prevalence in the General Population and Trends

Table 4 - Age-adjusted smoking prevalence by sex and Indigenous status, NT and Australia in 2007/08

•	Overall, the prevalence of smoking was much higher in the NT than Australia.
•	It was much higher in NT Aboriginals than non-Aboriginals, higher in males than females. 
Nearly half of NT Aboriginal people smoke and there are regional variations in the NT, with the East Arnhem region having the highest prevalence of smoking.

Population	Male (%)	Female (%)	Total (%)	
2007/08	 	 	 	
Aboriginal	54.6	45.5	49.8	
Non-Aboriginal	30.5	24.5	27.8	
NT	36	30.3	33.4	
Australia	22.9	19	21	

Trends in smoking prevalence

Figure 17 - Trends in smoking prevalence in the NT non- Aboriginal population, by sex
Figure18 -  Trends in smoking prevalence in the NT Aboriginal population, by sex
Smoking Prevalence in Pregnant Women

For Australia (data not shown), the prevalence of smoking has been declining from 26.6% in 1998 to the current 19.1% in 2007.  A similar declining trend is observed for NT non-Aboriginal women but the rate had been relatively stable for non-Aboriginal men. 

Conversely, the rate of decline was not shared by NT Aboriginal women. In Aboriginal men, there appears to be an early indication of slowing down of smoking.

Table 5 - Crude smoking prevalence of pregnant women in the NT, 1996 to 2005. 

Aboriginal status	1996-97
(%)	1998-99
(%)	2000-01
(%)	2002-03
(%)	2004-05
(%)	
Aboriginal	43.4	43.7	46.2	48.6
	52.9	
Non-Aboriginal	25.1	23.9	21.1	22.1
	21.9	

The trend in smoking prevalence in pregnant women mirrors the trend observed in NT women.  While there is a decline in the prevalence of smoking in NT non-aboriginal women, the trend is increasing for NT Aboriginal pregnant women.

This will be an area that requires intense focus as smoking during pregnancy is associated with many adverse pregnancy and foetal outcomes.

Tobacco Consumption

It is anticipated that the NT will be able to start reporting on tobacco wholesales data in the next round of reporting. 

Alcohol

Alcohol Consumption in the NT

Figure 19 – Per Capita pure Alcohol Consumption (PCAC) in the NT and Australia 

The NT per capita alcohol consumption (PCAC) is substantially higher than national figures, but there appears to be recent moderation in the PCAC trend. 

Prevalence of alcohol intake

Table 6 - Alcohol Prevalence and consumption behaviour, by Indigenous status and Australia

	Alcohol prevalence % (If alcohol was consumed during last 12 months)	Long term risky or high risk consumption (%)	
NT Aboriginal	49.2	30.1	
NT non-Aboriginal	88.7	17.2	
Australia	84.6	10.6	

Although NT Aboriginal people were less likely to report consuming alcohol over the last 12 months, those consuming alcohol had a higher prevalence of risky alcohol consumption. 

For both population groups, NT non-Aboriginal males (16.4%) were more likely to drink daily than NT females (6.3%) and exhibit riskier alcohol consumption patterns.  The similar drinking pattern is observed amongst NT Aboriginal men who had higher alcohol prevalence and consumption at risky levels. 

Alcohol Intake during pregnancy

Table 7 – Proportion of pregnant women reporting alcohol consumption at first antenatal visit, Northern Territory (2003-2006)

The prevalence of alcohol consumption is higher amongst NT Aboriginal pregnant women than NT non-Aboriginal pregnant women.  From 2003 and 2006, it is demonstrating an upward trend in consumption at first antenatal visit, whereas there was a slight decrease for NT non-Aboriginal women.  

At the third trimester of pregnancy, the prevalence of alcohol consumption remained stable in the NT Aboriginal women, indicating an improvement in the proportion of Aboriginal women who quit drinking after their first antenatal visit.  However, more work needs to be done to address this issue, especially in the context of reducing foetal alcohol syndrome.

Nutrition

Table 8 - The intake of Fruits and Vegetables in NT Aboriginal, NT non-Aboriginal and Australia

Population	Survey	Indicator	Prevalence (%)	
NT Aboriginal	NATSIHS 2004/05	% no usual daily fruit	18.9	
		% no usual daily Vegies	17.3	
NT non-Aboriginal	NT CATI Survey 2004	% ≥2 serves of fruit per day
% don’t eat fruit	
40.5
7.1	
		
% ≥ 4 serves of vegies per day
% ≤ 2 serves of vegies per day	
24.4
54
	
Australia	NHS 2007/08	% Inadequate fruit / vegies intake	93.8

The results above indicate poor overall intake of fruits and vegetables in all populations that were not consistent with the recommendations of national guidelines.  It also highlights the variations in measurements used to assess intake of fruits and vegetables, making it difficult to compare across populations.
Physical Activity

Table 9 - Physical Activity Levels in NT Aboriginal, NT non-Aboriginal and Australia

Population	Survey	Indicator	Prevalence (%)
	
NT Aboriginal	NATSIHS 2004/05	% Low sedentary exercise level	73.3	
NT non-Aboriginal	NT Physical Activity Survey 2003	% Insufficient / sedentary physical activity	45	
	NT CATI Survey 2004	% Insufficient physical activity	49.5	
Australia	NHS 2007/08	% Low sedentary exercise level	72.8	

Data indicate poor physical activity in all populations.  Comparisons across population groups are difficult due to the variations in measurements used to assess physical activity.
Body Mass Index

Table 10 - Prevalence of overweight and obesity in NT Aboriginal, NT non-Aboriginal and Australia

Population	Survey	Indicator	Prevalence (%)	
NT Aboriginal	NATSIHS 2004/05 (self report)	% Overweight / Obese 	49.8	
NT non-Aboriginal	AusDiab Study 2000 (measured)	% Overweight / Obese 

% Overweight
% Obese	59

39.6
19.4	
	NT CATI Survey 2004 (self report)	% Overweight / Obese 

% Overweight
% Obese	50.0 

33.9
16.1	
Australia	AusDiab Study 2000 (measured)	% Overweight / Obese 

% Overweight
% Obese	59.6

39.1
20.5	
	NHS 2007/08	% Overweight/Obese		
		Self Report	56	
		Measured	61.3	

The prevalence of overweight or obesity is consistently found to be higher using measured data over self report.  Overall, the prevalence of overweight or obesity is very high in all populations, with very similar results from self reports across Aboriginal and non Aboriginal people.  This highlights the urgent need focusing our efforts in instituting individual and population-based approaches to reduce obesity rates addressing both nutrition and physical activity issues.
Average cost of food basket 

Figure 20 – Cost of basket of foods in remote stores compared with Darwin Supermarket 2000-2010
Figure 21 – Average number of varieties of fresh fruit and vegetables in remote stores 2000-2010

The cost of the food basket in 2010 in remote stores was 43% higher than Darwin supermarkets.  However, this differential increased due to a reduction in price in the Darwin supermarket. Over the 10 year period, the cost of the food basket increased by 43% ($511 to $730) in remote stores compared to 34% ($383 to $515) in the major regional centres.

The average number of varieties of fresh fruit and vegetables available in remote stores was highest in 2009 when there was an average of 17 varieties of vegetables and ten varieties of fruit available. The quality has improved as well as quantity, with 88% of fruit and vegetables rated as good quality in 2010 compared to 66% in 2000.

Socio-economic factors

The section below outlines four socio-economic indicators – education, employment, income and housing that provide a brief overview of the degree of socio-economic disadvantage experienced by the NT population, in particular Aboriginal population.  A detailed analysis of this can be found in the AIHW Health Performance Framework Report.  All data reported here were obtained from this AIHW report unless otherwise stated. 

Education

Year 12 attainment rates

Table 11 - Proportion of youths with year 12 attainment, by Indigenous status, sex and state/territory, 2007 

	NT Aboriginal	NT Non-Aboriginal	Australia Aboriginal	Australia Non-Aboriginal	
Males	44.7	74.5	61.9	80.5	
Females	47.6	76.0	64.5	86.1	
Total	46.2	75.3	63.3	83.3	

Less than half of NT Aboriginal youths completed year 12. The year 12 attainments rates in this group was much lower than the rest of NT, other Aboriginal and non-Aboriginal Australians. 

Employment

The proportion of NT Aboriginals aged 15 to 64 years old who participated in the labor force were 51% compared with 79% in NT Non-Aboriginals.  

Income

Figure 22 – Mean gross weekly equivalised household income, by Indigenous status and state/territory, persons aged 18 years and over, 2006

Among all jurisdictions, NT had the lowest mean weekly income of under $379 per week and the widest gap between NT Aboriginal and non-Aboriginals. Almost 58.6% of the NT Aboriginal people are represented in the lowest income quintile, followed by 25% in the second lowest.

Housing

Overcrowding

Figure 23 – Proportion of persons aged 18 years and over living in overcrowded households, by Indigenous status and state/territory, 2006

Among all of the jurisdictions, NT has the highest proportion of Aboriginal people living in overcrowded households and 10 times more likely to be living in overcrowded households than NT non-Aboriginals. 

Dwelling condition

Approximately 31.3% of dwellings in the NT required major repairs or replacements in 2006. In this aspect, in comparison with other jurisdictions, NT ranks third with Queensland (30%) and Western Australia (38%) taking the lead.

Section B: Chronic Disease Activities across the NT

Overall implementation of CCPMS

Communication and Distribution

A communication strategy was developed in early 2010 that outlined strategies to promote CCPMS and its Implementation Plan.  Various actions were undertaken to promote the use of the strategy and its implementation, including:
•	Distribution of CCPMS and Implementation Plan to key DoH stakeholders and CCPMS partners. 
•	A Ministerial launch for CCPMS on November 2009.  The Implementation Plan was launched during the 2010 Chronic Disease Network (CDN) Annual Conference.
•	Developing a one-page brochure on CCPMS for general distribution.
•	Dedicating a CCPMS section in the quarterly CDN publication, The Chronicle, to update stakeholders about progress of implementation
•	Presenting at professional development and other forums / conferences such as the Preventable Chronic Disease short course and the Combined Networks Meeting.
•	Liaising directly with specific work units within the Department of Health and external stakeholders such as Heart Foundation NT, Cancer Council NT, Healthy Living NT and the General Practice Network NT. 
•	Making available electronic copies of both documents on the Chronic Condition Strategy Unit (CCSU) website and library site.
•	Production of the CCPMS annual report.
•	A specific brochure for other government departments is being progressed to create awareness and foster relationship.

Uptake of CCPMS and Implementation Plan

Direct liaison with internal and external stakeholders is an on-going activity. To date, there have been various levels of awareness on the CPPMS and its implementation plan across internal and external stakeholders, in particular on how to implement and include a range of strategies identified in the CCPMS into work units’ current business plans.

A number of stakeholders, internal and external, are using the CCPMS Implementation Plan to guide the development of:
1.	their business plan (DoH: Health Development Top End and Central Australia Team, Renal Services.  NGOs: Cancer Council NT)
2.	their reporting activity (Chronic Conditions Coordination Unit, Royal Darwin Hospital)
3.	their Implementation Plan (DoH: CanNet project and Renal Services)

Community Health Branch of the Department of Health has included new key performance measures in their Service Agreements with non-Government organisations.  As part of the funding agreement, non-government organisations must be able to report outcomes of activities that are aligned with the CCPMS.

The CCSU has developed a short training session to inform and assist managers to incorporate CCPMS and its Implementation Plan into their work plans.

Governance Structure

One of the key successes to implementing the CCPMS is having an effective and functional governance structure. 

The governance structure consists of a few Working Groups established to monitor the progress of activities outlined under key action areas (KAA)

The establishment of a Leadership Group with suggested members were from various government departments as well as senior officials of non-government organisations has not been eventuated.  There are a number of high (executive) level groups currently exist, for example Chief Executive Coordination Group, Territory 2030, Early Childhood Reference Group and the Territory Growth Towns Committee where strategic issues pertaining to chronic conditions can be included in the agenda and dealt with through inter-government partnerships; this will also include addressing issues pertaining to social determinants of health.  Department of Health continues the work to finalise this arrangement.

The Early Detection and Management Working Group was established in February 2011.  This working group monitors the progress of activities under KAA 3 and 5.

The Self Management Working Group was established in June 2011.  This is a time-limited working group responsible for the development of the NT Chronic Condition Self Management Framework due for completion in December 2011.

The Monitoring and Evaluation Working Group was established in June 2010.  This working group is responsible for the production of the CCPMS Annual Report.

Members of each of the working group are representatives from Department of Health, non-government organisations and Aboriginal Community Controlled Health Services.

National and NT Context 

There are a number of national and regional reforms that will influence the implementation of the strategy in a number of ways and contribute to the long term goals and intended outcomes of the strategy. The main reforms are, but not limited to:
•	National Health Reform
•	National Partnership Agreements in Preventive Health and Closing the Gap in Indigenous Health Outcomes, including the Indigenous Chronic Disease Package.
•	Establishment of the National Preventive Health Agency
•	Primary Health Care Reform
•	Expanding Health Service Delivery Initiative (EHSDI)
•	Territory Growth Towns
Progress against Key Action Areas
Key Action Area 1: Increase the focus on the Social Determinants of Health

Objective: Contribute to improving the Social Determinants of Health through improving living conditions, food security, education, employment and health literacy. 

How will we check progress in Year 1? 
•	Number of activities to raise awareness on the Social Determinants of Health
•	Number of partnerships between the health sector and other government departments
•	Number and proportion of Aboriginal staff employed within the Department of Health

Summary:
•	Raising awareness of the Social Determinants of Health (SDoH) – There is range of actions occurring in the health sector to raise awareness of SDoH for health professionals but there is a current lack of a strategic and systematic approach to raising awareness of SDOH. The incorporation of SDoH teachings into tertiary education in the NT is essential to develop the future health workforce who will understand the impact of SDoH and who are expected to act on the wider determinants of health.  Better coordination of effort is needed across sectors to address this gap. 
•	Inter-sectoral collaboration – There are a number of existing partnerships between Department of Health and other government departments on a wide range of projects related to addressing social determinants of health.  Some of these partnerships are stronger than the others in terms of real collaborations resulting in tangible outcomes.  These types of partnerships can and should be utilised to progress the health sector’s agenda on social determinants of health.  For example an inter-Government partnership involving Departments of Education, Health, Children & Families, Police, Local Government and the Chief Minister was formed to guide the development and implementation of an NT wide Early Childhood Development Plan that will seek to improve early childhood outcomes by identifying priority strategies for more coordinated cross-agency activities, and by delivering high quality services and programs for young children and their families.
•	Increasing health care access through improving health literacy – The 2010 Chronic Disease Network (CDN) Conference provided the forum for sharing of information, experience and lessons on health literacy.  The majority of activities undertaken to improve health literacy are led from operational levels and have taken a reactive rather than strategic approach.  Planning for health literacy activities at the systems level will yield significant benefits and will include the development of benchmark measures.
•	Aboriginal employment – The proportion of Aboriginal employment in NT Department of Health (6%) does not reflect the demographic profile of Aboriginal people in the NT (approx. 30%).  The majority of Aboriginal people are employed in lower job classifications with very small numbers in executive or professional levels.  Whilst there are efforts to increase the Aboriginal workforce, the development and implementation of effective strategies to improve the recruitment and retention of Aboriginal staff is essential.

1.1	Raise awareness of the impact of the Social Determinants of Health  in chronic conditions and increase the capacity to take action	
What are we measuring?	What did we do?	

Number of activities to raise awareness  to health professionals on the Social Determinants of Health (SDoH)

	
Professional development, orientation, training:
•	While SDoH has been discussed in several chronic conditions professional development activities such as the Preventable Chronic Disease (PCD) short course and Respiratory workshops, it has not been formally included as a unit in these courses.  Plans are being made to include SDoH as a topic area in these courses. 
•	A module of SDoH study was written into the development of the DoH Remote Health online staff orientation manual. 

Tertiary education in the NT:
•	SDoH was included into the course content of Certificate IV in Population Health in Charles Darwin University (CDU).  It will also be embedded into the Bachelor of Health Sciences degree that is currently offered through CDU.

Research
•	The NT Research and Innovation Board and Fund has approved the funding to commence research on “Understanding social capital in remote Indigenous schools and health service settings”
•	The DoH Health Gains Planning Unit has undertaken several research projects in varying stages of completion that assess the relationship between socio-economic status and inequalities in health outcomes.  

1.2 Provide leadership to strengthen inter-sectoral collaboration in relation to chronic conditions	
What are we measuring?	What did we do?	

Number of partnerships between the health sector and other government departments
	
Appendix 3 outlines the range of partnerships in place between the DoH, other government departments and non-government agencies that address a range of factors including education, workforce and early years.

Some of these partnerships are stronger than the others in terms of real collaborations resulting in tangible outcomes.  These types of partnerships can and should be utilised to progress the health sector’s agenda on social determinants of health.

1.3 Improve access to health services for all Territorians	
What are we measuring?	What did we do?	

Improving health literacy
	
There are numerous initiatives across the NT aim to improve health literacy in communities.  These were brought together during the CDN Conference held in Darwin in September 2010 that had a theme on health literacy.  
•	The conference “Health Literacy: Opening Doors to Health and wellbeing” was well attended by a broad range of health workers from the NT and Australia.  It provided the opportunity to discuss the roles and impact of health literacy on chronic conditions prevention and management and share their experiences on the implementation of health literacy activities in their communities.  
Many sessions had a particular focus on Aboriginal people. 
•	A full summary of conference programs can be found in the December 2010 edition of the Chronicle.  It also contains a range of other initiatives to improve health literacy in the NT, including the work done by the Aboriginal Resource Development Services. 

The other area in development is the inclusion of health education into numeracy and literacy programs. For example:
•	Work is underway to develop a teaching manual aimed at primary school aged students including nutrition, physical activity, oral health and hygiene information that are consistent with national guidelines.
•	There is ongoing work to increase the provision of sexual and reproductive health services to Indigenous teenagers through the school curriculum.

Service Agreement (National Partnership Agreements on Closing the Gap) has been drafted to progress research relating to health literacy benchmarks. 

A research proposal has been submitted by DoH to the National Health and Medical Research Council (NHMRC) relating to Indigenous health communication with CDU.

1.4 Increase Aboriginal employment in the health sector	
What are we measuring?	What did we do?	

Number and proportion of Aboriginal staff employed within the Department of Health
	
Within the NT, health care and social assistance are the second largest industry for Aboriginal employment, accounting for 17.9% of total Aboriginal employment in 2006. 

At the beginning of 2011, a total of 445 Aboriginal staff was employed within the then Department of Health and Families accounting for 6.6% of the total workforce.  Following the establishment of the Department of Children and Families:
•	DoH employed 369 Aboriginal staff, or 6% of total DoH workforce
•	DCF employed 76 Aboriginal staff, or 11.4% of total DCF workforce. 

Of these, Aboriginal people were predominantly recruited to lower job classification levels, largely in administrative areas, followed by Aboriginal Health Workers and physical areas, please refer Appendix 4.  Note that a proportion of the administrative areas will include Aboriginal community workers who as part of the Remote Health and Families Team assist with activities to promote health and wellbeing in the community.  

Training and mentoring 	
Refer Key Action Area 6: Workforce development
	
Key Action Area 2: Increase the focus on primary prevention to prevent and reduce risk factors

Objective: To reduce the impact of behavioural and lifestyle factors and create supportive environments for healthy behaviours

How will we check progress in Year 1? 
•	Number of community education/health promotion/social marketing activities to promote quitting and smoke free environments.
•	Number and proportion of PHC services that provide antenatal, early childhood, school age and adolescent programs.
•	Number of education opportunities for health professionals to increase knowledge, understanding and skills about health promotion and prevention.

Summary
•	The range of tobacco control activities listed here provided examples of initiatives undertaken across the NT.  Some of the key highlights in tobacco control initiatives were: (a) regulatory changes related to smoke free areas, an effective population-based approach to reduce smoking rates and safeguard against environmental tobacco smoke, (b) implementation of Smoke Free Policy in DoH, (c) increase taxation on the price of cigarettes, another effective population-based approach undertaken by Commonwealth;  mandatory reporting of tobacco wholesales data that will enable the monitoring of tobacco consumption in the NT and provide timely data for policy planning, (d) development of a tobacco control framework, and (e) expansion of the tobacco workforce, especially in remote communities. There are a number of community based activities undertaken across the NT, many of which focusing on implementing smoke free areas.  All of these efforts are timely, given that NT had been lagging behind other jurisdictions in tobacco control efforts. The areas that appear to be lacking are well-designed and sustained social marketing campaigns for both urban and remote populations as well as good coordination of tobacco control efforts, especially at community levels to prevent duplication of efforts and promote sharing of ideas and resources.
•	There are a number of activities to tackle high obesity rates including key initiatives to improve the availability and affordability of food in remote settings and the implementation of healthy school canteen policies, for example ongoing partnership with outback stores to facilitate the supply and demand for healthy food choices in remote communities. The majority of physical activity and nutrition programs are limited to urban areas.
•	Creation of supportive environments: The use of Health Impact Assessments (HIA) is very limited in the NT, lack of initiatives/partnerships that support the creation of healthy environments, especially in remote settings. There are some good opportunities, for example through the Territory Growth Towns to initiate partnerships with other departments.
•	Early years: There are some well-established programs in place such as the Healthy Kids Under 5 and the Family as First Teacher’s Program for the early years and good partnerships established to improve the delivery and integration of early childhood services in the NT. The Department of Education, in collaboration with other government departments, including health are developing an early childhood plan for the NT and consultations are currently underway with a wide range of stakeholders to inform the plan. In 2010, the prevalence of Aboriginal low birth weight babies is 14.4% (compared to non-Aboriginal 7.7%), highlighting that further work needs to be done during antenatal care to reduce the prevalence of smoking during pregnancy. 

2.1	

Increase community awareness about risk factors and promote consistent messages
2.2	Encourage behaviours that promote health and well being	
What are we measuring?	What did we do?	

NT Social Marketing 	
A NT Social Marketing Implementation Plan is being finalized, which is a part of the Preventive Health aspect of the National Partnership Agreements.

Tobacco control
Number of community education/health promotion/social marketing activities to promote quitting and smoke free environments.

	
The layout of this section will be mapped to the framework of the three priority activity areas of the NT Tobacco Action Plan 2010-2013: a) Policy and legislation Interventions, b) Community Initiatives and c) Health Care Interventions. 

a)  Policy and Legislation Interventions 
The NT Tobacco Action Plan 2010-2013 was launched in 2010 to provide a framework for evidence based tobacco control activities for the NT. The Implementation of the NT TAP will be monitored by the NT Tobacco Advisory Committee that will be established by mid 2011.  
 
Department of Health Smoke Free Policy
•	The DoH Smoke Free Policy came into effect on I July 2009 across all Department services, premises and grounds. 
•	The policy resulted in complete smoking ban on all DoH worksites from July 2009 and extended to DoH funded agencies in July 2010. It also provides smoking cessation support for staff, patients and clients of DoH through smoking cessation courses and nicotine replacement therapy.
•	The implementation of the policy is being monitored by the DHF Smoke Free Evaluation Committee and evaluation of the Policy is currently being undertaken. 

NT Tobacco Control Act amendments: A new range of tobacco reforms have been introduced in the NT on smoke free areas, tobacco display and licensing. 
•	From January 2010, all enclosed public areas in the NT will be required to be smoke free. 
•	From July 2010, all licensed tobacco retailers will be required to report tobacco sales to the Department of Justice (DoJ), with a “voluntary period” of reporting established until October 2010 to enable retailers to establish systems. This will enable the monitoring of tobacco consumption in the NT. 
•	From January 2011:
o	Smoke free areas will be extended to all outdoor eating and drink areas in the NT, except at liquor licensed premises where a maximum of 50% of the outdoor area can be designated for smoking. 
o	Organisations can declare outdoor areas as “smoke free” and enforce penalties under legislation. 
o	Display of any tobacco products will be prohibited at the point of sale for licensed retailers.

o	An annual licence fee and renewal processes will be introduced, as well as new licence conditions that will ban fruit and sweet flavoured cigarettes and require sales data to be submitted to DoH. 

Increase tax on tobacco products
At the national level, the Australian Government increased the tobacco tax from 30 April 2010, resulting in a 25% increase in the price of cigarettes following the recommendations of the Preventative Health Taskforce.  Increasing the price of tobacco has been shown to be one of the most effective tobacco control intervention in other countries and settings. The impact of this price hike will be monitored by the Tobacco researchers in Menzies School of Health Research (thereafter will be cited as “Menzies”).

The Australian Government is introducing plain packaging of tobacco to significantly reduce the impact of tobacco advertising in Australia.  In August 2011, plain packaging legislation has passed through the House of Representatives

b)  Community Interventions

There are a wide range of community interventions happening across the NT that promotes smoke free environments and smoking cessation, for example:

Social Marketing campaigns
•	DoH has developed a series of campaigns: television and radio advertisements, paper-based resources and promotional materials (e.g. “Nobody Smokes Here Anymore”) to raise awareness of the new smoke free reforms, health effects of smoking and smoking cessation supports.  
•	A series of Quit television and radio commercials was implemented targeting young people (“I’m Smarter than Smoking – Youth campaign featuring Jessica Mauboy, a young upcoming NT singer). However, this was a time-limited campaign that occurred for a short duration. 
•	Collaborations between DoH and Cancer Council to increase exposure to social marketing on tobacco.
•	Collaboration and financial support to James Cook University (JCU) Top End Tobacco project to get tobacco poster printed in Aboriginal languages.
•	Promotion of annual World No Tobacco Day 2010 that had the theme “Gender and tobacco with an emphasis on marketing to women”: For example, Alcohol and other Drug Services and Remote Health displayed World Health Organisation posters around Alice Springs retail outlets, pubs and restaurant windows designed to target young women about the harms of tobacco. 

Tobacco control policies/projects, including smoke free areas in a range of settings: communities, schools, workplaces etc
•	Top End Tobacco Project - a five-year multi-component, community-action intervention project implemented by JCU in three remote Aboriginal communities plus several homelands in East Arnhem since 2007.  A wide range of activities were implemented including tobacco surveys to assess prevalence, brief intervention training for local health workers, provision of tobacco cessation support and activities and development of local resources and smoke free policies.
•	There are also a wide range of other community based projects happening across the NT that promotes the creation of smoke free areas, health education and tobacco cessation and support. For example: 
   Top End:
o	Milingimbi – the range of activities conducted include brief intervention training, conducting a community smoking survey, establishment of community QUIT groups, smoke free policies.
o	Ramingining – Increasing smoke free areas in the community and supporting tobacco cessation activities.
o	Gapuwiyak – Community development approach that involves development of local resources, increasing smoke free areas in community and supporting health centre to assist community members to quit smoking. 
o	Tiwi – Development of a tobacco cessation program and training of Aboriginal Community workers
o	Sunrise: “Clean Air – Healthy Lungs” program to educate young people about the dangers of smoking and to develop culturally appropriate education resources. 

    Central Australia

o	Alice Springs sporting clubs – Development of smoke free policies in Federals Cricket Club and Federals Netball Association at their respective ovals, courts and club facilities.
o	Santa Teresa “Feel Good” Program: Training health clinic staff in Brief Intervention and smoking cessation and supporting the Ltyentye Apurte Community Education Centre Health Week and school based programs and curriculum to cover tobacco.   
o	Areyonga - JCU, Heart Foundation NT, Central Australian Aboriginal Congress (CAAC), Western Arranda Aboriginal Health Corporation and ADSCA supported the Areyonga Community by way of a Tobacco Survey to develop tobacco control initiatives, for example reducing the supply of tobacco sold, from 5 and a half days a week to 3 days. 
o	Papunya -  Promote music studio as smoke free and assist musicians to develop smoke free messages and healthy lifestyles
o	Central Australian Aboriginal Alcohol Programmes Unit: the development of Smoke Free Policy and provision of Quit courses for staff and clients.  
o	Schools: Health Promoting Schools Drug Officer and School Nurse currently assisting principals of schools in Central Australia to develop and implement policies to support smoke-free environments. There are also plans for youth specific Quit training workshop in 2011 to help school students with tobacco cession.
o	Provision of alcohol and other drug group behaviour therapy to clients participating in the Reintegration Program at the Alice Springs Correctional Centre by the ADSCA Community Support Officers. The two sessions had an emphasis on tobacco cessation.

School based activities

•	School teachers and staff received Professional Learning sessions at a number of schools in Central Australia to support and deliver the NT Indigenous Drug Education Support Materials and Resilience Education and Drug Information curriculum resources, with a special emphasis on tobacco from HPS Drug Officer Student Services Division CA. 
•	150 NT Police Officers under the Katherine/East Arnhem command received professional learning sessions to help deliver Drug Education and Tobacco Cessation classroom lessons and programs. 
•	A number of other school based activities were implemented, including provision of Critics Choice 2010 tobacco awareness lessons in high schools and school Health Expos in Central Australia. 
	
	c)  Health Care Interventions

Hospital based interventions project at RDH and ASH: Funded through the Closing the Gap initiative, this project delivers:
•	Systemic screening for alcohol and tobacco use for hospital inpatients;
•	Brief advice and interventions on smoking and alcohol;
•	Deliver cessation support services on tobacco
•	Provide clinical expertise on withdrawal management in both inpatient and outpatient settings, and 

Training in tobacco cessation activities

•	Ongoing provision of brief intervention training health staff and clinical nurses. Participants trained in tobacco cessation, including aspects of addiction, prescribing Nicotine Replacement Therapies and Nicotine Free pharmacotherapy.
•	Provision of QUIT training to health centre staff. 
•	Development of culturally appropriate tobacco awareness posters: For e.g 
o	Time to stop or slow down? In four Central Australian language groups, including Luritja, Arranda, Pitjantjatjara and Pintupi-Luritja.
o	Talking poster entitled “Smoke is No Good” by Menzies
o	Various DVD and posters produced by Miwatj 
•	Increased availability of free NRT for hospital inpatients and two free courses of NRT for DoH staff. The PBS listing of NRT commencing February 2011 will promote wider availability. 
•	Work is currently being undertaken to enhance the Quitline service to make it more culturally appropriate for Indigenous people. An Indigenous Officer to support the enhancement of the Quitline telephone counselling service has been employed to make it more appropriate for Indigenous people, especially those in remote areas of the NT.

d) Others
Expansion of Tobacco Workforce
•	Adequate and capable workforce is required to effectively deliver and implement tobacco activities. AMSANT and DoH are working closely with the Australian Government to rollout of the Indigenous Tobacco Control Initiative and help coordinate Indigenous tobacco action workers and coordinators across the NT. 
•	In 2010, the Commonwealth Indigenous Chronic Disease Package funding led to the creation of a number of community-based tobacco control positions in a number of Aboriginal Community Controlled Health Services (ACCHs) across the NT.

Information sharing
•	East Arnhem Health Promotion Tobacco Free Forum: Two forums were held in 2010 in Nhulunbuy attended by a wide range of health and community workers that provided the opportunity to share their work and experiences across the region.

Research
•	A number of research studies undertaken by Menzies School of Health Research in Indigenous Tobacco Control.  (Appendix 5) 	

Nutrition and Physical Activity	
Policy and legislation
•	A collaborative project between DoH and non-government agencies is currently in plan to reduce soft drink consumption in remote Indigenous communities. Project will include the production of materials that describe the links between high consumption of high sugar soft drinks, overweight/obesity and diabetes. Strategies will focus on discouraging high sugar soft drink consumption and promoting the consumption of water.
•	Contributed to the DET review of the Canteen, Nutrition and Healthy Eating Policy implemented in 2009 in NT Schools.
•	Supported and contributed to the planning of Healthy Palmerston, under the Healthy Communities initiative.
•	Ongoing partnership with Outback Stores to facilitate the supply and demand for healthy food choices in remote communities.

Program specific
Cooking Healthy and Physical Activity Project - Healthy Living NT (HLNT)
•	Organised by HLNT, this is a ten-week nutrition and physical activity program aimed at people with heart disease and type two diabetes to improve quality of life by increasing level of physical activity; improve knowledge about healthy eating; develop skills in healthy cooking, facilitate development of a social and support network, encourage self management. 
•	Four ten-week group programs was conducted in Darwin, Palmerston and Bagot community
•	It was delivered in group settings by a multidisciplinary team of allied health professionals including dietician, exercise physiologist and psychologist, cardiac and diabetes education.
•	Evaluation of program showed improvements in Blood Pressure, fitness levels, quality of life indicators, nutritional knowledge and application, body weight, BMI, waist measurements, self management, knowledge and confidence. 

'Eat Better, Move More'
•	A resource kit for the promotion of nutrition and physical activity in remote communities. It is available to health staff and educators who regularly promote nutrition and physical activity in remote NT communities. 
•	Thirty health educators were trained in the delivery of 'Eat Better, Move More'.  Over 500 people participated in one or more 'Eat Better, Move More' education sessions.

Activate NT-MBF Healthy Lifestyle Challenge 
•	Nine-week program in Darwin and Palmerston aims to encourage and support community members to adopt a healthier approach to life through positive lifestyle change. It Includes 20 free physical activities each week, as well as special events, motivation and education sessions and regular health checks to monitor progress.

Heart Foundation Walking Groups
•	An initiative by the Heart Foundation to support active living is community walking groups. The Heart Foundation working with Government and non-government organisations run a number of walking programs that can be accessed by community members.
 
Measure up campaign (Upcoming)
•	A DoH Project Coordinator position has been created to coordinate NT Social Marketing Campaign relating to the Measure Up Campaign, which is a joint Australian, State and Territory government initiative that works with peak industry bodies aims to reduce the risk factors for chronic diseases by providing healthy lifestyle messages and to reduce waist measurements.

Health education and skills development
•	There were a number of health education sessions (groups based and individual) to community members on a range of topics including diabetes prevention, healthy eating and youth health promotion in healthy eating and healthy weight by a range of service providers including NGOs and public health nutritionists across government and the ACCHS. Some of the sessions also include skills development through healthy cooking sessions and supermarket tours.  For example, Katherine West Health Board (KWHB) conducted numerous VegieMan days with primary schools in the wider Katherine West region that involve spending time in primary schools, doing one-on-one bush cooking demonstrations and extensive nutrition education with kids and parents.  
•	There were also work going on in training to school staff and supporting nutrition education classes in schools e.g. Maningrida.
•	There are also a number of Men’s health programs at Wurli Wurlijang, Central Australian Aboriginal Congress (CAAC) and Danila           Dilba that provided culturally secure education and support to Aboriginal men to reduce lifestyle risk factors. 

Through the Indigenous Chronic Disease Package there is also a current expansion of primary health care workforce focusing on healthy lifestyles as well as the prevention, early detection and management of chronic disease for Aboriginal people.	

Alcohol 	
NT Alcohol Reforms 2010: Enough is Enough
•	The NT Alcohol Reforms consist of a series of major policy proposals targeting problem drinkers in the NT that will commence in July 2011. Briefly, the policy includes:
o	Introducing a Territory-wide Banned Drinker Register in all take-away liquor outlets;
o	Banning problem drinkers from buying take-away alcohol
o	Introducing mandatory rehabilitation treatment for problem drinkers
o	Increasing rehabilitation and treatment options for problem drinkers
o	Replacing the Alcohol Court with a Substance Misuse Assessment and Referral for Treatment (SMART) Court

In Primary Health Care centres, PHC capacity to detect and treat alcohol and other drug problems continue to increase with the expansion of AOD workforce with PHC services supported by a workforce support program. 

Some examples of programs in place in PHC are the Safe and Sober Support Services in Congress is a non-residential, multi-disciplinary rehabilitation program based on three streams of care – medicines, Cognitive Behaviour Therapy and social support such as housing, education and employment. Another example is the Alcohol, Tobacco and Other Drug (ATOD) outreach program in Danila Dilba that provide intensive case management support to clients and also innovative strategies to address substance misuse, which include the trialing of the Danila Dilba Respite and Rehabilitation Project (R&R Project). This project provides support to access short term accormodation for clients awaiting for admission to treatment facilities or upon completion from various programs or treatment centres. During the stay, the project focus on goal setting, care planning, relapse prevention, community inclusion activities and addressing health issues. 

Quality Improvement Program Planning System (QIPPS) 
	
Quality Improvement Program Planning System (QIPPS) is an online tool designed for the planning and evaluation of a variety of health promotion, community development and secondary prevention projects. The use of this planning tool allows projects to be shared with external partners and makes collaborative work easier.
•	There is continuing expansion of QIPPS membership in the NT, with a 20% increase 2009 to 2010 and over 100 health promotion projects entered into QIPPS in 2010. 
•	Agreement has been reached to establish a joint QIPPS subscription with DET. 
•	The Health Promotion Strategy Unit of DoH runs periodic training sessions on QIPPS.
	
2.3	Support communities to create healthy environments	
What are we measuring?	What did we do?	

Health Impact Assessment (HIA)
	
To date, health impact assessment in the NT has been done within the context of the environmental health assessments on significant developments.  For example, providing strategic advice in relation to industry-based assessment processes (e.g. Inpex) and using HIA in the Health Risk Assessment of Outstation Water Quality.

It has not been incorporated into other settings such as using HIA to act on the social determinants of health or as a mechanism to minimise health inequities.  

As part of capacity building process in undertaking HIA assessments, two HIA workshops were conducted in Alice Springs and Darwin in 2010. It was attended by 29 people from across the government departments.  The evaluation of the workshops revealed improved awareness, understanding and application of the HIA framework and how it can facilitate engagement across government and communities.
	
2.4	Increase the focus on the early years of life, children and young people	
What are we measuring?	What did we do?	

Birth weight in Aboriginal and non-Aboriginal babies
	
•	The proportion of NT Aboriginal babies with a Low Birth Weight (LBW), less than 2500g, declined between 2006 and 2009. 
•	In the 2010 financial year the proportion of LBW Aboriginal babies increased from 12.9% to 14.4% (Table 13).  However, this increase is not statistically significant and may be influenced by the rising proportion of preterm babies and increased rates of smoking among Aboriginal pregnant women both working against a marked decline in perinatal death rates including stillbirths and neonatal deaths. In small population groups such as NT Aboriginal women it is often sensible to group data into five year periods to reduce the statistical variation associated with interpreting small numbers.
•	In the 2011 financial year the proportion was unchanged: 14.4% comprising 208 LBW Aboriginal babies born in public hospitals.  (Figure 25) 

Underweight in children less than 5 years of age
	
The following are data reported on NT Aboriginal children aged 0-5 years in remote areas (WHO growth reference):
•	8% of children are underweight, 
•	14% of children are stunted, and 
•	5% of children are wasted.

Number and proportion of PHC services that provide antenatal, early childhood, school age and adolescent programs.

	
Antenatal: 
•	The Strong Women, Strong Culture, Strong Babies program has been operating in the NT since 1993 and provides contemporary health knowledge in a culturally safe way to Aboriginal women and girls in remote communities around sexual health, pregnancy and early parenting education. It recognises the value of cultural knowledge held by Aboriginal women who were employed as Strong Women Workers (SWW) to implement the program. 
•	The Core of Life is a national program that provides culturally respectful and locally inclusive pregnancy, birth and parenting education to youth, with the aim of decreasing teenage pregnancy rates and improving early access to health care during pregnancy.

Early Childhood:
•	The Healthy Kids Under 5 (HUK5) program incorporates a series of age specific child health checks, which include growth assessment and the childhood vaccination schedule. It is being rolled out progressively across NT, with primary focus in Remote Health & community-controlled health services. An audit of the program is being undertaken to assess the program implementation across the NT. The Growth Assessment and Action component reported coverage of around 50% to 70% for measurement of weight and anaemia in 2010.

•	The Healthy School Age Kids (HSAK) is a joint initiative between DoH and the DET consists of three main components: health promotion in the school and community setting, child health checks and integration of other services and programs. The HSAK Program is being reviewed.

•	The Family as First Teachers Program is a collaborative program between DoH, DET and Primary Health Care (PHC) clinics that focus on the active engagement in quality early childhood education programs, supporting the development of children’s knowledge, addressing issues pertaining to health, hygiene and nutrition and providing parenting and family support.  It has been implemented in over 18 communities in the Top End, Central and Katherine region.

•	The Australian Nurse Family Partnership Program in Congress, an early childhood program that is based provides intensive support to pregnant women extending until the child turns two by nurses working with Aboriginal family support worker.

•	The Targeted Family Support Services in a number of PHC centres including Congress, Wurli Wurlijang and Larrakia Nation provides case management and support for high-need families to promote the safety, stability, development and well being of vulnerable children and their families. 

•	Good partnerships have been established to improve the delivery and integration of early childhood services in the NT. The Department of Education, in collaboration with other government departments, including health are developing an early childhood plan for the NT and consultations are currently underway with a wide range of stakeholders to inform the plan.

Adolescent
•	The two systematic health checks available for adolescents in PHC are the HSAK checks for children under 15 and the Adult Health Checks for those aged 15+.  A Working Group in adolescent health is in the process of developing a screening tool for adolescent in PHC based on a validated assessment guide developed in Victoria. 
•	Adolescent Sexual health
o	The Adolescent Sexuality Education Project has come out of the National Partnership Agreement on Indigenous Early Childhood Development for sexual health promotion and education through NT schools and health centres.  It aims to improve access to sexual and reproductive health education for Aboriginal adolescents across the NT and to create a more consistent and coordinated approach to delivery of this education. 
o	The Mooditj program was designed for Aboriginal youth aged 11 to 14 years in rural and remote communities on sexual health and positive lifestyle program.  

2.5  Increase workforce capacity for action to reduce population risk factor levels	
What are we measuring?	What did we do?	

Healthy Workplace policies 
	
Healthy Worker initiative was developed as part of the Preventative Health National Partnership Agreement. NT Healthy Worker Implementation Plan was drafted and submitted to Australian Government for approval.  In August 2011, the DoH recruited a Healthy Worker Program Development Officer.  

The DoH Climate Change committee has been established to progress the development of DoH Climate Change Policy and is also working with other NT and national agencies to support climate change initiatives.

Number of education opportunities for health professionals to increase knowledge, understanding and skills about health promotion and prevention.	
See Key Action Area 6: Workforce development	

2.6 Ensure health sector reforms are responsive to the need for primary prevention	
What are we measuring?	What did we do?	

Promotion of health sector reforms based on recognised health promotion framework and principles and integration of primary prevention across multiple professional groups.
	
The Expanding Health Service Delivery Initiative (EHSDI) has led to several reforms in Primary Health Care (PHC) service delivery that will have an impact on the delivery of chronic conditions preventive care through:
•	The regionalisation process where preventive services are delivered by a multidisciplinary team working together in a team for a particular service delivery areas 
•	Introduction of new roles, such as public health coordinators that will coordinate integrated public health services for remote communities and Aboriginal community workers who will assist to promote health and wellbeing programs in the community  
•	Increasing number of health promotion positions across the NT to assist in program planning, coordination and evaluation.
•	The development of NT Health Promotion Framework.
•	A transition to community control should improve capacity to have preventative activities driven by Aboriginal leadership through health boards. 	
Key Action Area 3: Early detection and secondary prevention

Objective: Increase the early detection and management of disease markers in the at risk population to delay or halt the progression of chronic conditions. 

How will we measure progress in Year 1?
•	Description of strategies to improve recording of risk factor status in health records in different settings
•	Number and proportion of Aboriginal people aged 15-54 years who have had a full adult health check 
•	Number and proportion of Aboriginal people aged 55 years and over who have had a full adult health check in the past 12 months. 
•	Number of non Aboriginal people who have had a 40-45 year old health check.

Summary:
•	The 5th edition of CARPA was released in 2010 and contained changes in the chronic conditions chapter, including a section on cardiovascular risk assessment. The cardiovascular risk assessment (CVR) tool was incorporated into electronic primary care systems.
•	The rates for health checks (adults and children) are low at national and state/territory levels.  In 2009-10, less than 12% of the eligible Australian Aboriginal population received a check.  National data also showed that 80% of people who received health checks had problems identified that needed follow-up service. In 2009-10, an average of 8.4% of eligible Australian Aboriginal children received a check; the NT had the highest proportion (12.4%) of its eligible NT Aboriginal children (<15 years) received a health check.  
•	Amongst the non-Aboriginal adult population in 2010, a total of 197 people received a health check; this is a decline from 2009 of 594. GPNNT have continued activities to improve the uptake of health checks, including promotion at conferences, forums and in face to face visits. They support practices to identify eligible clients for health assessments, provide motivational interviewing workshops, ongoing promotion of lifescripts, and provide the installation of the Pen Cat data collection tool to facilitate quality improvement.  
•	There are various strategies in place in primary and tertiary settings to improve the assessment and recording of risk factors in paper based or electronic clinical systems; however this is an area that still needs further improvements.
3.1  Enhance primary health care capacity to implement a coordinated, systematic approach to early detection and management of disease markers that targets vulnerable/at risk populations	
What are we measuring?	What did we do?	

Description of strategies to improve recording of risk factor status in health records in different settings
	Hospitals 
•	RDH and ASH has commenced using a new Admission/Risk Assessment form for all patients being admitted into hospital that incorporates questions pertaining to the use of tobacco, alcohol and other drugs. Clinical staff are required to complete these forms on admissions and make the appropriate referrals as required.    
•	A new smoking assessment and intervention tool is also being developed that contains more in-depth assessment on smoking and there are plans to incorporate these into administrative procedures for hospitals.

Primary Health Care sector
•	A template for recording risk factors (Smoking Nutrition Alcohol Physical Activity and Emotional Wellbeing, SNAPE-brief intervention) is available in the Primary Care Information System (PCIS) and Communicare 
•	Risk factors are also screened and recorded through the use of adult health checks and the cardiovascular risk assessment tool.
•	Risk factor recording has also been embedded into health service planning, e.g. East Arnhem service plans for smoking assessment
•	Improving the recording of risk factors through continuous quality improvement (CQI) process, for example the One-21-Seventy audit (previously known as the Audit of Best Practice on Chronic Disease – ABCD).

Private General Practice
•	GP Practices are encouraged to utilise a clinical audit tool called Pen CAT produced by PENN computers. This is a clinical data extraction tool setup for practices using Medical Director, Genie and other systems. The General Practice Network Northern Territory (GPNNT) assists practices to extract de-identified data for PAP smears Hb1Ac results, proportion of patients with heart disease whose blood pressure is 130 /80 or less. Currently there are 22 practices who participate in this program. 
•	GPNNT has in the past run the Collaboratives Program funded through the Australian Collaboratives Primary Care Partnership. This funding has ceased and therefore is no longer supported.	

3.2  Develop, implement and evaluate flexible approaches to early detection and follow up of disease markers in a range of settings, based on local needs of at-risk populations	
What are we measuring?	What did we do?	

Evidence based guidelines
	
The fifth edition of the Central Australian Rural Practitioner’s Association (CARPA) Manual was launched in 2010 and contained several changes in the section of chronic conditions, such as having expanded guidelines on tobacco, cardiovascular risk assessment and reduction, interpreting results in one guideline and having combined checks for chronic disease. 

Introduction of the Cardiovascular Risk Assessment Tool
The CVR Assessment Tool is a simple tool that uses the absolute risk approach by taking into account of the combination and intensity of multiple risk factors to estimate the overall, individualised risk of developing cardiovascular disease (CVD). From there, individuals are stratified into different risk groups that have different clinical management strategy.  The use of CVR has been incorporated into clinical information systems across the NT. However, the NT also has surveillance systems for children which are not Medicare rebatable. These include school age screening and Healthy Kids Under Five. 

Protocol Management and Production Tool (PROMPT)
The DoH has developed a web-based document management system (PROMPT) to provide quick and easy access to approved clinical policies, procedures and guidelines across the five hospitals.  DoH non-hospital staff can access PROMPT via intranet on http://healthguidelines.nt.gov.au/Search/SearchLibrary.aspx 
	
Adult and children health checks	The rates for health checks (adults and children) are low at national and state/territory levels.  In 2009-10, only 12% of eligible Australian Aboriginal population received a check.  National data also showed that 80% of health checks showed health problems that needed follow-up service; however the delivery of such follow-up service has legged.  In 2009-10, an average of 8.4% of eligible Australian Aboriginal children received a check; the NT had the highest proportion (12.4%) of its eligible NT Aboriginal children (<15 years) received a health check.

NT Aboriginal:
•	Health checks for kids aged <15 years.  In 2010, there were 3191 children received a health check; this was a decline from 2009 figure of 3375 children. This decline can be explained by the cessation of the NT Emergency Response. 
•	Health checks for teenagers and adults aged 15-54 years.  In 2010 a total of 5847 (3137 females, 2710 males) teenagers and adults received a health check, this is an increase from 2009 figure of 3948 (2047 females, 1901 males).
•	Health checks for older adults aged 55 and over. In 2010 a total of 1432 people (821 females, 611 males) received a health check, this is an increase from 2009 figure of 1065 (607 females, 458 males).
NT non-Aboriginal:
Number and proportion of 40-45 year old health checks to at risk patients
•	In 2010 a total of 197 people received a health check; this is a decline from 2009 figure of 594.
•	GPNNT have continued measures to improve the uptake of this item number, such as promoting at conferences, forums and in face to face visits, supporting practices to identify clients for health assessments through motivational interviewing workshops and installation of the Pen Cat data collection tool and ongoing promotion of lifescripts to support the Item number.  	
Key Action Area 4: Self management

Objective: Implement a Territory-wide approach to self management 

How will we measure progress in Year 1?
•	Development of an NT Framework for chronic conditions self management. 
•	Description of opportunities for community members to access information about chronic conditions.

Case study: Better Outcomes for Lung Disease (BOLD)
•	A collaborative and multidisciplinary project developed by Asthma NT aimed at people with chronic lung disease to improve general physical, social and emotional well-being. This was done by encouraging active patient self-management, promoting healthier lifestyle and supporting lifestyle and risk factor modification and encouragement of peer support group.  
•	The program was conducted over a time frame of forty weeks and conducted in two stages:  
o	Stage 1: (Pilot) A holistic 12-week self-management program that operated twice weekly exercise, diet and asthma education.  All sessions applied evidence based practices and program was reviewed and participants reassessed at the end of the program.
o	Stage 2: Recruited participants to the updated 12-week self-management program and conducted for a further 12-week session, with pilot program content refined to meet the needs of the participants.
•	At the end of the project, all participants indicated that BOLD had enhanced their health knowledge and skills in COPD/asthma self management, improved exercise tolerance and physical functioning.  There was also improvements in lung function, improved recovery rates of ill-health, reduced hospitalisations and greater medication compliance.  There was a high level of project satisfaction with many achieving personal goals within the specified timeframe.  Program success can be attributed to many factors including a motivated project officer who provided ongoing support to participants. 	

Summary:
•	An NT Chronic Conditions Self Management Framework is currently being developed.  The Framework will identify key principles which are fundamental for the implementation of self management.  The Framework will guide and inform: (a) service providers across a range of health settings about how a self-management approach can be promoted and integrated into current practice, (b) health staff to deliver evidence based self management initiatives including to ensure clients are prepared and empowered to manage their chronic conditions, and (c) policy makers on how to better structure the health services in order to support health staff to provide self-management initiatives to clients, and to create an appropriate environment conducive to clients participating in self management.
•	There are a number of self management programs in the NT, the majority of which are disease specific and are mostly held in urban areas. Further work needs to be done to expand programs to remote areas and program evaluation needs to be included as part of the whole program.
•	There were a number of training opportunities about self management for health professionals organised by various health services.
4.1  Develop and implement a framework for self management to support consistent approaches for people with chronic conditions across the NT	
What are we measuring?	What did we do?	

Development of an NT Framework for chronic conditions self management. 
	
A Self Management Forum was held on March 2010 that was attended by health workers from across sectors including DoH, non government organisations, private sectors, Aboriginal community-controlled health services and education and research organisations. The forum led to:
•	Presentations on a range of self management practices across the NT by various organisations
•	Discussion of the elements required in the development of the NT framework, e.g. key principles, strategies, description on models of self management programs, training and support. 
•	The establishment of a Self Management Working Group.

A working group on chronic conditions self management was established on May 2011. It is envisaged that the NT framework will be finalised in December 2011. 
	
4.2  Empower and support individuals/carers to be active participants in monitoring and  management of their chronic condition	
What are we measuring?	What did we do?	

Description of opportunities for community members to access information about chronic conditions
	
There is a wide range of opportunities for community members to access information on chronic conditions:
•	Paper-based materials: 
o	Brochures, information sheets on a range of conditions, for e.g. asthma, diabetes, heart disease, cancer and lifestyle risk factors.
o	Newsletters and magazine, e.g. Asthma Update by Asthma Foundation NT (AFNT), Territory Way by Healthy Living NT (HLNT) that are distributed to members, health professionals and relevant government and community organisations.
•	Electronic websites that contain a wealth of resources for the general public or members, for e.g websites by AFNT, HLNT, CCNT, HFNT
•	Telephone education and support services by non-government organisations such as AFNT, HLNT, CCNT
•	Campaigns e.g. National Asthma Week, World Asthma Day campaigns
•	Radio sessions, e.g. Monthly asthma sessions on 104.1 Territory FM and community service announcements promoting AFNT on Southern Cross Television and radio station. 

•	Education sessions to individuals or community groups.  For example: 
o	Diabetes and lifestyle sessions provided by HLNT to community groups, individuals in a range of settings, including to general public, regular outreach sessions to Darwin Correctional Facility and Aboriginal Medical Services
o	Asthma education or awareness sessions provided by Asthma NT and in collaboration with GPNNT and ACCHS across the NT. 
o	Range of other education sessions provided in the PHC sectors by health professionals
•	Development of culturally appropriate resources for Aboriginal people, for e.g. chronic kidney disease flipchart, flipchart and poster for Aboriginal women with gestational diabetes, mental health flipcharts by the Australian Integrated Mental Health Initiative NT (AIMHi) and flip charts for Aboriginal Health Workers on Chronic Suppurative Lung Disease, Pneumonia and Bronchiolitis.
	
Number of opportunities for individuals/carers to participate in self management training
	Cardiovascular Disease
Healthy Living NT(HLNT) implemented a pilot program for self management of people with chronic heart failure – “Heart Failure Self Management Pilot Project”
•	This was a six week program delivered by a multidisciplinary team consisting of a nurse, dietician and an exercise physiologist. It consisted of group and individual-based activities focusing on the provision of education on a range of topics such as heart failure, risk factors and lifestyle modifications as well as physical activities. 
•	It also led to the development of resources such as Home Exercise for People with Heart Failure booklet and Heart Failure Management Plan.
•	Program evaluation showed a reduction in hospitalisations due to heart failure of clients who participated in this program.

Asthma or Chronic Obstructive Pulmonary Disease (COPD)
Asthma Foundation NT has a range of initiatives that promotes self management in asthma. This includes:
•	The Better Outcomes for Lung Disease (BOLD) program for COPD and asthma patients. Please refer to case study.
•	Providing information on asthma self management including use of an Asthma Action Plan to individuals and families. In 2010, 407 individuals had asthma action plans developed.
•	Providing group sessions for community organisations including schools, Aboriginal interpreter staff, Darwin Aboriginal and Islander Women’s shelter participants on asthma management with an emphasis on self-management in an emergency.  In 2010, 114 sessions were held and attended by 1803 people.
•	The ConocoPhillips Asthma Swim Program that encourages a healthy lifestyle for children and provides asthma management strategies to parents. It is anticipated that exercise and appropriate asthma self-management will become part of the child’s future lifestyle. Currently there are 74 children enrolled in this program.
•	Asthma, Child and Adolescent Program and the Community Support Program both funded by the Commonwealth Government and the Asthma Friendly Childcare Program. Target groups for the Community Support Program include Aboriginal groups, low socio-economic groups, the elderly and Culturally and Linguistically Diverse groups. 

Diabetes
•	HLNT provides group education sessions for people with newly diagnosed Type 2 diabetes in Darwin/Palmerston and Alice Springs aim at providing a comprehensive understanding of diabetes that is sufficient to commence immediate self-management initiatives. Regular review sessions are provided to individuals to assess client’s progress and understanding of disease management as well as managing long term complications of diabetes. 
•	The DoH Diabetes Educator established a diabetes self management support group in Tiwi Island for community members with insulin dependent diabetes. Regular sessions were held on a range of topics in health education, insulin and healthy lifestyle, development of skills in cooking and physical activities. The program aims to build community capacity to self manage their diabetes effectively and facilitated a mechanism for peer support.

  PCD Management Group Models Wilora pilot:
•	A community based group education project providing self-management support for individuals and families with diabetes and vascular disease.
•	It is a multidisciplinary and participatory action project with close involvement by the local health workers.  Activities include goal settings, group education, physical activities and healthy meals. 
•	The project was evaluated; the results showed improved health staff understanding on key elements essential for group self-management models in remote communities that will support sustained behaviour change and promote community control.
 
Chronic Kidney Disease
Emotional social and well being program for urban Indigenous people living with chronic kidney disease. 
•	Two 12 weeks self management program for Chronic Kidney Disease clients was conducted in Danila Dilba in 2010. It was adapted from the Stanford model for self management to suit Indigenous client’s needs. 
•	Program sessions were structured to fit the self management theme for the day; each session had an exercise, music, social interaction, self management training and nutritional education components. 
•	Evaluation showed some positive outcomes, such as improved knowledge in healthy lifestyle and self management and established peer support groups. The evaluation did not include objective measures, eg blood pressure.
	
4.3  Develop a skilled workforce to support individuals/carers/families to manage their health and health care	
What are we measuring?	What did we do?	

Educational opportunities for health professionals to develop skills in supporting/promoting self management. 	
See Key Action Area 6	
Key Action Area 5: Care for people with chronic conditions

Objective: Ensure clients with chronic conditions receive high quality clinical care and co-ordinated and integrated multidisciplinary care across services, settings and time.

How will we measure progress in Year 1?
•	Number and proportion of clients in Aboriginal PHC service aged 15 years and over with Type 2 Diabetes and/or Coronary Heart Disease who have a chronic disease management plan.
•	Number and proportion of resident clients aged 15 years and over with Type 2 Diabetes who have had an HbA1c test in the last 6 months.  (AHKPI 1.8).
•	Number and proportion of diabetic patients with albuminuria who are on ACE inhibitor and/or ARB.
•	Description of care co-ordination process for people with complex chronic conditions.
•	Improved linkages between mental health and AOD services and PHC services.

Case studies: Renal Care Coordination
The renal care coordination is one of the more established care coordination models for chronic conditions in the NT. It commenced in 2008 to provide a model of multidisciplinary care for people with late stage kidney disease across the whole of NT. The process involves a multidisciplinary group comprising of renal services, DoH PCD nurses and CKD Coordinators in ACCHS. It involves:
•	Facilitating case finding and establishment of chronic kidney disease register.
•	Improving sharing of information and management of clients between renal services and primary health care centres through case conferences and use of standard referral templates. Reviewing and strengthening recall systems with specific review of biochemistry, objective clinical measurements, usage rates of medicines and timely formation of access in preparation for dialysis.  
•	Providing regular feedback to patients regarding progress of disease and management options in end stage disease, including conservative treatment options. 
•	Embedded within is a system for monitoring performance indicators to monitor the quality of care received. Ongoing work to continuously improve the quality and robustness of data. 	

Summary:
•	Evidence based clinical care: During 2008-2010, there has been a steady increase in the proportion of management plans prepared by GPs for Aboriginal clients with Type 2 Diabetes. In 2008, approximately 39% of clients have management plans prepared by their GPs.  In 2009 and 2010, this figure has increased to 74% and 81% respectively. Similarly, for the same period, there has been a steady increase in the proportion of clients with Type 2 Diabetes who have had an HbA1c test in the last 6 months.  In 2008, 54.4% of clients had an HbA1c check in the last 6 months.  This figure increased to 76.5% in 2009 and 76.7% in 2010.
•	Specialist outreach services have been extended to include more medical specialties and allied health focused on chronic disease management with increased coverage of geographical areas. NT Renal Services have established regular telephone case conferencing with remote PHC centres for over 2 years; other chronic conditions are interested to explore this type of service. 
•	There are several care coordination models of service in place for renal, cardiac and respiratory disease. Renal care coordination is the most established of the three and provides a good model of care for other conditions to replicate.  There are also initiatives in place to improve care coordination at the PHC / Community Health level.  
•	One of the identified gaps is linking mental health services with other services and introducing screening for co-morbidities of chronic mental and physical illness.
•	There are limited cardiac, pulmonary and other rehabilitation services in the NT, in particular for clients in remote areas.  Further work needs to be done to increase these services.
In the area of palliative care, twenty-five per cent of referrals to palliative care were due to chronic conditions.  Of this, over half were referrals from end stage chronic kidney disease patients, where a model of referral pathways has been developed.  Work needs to be progressed to translate this model for other.

5.2	Provide access to high quality evidence-based clinical care	
What are we measuring?	What did we do?	

Chronic Disease Management Plan for people with Type 2 Diabetes and/or Coronary Heart Disease
	
Data on chronic disease management plan, HbA1c and diabetic medication for NT Aboriginal non DoH clients has not been released and therefore cannot be reported in this Report.  The following data has been obtained from CQI data for a number of DoH remote health clinics.

During 2008-2010, there has been a steady increase in the proportion of management plans prepared by GPs for clients with Type 2 Diabetes. In 2008, approximately 39% of clients have management plans prepared by their GPs.  In 2009 and 2010, this figure has increased to 74% and 81% respectively.

HbA1c check in Type 2 Diabetes 	
Similarly, for the same period, there has been a steady increase in the proportion of clients with Type 2 Diabetes who have had an HbA1c test in the last 6 months.  In 2008, 54.4% of clients had an HbA1c check in the last 6 months. This figure increased to 76.5% in 2009 and 76.7% in 2010.
	
Diabetic patients with albuminuria on ACE inhibitor and/or ARB	Medication	
2008	
2009	
2010	

 Total	
270	
219	
120	

ACR >3.5	
112	
41.5%	
87	
39.7%	
60	
50.0%	

ACEi only	
65	
58.0%	
52	
59.8%	
39	
65.0%	

ARB only	
7	
6.3%	
4	
4.6%	
2	
3.3%	

Both ACEi and ARB	
22	
19.6%	
24	
27.6%	
13	
21.7%	

Neither	
18	
16.1%	
7	
8.0%	
6	
10.0%	

No. of outreach medical specialist services for people with chronic conditions
	
•	A new model for NT specialist outreach services, Medical Specialist Outreach Assistance Program (MSOAP) has been developed under the Australian Government Indigenous Chronic Disease Package (ICDP) to increase delivery of specialist services for five chronic diseases (Cancer, Cardiac, Respiratory, Diabetes, Renal)
•	An Administration team to support the service has been established and the Outreach Website database has been developed to keep all interested parties informed of outreach activities.  
•	The incorporation of the medical specialist outreach services into the shared database occurred over a transition period of a few months in early to mid 2010; it may not fully capture all visits that occurred in 2010. 
•	For the period of 2010, there were over 620 specialist outreach visits days conducted across the NT in 2010 for cardiology, respiratory, renal, and physician. (Appendix 15)  
•	Services were negotiated with communities through Health Service Boards and DoH clinics to facilitate improved access to outreach services.
•	To date, coverage is most extensive for cardiology and renal outreach services, with visits to both Top End (communities in East Arnhem, Katherine, Top End West and Rural Darwin) and Central Australia (Alice Springs and Barkly region). Respiratory outreach services have recently commenced in 2010 to 10 Top End communities.
•	The MSOAP – ICD package also provides allied health services as part of comprehensive PHC. 
	
Number of renal teleconferences
	•	Another model of service in providing specialist services into the management of advanced chronic kidney disease is through teleconferencing. In the NT, the renal care coordination program led to the establishment of renal teleconferencing between primary health centres and renal services. 
•	In 2010, it provided 120 case conferencing sessions in the Top End and 64 sessions in Central Australia. 
•	Since its introduction in mid 2008 to end of 2010, it has provided a total of 518 sessions across the NT.

5.3  Provide access to quality, co-ordinated and integrated multidisciplinary care	
What are we measuring?	What did we do?	

Description of care co-ordination process for people with complex chronic conditions
	
Renal: Please refer to case study,

One of the Closing the Gap initiatives is the establishment of a Chronic Disease Coordination Unit within RDH in 2009.  The Unit is staffed by a Unit Manager, a respiratory nurse coordinator, a respiratory specialist, a cardiac nurse coordinator and an administration officer.

Cardiac
The RDH cardiac nurse coordinator focuses on providing coordinated and multidisciplinary care for people with acute myocardial infarct and priority 1 Rheumatic heart disease. The position is responsible for case coordination to ensure seamless transition of clients and their relevant clinical documentation between community/home, RDH and to Flinders Hospital.  As a Case Coordinator, this position maintains contact with the PHC team upon the person’s return until 12 weeks post surgery to advise on clinical issues.  It also regularly communicates with multidisciplinary team to ensure clients receive appropriate outpatient appointments.

The ASH has increased the number of clinical staff (on permanent and temporary basis) to improve services for clients with chronic conditions; this include 1 FTE Chronic Kidney Disease coordinator, 2 FTE Diabetes Educator, 2 FTE CNC Respiratory, 1 FTE CNC Preventable Chronic Disease, 1 FTE Cardiac Project Nurse, Clinical Technicians to assist with exercise stress testing.  These increased resources will provide ASH the capacity to improve link with PHC to reduce hospital admission and hospital length of stay.

Respiratory
The RDH respiratory nurse coordinator working closely with the respiratory physician in identifying people with severe COPD or bronchiectasis who will benefit from care coordination. The position provides education to patient and family, communicates with multidisciplinary teams to ensure clients receive appropriate appointments, identify gaps in care, assess home oxygen requirements and in the process of establishing case conferencing with PHC teams.

A referral system is in place between AFNT, RDH, Darwin Private Hospital (DPH) and GPs with ongoing collaboration with the respiratory team at RDH; clients to include remote areas

GP Superclinic
The GP Superclinic in Palmerston was established in October 2010 to provide coordinated and multidisciplinary care for people with chronic conditions and increase focus on health promotion and preventive activities. To date, work is being progressed to establish this multidisciplinary model of care.

Oral Health Services
Oral Health Services, NT is working in collaboration with the Alan Walker Cancer Centre and Renal Services as well as other key program areas to support cancer and chronic kidney clients to improve access to and receive quality dental care through the Special Needs Dental Clinic located within the Royal Darwin Hospital.

Project to improve PHC services  and coordination of people with Diabetes and Heart disease
Funded by the Australian Better Health Initiative, this is a collaborative project with DoH Community Health, HLNT and GPNNT on the development and initiation of a project to improve PHC services to people with chronic disease in Darwin/Palmerston and Alice Springs. It aims to facilitate the delivery of integrated and co-ordinated care to people with Type 2 Diabetes and Heart disease, increase the ability to work in effective partnership to reform and integrate urban PHC services according to best practice and develop or promote health promotion activities and resources for use by practices. 	

Access to General Practitioners and Allied Health Care Professionals: 
Ratio of Services delivered by Allied Health Professionals to GP 
	
In 2009/10, Medicare data shows that the NT ratio of occasions of patient services delivered by Allied Health Professional (AHP) Items relative to services by General Practice (GP) was 1:6.6, compared to the national ratio of 1:7.8. The results imply that the services provided by AHP relative to GP are higher in the NT than Australia and reflect access to primary health care services that include a multi-disciplinary approach. 

In comparison with 2008/09, there has been an 82.8% increase in the NT in the usage of practice nurse / allied health items in comparison with a 32.8% increase nationally for the same items. For the NT, the largest contributing group of items to this increase comes from items claimed by practice nurses in particular immunisation services

Table 16 in Appendix 4 provides the total number and a breakdown of service items claims by AHP and GP. 
	
5.4  Raise awareness of co-morbidity of chronic mental illness with other chronic conditions, and enhance early detection and care for these people	
What are we measuring?	What did we do?	

Improved linkages between mental health & AOD services & PHC services
	
•	Preliminary work has already started on identifying the priorities in mental health. The two key aspects are improving mental health screening for people with chronic conditions in primary health care sectors and improving chronic conditions management for people with mental illness. These pieces of work will be addressed by the Early Detection and Management Working Group, a working group that monitors the progress of activities within the key action areas 3 and 5 of CCPMS. 
•	The other area to progress is the strengthening of the mental health component of the vascular risk audit tool in the ABCD project. 
•	 Health Development teams had been supporting mental health team to ensure that PCD checks are completed for clients. 
•	Danila Dilba has incorporated the IRIS tool to screens mental health and wellbeing into care plans. In addition, the Danila Dilba Community Services Division has a few programs that focus on social and emotional wellbeing. These consist of the Emotional and Social Wellbeing Centre located at Malak Shopping Centre, Darwin that provides both on-site and off-site services and support to its clients; the Bringing them Home (BTH) counselling service and the Dare to Dream Program (D2D) that provides assessment, counselling, support and educational services to local Indigenous youth to ensure that youth have open access to appropriate mental health care and community support services.   
	
5.5  Improve rehabilitation services for people with chronic conditions in order to maximise function, improve quality of life and reduce the risk of further complications 	
What are we measuring?	What did we do?	

Cardiac Rehabilitation	
One of the 2011 priority of the Early Detection and Management Working Group (please refer to the governance structure part of this Report) is progressing a piece of work to explore issues on cardiac and pulmonary rehabilitation services including the link between these services and other rehabilitation services. This piece of work will produce information serves as a resource for the development of pulmonary/cardiac rehabilitation in the NT.

Cardiac education and rehabilitation services (urban)
•	Provided by HLNT through Memorandum of Understandings with RDH, DPH, ASH, NT National Heart Foundation (NHF) and NT Cardiac.  This service is available in Darwin and Alice Springs. Other locations are supported by telephone support services. 
•	The service was developed based on national guidelines and quality standards, in particular the “Recommendations for Cardiac Rehabilitation” by NHF and consist of a range of cardiac rehabilitation and education services which aid people with heart conditions to get back into the community and to improve their lifestyle. 
•	The service runs over 3 phases: 
o	Inpatient program
o	Outpatient program (Healthy Heart Program) focuses on secondary prevention and promote education and appropriate physical activity following a cardiac event. 
o	Maintenance program that involves follow up of cardiac risk factors, education and information sessions, continuing exercise program.
•	Telephone support services are available throughout the phases to support the clients.
•	In 2009/10, this service was provided to around 631 new clients (for Phase 1 and 2), 108 maintenance education, the majority in Alice Springs and 430 episodes of maintenance exercise (all in Alice Springs) and 33 seen in external clinics.
•	Including indirect episodes, there was a total of 1400 cardiac episodes with 1066 referrals received.	

Pulmonary Rehabilitation	Top End
•	This program is managed by Community Health, DoH and funded by RDH. 
•	It is an 8-week program held in the Palmerston Health Precinct that utilises self-management approach.  It involves the promotion of health literacy and physical activity
•	It is available for clients with chronic lung conditions who have symptoms of breathlessness and decreased ability to perform daily activities of living. 
•	An evaluation process has been included in the project plan.

Central Australia
•	In May 2010 ASH commence its pulmonary rehabilitation program based on the national “Breathe Easy-Walk Easy” program.
•	It utilises a self-management approach for clients (inpatients and outpatients) with COPD/bronchiectasis.
•	It is an 8-week program aimed to optimise physical and social wellbeing; clients are encouraged to transition to a maintenance program following completion.
•	Referrals can be from GP, allied health or self.
•	Pre assessment includes 6 minute walk test, spirometry, and a quality of life questionnaire.	

5.6  Provide people with chronic conditions access to appropriate, quality, integrated palliative care services	
What are we measuring?	What did we do?	

Referral to palliative care
	
In 2010, 25% of referrals to palliative care were due to chronic conditions such as renal, cardiovascular disease and respiratory disease and the other 75% were from cancer and other conditions. This proportion remained consistent from 2009 to current.  

Of renal, cardiac and respiratory conditions, referral for end stage renal disease was the most common source. This was largely due to the “Palliative Care for Renal Clients Living at Home” project that was a Commonwealth-funded initiative.  The project established a palliative pathway for renal patients, mapped out education and training requirements and identified barriers to remote area patient palliative management. During the project, the estimated number of renal patients assisted through palliative care from 2006 to April 2010 was 105 in the Top End and 184 in Central Australia.   
	
Key Action Area 6: Workforce planning and development

Objective:  Recruit, develop and retain appropriately skilled workforce

How will we measure progress in Year 1?
•	Evidence of collaboration with education providers to provide educational opportunities across disciplines and settings.

Summary
•	The collaborative work between Department of Health and CDU has resulted in the establishment of the new Bachelor of Health Sciences degree.
•	Flinders University and CDU have established a fulltime medical school with an emphasis on training Aboriginal doctors.
•	There are a range of educational programs organised by key education/research organisations, Department of Health and non government organisations in the form of professional development courses, lectures/seminars, symposium or group sessions.  A number of accredited chronic conditions professional development courses can be utilised towards gaining Continuing Professional Development points.  However, coordinated approaches to the planning and delivery of education sessions in the NT are required to maximise the use of the limited current resources.

6.1  Provide education, training and professional development opportunities that encompass all aspects of the chronic conditions prevention and management strategy	
What are we measuring?	What did we do?	

Evidence of collaboration with education providers to provide educational opportunities across disciplines and settings
	
The new Bachelor of Health Science course is currently being offered by CDU.  The development of this course was a result of collaborative work between CDU and DoH.

A report reviewing the options for health promotion education and training for the NT health workforce was completed in 2010 by DoH.  
	
Professional Development Training for Health Professionals	There are a range of professional development training programs, the majority of which are on-going programs, available for health professionals in the NT on chronic conditions prevention and management:

In 2010, the DoH Chronic Conditions Strategy Unit conducted two PCD short course in Darwin and Alice Springs, 5 diabetes course in Darwin, Katherine and Alice Springs, 1 Cardiac short course, 1 renal short course, 2 Well Women’s course, 1 Indigenous diabetic foot course  and 1 respiratory workshop. Almost all of these courses are accredited to continuing professional development points. Course content cover a range of topics on prevention and management topics, including self management. 

Menzies offered a number of short courses on Indigenous Health, Indigenous Mental Health, Program Evaluation, Nutrition and Community Development and Public Health. Menzies also offered research-focused courses relating to Indigenous Health Research and development of research skills.

GPNNT organised a range of educational sessions throughout the year on a variety of topics including cardiac, mental health, healthy lifestyle, asthma and respiratory.

Baker IDI organised a symposium on diabetes in August 2010, entitled Diabetes Care at the Centre: Grassroots care and prevention. An Educational Symposium.  It aimed to showcase some best practice examples of effective care programs and explore the social, cultural, psychological and other risk factors impacting diabetes and related chronic diseases; promote engagement between local health care providers, educators, researchers and policy makers and  to expand knowledge of evidence based care Topics covered include Primary prevention, care planning, lifestyle modification, Maternal and Child Health, integrating primary and tertiary care, managing complications of diabetes

Non-government organisations, such as HLNT, AFNT and CC NT also provide education sessions to health professionals on diabetes, asthma and cancer across the NT. For example, HLNT supplied diabetes education services and support to GPs, practice nurses and other diabetes educators across the NT (Darwin, Alice Springs, Katherine and Gove). Asthma NT provided group sessions for health professionals on asthma medications and use of Asthma Action Plans to encourage self management - In 2010, 54 sessions were held with 450 health professionals in attendance. Cancer Council NT organised outreach visits to regional and remote sites to provide education and support to PHC staff on cancer.

6.2  Build workforce capacity to meet future population needs through research and innovation initiatives	
What are we measuring?	What did we do?	

Realignment of existing health workforce and creation of new roles
	
The implementation of Extended Health Delivery Service Initiative and Closing the Gap Chronic Disease Indigenous Package have resulted in the creation of new positions across the NT that will impact on the delivery of care for people with chronic conditions. Most of these positions are based in the Aboriginal community-controlled health services. They include:
•	Public Health Coordinator
•	Tobacco Coordinators and Tobacco Action Workers
•	Healthy Lifestyle Workers
•	Continuous Quality Improvement Coordinators
•	Health Promotion Officers
	
6.3  Develop and support employment of Aboriginal people in management, policy and operational areas of chronic conditions	
What are we measuring?	What did we do?	

Provide education, training and professional development opportunities that specifically target Aboriginal people	
20 places with the Productivity Places Program have been secured for the Certificate IV in Population Health. There has been ongoing planning to support their delivery by CDU in 2011. Preference will be given to ATSI people and AMSANT have been invited to identify relevant workers.

DoH Aboriginal health promotion careers pathway project was endorsed in Dec 2010 and will commence in early 2011. This includes the evaluation of all DoH Aboriginal Health Promotion positions and the development of Aboriginal Health Promotion competencies. These positions will improve the capacity to undertake further health promotion activities targeting Aboriginal clients. 

DoH in partnership with AMSANT and OATSIH participated in a project to develop a framework for the Aboriginal primary health care workforce in the NT. This will be completed in 2011.

Stepping up program
•	A program currently in place within DoH for Aboriginal staff career pathways. It was developed in 2008 to provide practical skill-based learning and experience to perform in higher positions.
At the time of writing, the program has provided training to a total of 18 people, with rotations in a variety of work areas within DoH as well as non-government sectors such as the ACCHS, CDU and Fred Hollows Foundation. 
	
Key Action Area 7: Information, communication and disease management systems

Objective: To improve connectivity, sharing of useful information and access to appropriate services to support chronic conditions prevention and management.

How will we measure progress in Year 1?
•	Number of health services with electronic care planning and recall systems.
•	Evidence of collaboration with IM and ICT areas to incorporate needs of chronic conditions prevention and management strategies into systems.
•	Report on the activities of the NT CDN.
Summary
•	With the exception of four Department of Health remote health clinics that are still paper-based, all of the other Aboriginal PHC centres in the NT have electronic patient information and recall systems, and plans are underway to connect the four paper-based centres. This helps facilitate chronic disease management activities by having a uniform, effective and efficient system that will support the work of PHC and other multidisciplinary teams. 

•	There are existing collaborations in place between the information communication technology teams on a variety of projects relating to chronic conditions care. These collaborations should be strengthened and progressed further to enhance the system and incorporate the needs of chronic conditions prevention and management into systems. 

•	The development of a system to generate routine electronic reports relating to chronic conditions care in PHC should be made a priority. The development of these could be undertaken in a coordinated and structured approach to include both government and the Aboriginal community-controlled health services.  This will enable a NT-wide reporting system similar to the approach that is being implemented for the NT AHKPI data system. 
•	The continuing expansion of the e-health initiative to enable the sharing of electronic health records and other added features further support the integration and coordination of care for patients. 

•	The activities of the Chronic Disease Network (CDN) continued to facilitate networking and information sharing between a wide range of stakeholders working across the health sectors in the NT. The main activities of CDN include the annual CDN conference, quarterly newsletters, fortnightly e-CDN news and the sharing of information through CDN website.

7.1 Utilise existing and emerging information management (IM) and information communication technology (ICT) to facilitate efficient and effective chronic conditions prevention and management.	
What are we measuring?	What did we do?	

Number of health services with electronic care planning and recall systems
	
In 2010, DoH expanded the coverage of the Primary Care Information System (PCIS) to include health services in the two NT Prisons and one Juvenile Detention facility in addition to 54 departmental health centres using fully electronic health records. At the time of writing, the four PHC centres on paper-based systems: Gapuwiyak, Ramininging, Milingimbi and Yirrkala are in the process of being computerised.
 
All of the ACCHS are using electronic system, the most common system used is Communicare, a few on PCIS and Medical Director.

In private General Practice practices, the most common computer system being used is Medical Director, followed by Genie, Communicare and Ferret. The 2009/10 survey of GPs in the NT showed that 58 practices (48%) are confirmed using electronic systems, 9 additional practices used manual systems (7.5%). 52 practices (43%) reported having no particular system, however, the status of this is questionable due to data collection issues and many of practices in this group may have computer systems but do not report it as such. (Appendix 16)

The Palmerston General Practice Super clinic is online using Best Practice software. 
	
Evidence of collaboration with IM and ICT areas to incorporate needs of chronic conditions prevention and management strategies into systems.
	There are existing collaborations in place between the information communication technology teams on a variety of projects relating to chronic conditions care.

In private GPs, GPNNT support the Secure Electronic Messaging system (a system that has been in operation for four years) in the NT for all hospital, GP, Allied health professional communication. DoH supports discharge summaries, notifications, and outbound referrals among health professionals particularly allied health. GPNNT has also developed and implemented a computer system that allows GPs to receive patient data directly from the Shared Electronic Health Record (SEHR). There are 5 practices that have this facility in the NT: 3 urban and 2 remote practices. This capability is subject to further funding available to develop the tool further and to achieve improved integration of patient information between health systems.
	
7.2  Support and develop continuity of care initiatives that support health professionals and health services working together in an integrated, seamless, and coordinated way and enhancing the interface between health and other sectors.	
What are we measuring?	What did we do?	

Shared Electronic Health Records status
	
2010 saw the increased in registrations for the e-Health NT SEHR service to almost 40,000 patients (including 67% of Indigenous people living in rural and remote communities in the NT).  There are 105 participating health centres (including correctional facilities) with the SEHR fully implemented along with GP clinics and all NT hospitals. There are more than 3,000 clinicians currently registered with SEHR, every month sending >58,000 healthcare event summaries (an increase from >45,000 in 09/10 and <15,000 in 2008/09) and accessing on >9,000 occasions (an increase from >3,500 in 09/10 and around 500 in 2008/09).

The Advanced Shared electronic Care Plan development project (ASeCP) is a part of the Digital Regions Initiative and is aimed at improving the lives of Territorians across seventeen growth towns. The core goal of ASeCP is to enable the creation of data rich plans of care including future scheduled events and results that can be shared across multiple clinical systems. Supporting this will be the clinical decision support to allow customised plans of care to be created for each individual patient.
	
7.4  Implement strategies to share information across the NT	
What are we measuring?	What did we do?	

Report on the activities of the NT Chronic Disease Network

The activities and products of the CDN in 2010 include:
CDN Annual Conference 2010
•	The theme of the 2010 conference was Health Literacy, which highlighted excellent work in the NT. 
•	The CCPMS Implementation Plan also was launched at the conference by Dr Christine Connors. The topic Health Literacy was highlighted in the strategy as a potential benchmarking tool. 
•	The theme “Mental Health and Wellbeing and Chronic Disease” for the 2011 CDN Conference was proposed by people who attended the 2010 CDN Conference.  This is an indication on health workers’ need on mental health information in relation to other chronic conditions and an acknowledgement of the current NT burden of disease contributed by mental health (16.3%). The conference will explore the theme in relation to Aboriginal and Torres Strait Islander and Culturally and Linguistically Diverse populations, Social Determinants of health, Self management and prevention, substance abuse, prison health and policy/strategy approaches. 

Production of The Chronicle, a quarterly newsletter with articles written by members. The Chronicle Themes for 2010 were on chronic kidney disease, cancer, diabetes and the 2010 CDN conference.  

Electronic-CD News, a fortnightly email newsletter distributed to members on information about current issues, research, reports, events and opportunities.

Combined Networks – The CDN, in collaboration with CanNet, Pallcare Network, Renal, CCNT and GPNNT formed a combined network that meet monthly in regional areas. The Combined Networks visit the NT five major towns: Darwin, Alice Springs, Nhulunbuy, Katherine and Tennant Creek. During these visits, the Network highlight services or programs available to clients and/or health workers. The Combined Network provides networking opportunities for services working in chronic conditions and provide professional development opportunities to rural and remote staff in the NT. 

CDN Website - provides useful information on chronic conditions and is currently being reviewed. 	
Key Action Area 8: Continuous Quality Improvement

Objective: Improve chronic conditions prevention and management through continuous quality improvement activities

How will we measure progress in Year 1?
•	Evidence of CQI approach in PHC services
•	Evidence of collaborative research and innovation initiatives between the health sector and researchers to improve and extend CQI 

8.1  Increase continuous quality improvement (CQI) activities in all aspects of chronic conditions prevention and management	
What are we measuring?	What did we do?	

Evidence of CQI approach in PHC services:

a)	REMOTE

b)	URBAN	
The ESHDI CQI Needs Analysis Report in late 2009 revealed that there are a range of CQI process in place in PHC services that are conducted in a variety of ways using formal/informal tools.  The report showed a high level of readiness and a positive attitude towards the use of CQI.

•	There is a wide range of CQI activity / programs being implemented across the NT. This included the Quality Assurance for Aboriginal and Torres Strait Islander Medical Services (QAAMS) monitoring quality of Point of Care testing, Audit and Best Practice in Chronic Disease (ABCD - now One21Seventy, the National Centre for Quality Improvement in Indigenous Health) an action research project led by Menzies School of Health Research, Healthy for Life,  Australian Primary Care Collaboratives (APCC) and GP accreditation through Australian General Practice Accreditation Limited (AGPAL),. 
•	A wide range of CQI tools and techniques were used. The common tools that were used were ABCD audit files, ABCD Systems Assessment Tools, file auditing, check sheets, clinical case reviews and action planning, followed by client feedback, charts and process mapping.

The CQI Planning Committee met four times in 2010 to oversight the development and implementation of the CQI approach in PHC. The two CQI coordinators based with AMSANT worked with the whole sector to support and skill PHC staff in CQI approaches. There are 13 new Australian Government funded positions for CQI Facilitators across the NT. These positions work closely with PHC staff in a given Health Service delivery Area (HSDA) to undertake needs analysis, training, auditing and goal setting. To date, 10 positions have been recruited and they are doing considerable consultation in their regions to identify key regional priorities for CQI activities. 

Training in CQI
•	CQI Facilitator Orientation for 10 CQI Facilitators – CQI Program, CQI skills and tools, background on the NT AHKPIs, engagement skills and shared learning from more experienced CQI Facilitators.
•	One21Seventy training in use of audit tools delivered in Darwin, Alice Springs and Tennant Creek for 55 clinicians and health service staff.
Ongoing development of the NT AHKPI collection covering the Government and Non-Government sectors to improve the quality and robustness of data collection in PHC service planning and management through CQI.
•	The first NT AHKPI Collaborative Workshop was held in Darwin in November 2010 with 70 clinicians and health service staff attending. This workshop provided opportunity for shared learning around CQI activities undertaken by NT Government and ACCHS health services utilizing the NT AHKPIs. Presentations were given on the background of the NT AHKPI development, interpretation and analysis of data and CQI skills and tools.	
Oral Health – The Oral Health Service NT (OHS-NT) of the Department of Health is focused on organisational wide quality improvement. As part of the ongoing accreditation process, in 2010, the OHS-NT undertook a number of activities in order to prepare themselves for a full accreditation in 2011.  Activities in 2010 included: 
•	Providing training for staff on the use of Quality Improvement Program Planning System (QIPPS), and 
•	Developing a comprehensive work instruction for staff (including clinical guidelines) to ensure the provision of timely dental care for Rheumatic Heart Disease clients in particular all priority one (most severe) clients
Community Health – The accreditation of the Department of Health Community Health Branch including: its six clinics in cities and towns across the Northern Territory, the home visiting services in those towns and cities, the school health services, immunisation services, and the family and child health services, is undertaken by the Institute for Healthy Communities Australia Ltd using the Quality Improvement Council (QIC) standards and review process (corporate and clinical reviews).  

The QIC review cycle emphasises population (community) and individual client outcomes and is a cycle of continuous quality improvement utilising an organisational development model of quality management.  It has a strong consumer focus that encourages adoption of primary health philosophy and therefore it enhances the capacity of individuals and communities to take control of their own healthcare.  
In 2010, QIC released its 6th Edition Standards and replaced the 5th Edition published in 2004, upgrading their requirements for governance, safety and quality integration, assessment & planning, and consumer rights.

In 2009-2010, the Community Health Branch, as part of its continuous quality improvement cycle, conducted an annual Staff, Clients and Stakeholders Satisfaction Survey. A review of its policies and procedure documents were also undertaken.  Recommendations out of these activities were included in the Community Health six monthly quality work plan to improve and strengthen service delivery.  The Branch was accredited in December 2009 by the Quality Improvement Council for a period of 3 years.

Hospital – All five of the NT public hospitals have current accreditation.  In 2009-2010, the Royal Darwin, Alice Springs, Gove District and Tennant Creek Hospitals underwent accreditation surveys and have been granted full accreditation by the Australian Council and Healthcare Standards (ACHS) through their Evaluation and Quality Improvement Program (EQuIP).

Hospital accreditation addresses clinical, support and corporate functions through assessment against the following standards:,

•	Clinical function: Continuity of care, Access, Appropriateness, Effectiveness, Safety, Consumer focus.
•	Support function:  Quality improvement and risk management, Human resources management, Information management, Population health, Research.
•	Corporate function:  Leadership and management, Safe practice and environment.	
8.2  Improve service delivery through research and innovation initiatives	
What are we measuring?	What did we do?	
Evidence of collaborative research and innovation initiatives between the health sector and researchers to improve and extend CQI	The Audit and Best Practice in Chronic Disease action research, has been a collaboration between MSHR, NT Department of Health and more recently AMSANT. The project moved into a national phase in 2010 with the successful awarding of an NHMRC partnership grant, with collaboration between Health Departments, research institutes and community controlled peak bodies in NT, Queensland, SA and WA. The aim is to expand the use and sustainability of the CQI tools and to understand the factors underlying variation in delivery of services and outcomes. It will also identify characteristics of health services that promote best practice and share effective strategies.
A number of new tools are being finalised including the Rheumatic heart disease audit which has completed the pilot phase; the health promotion audit tool which has required significant work to align this with the clinical audit tools. 

STRIVE is a new research collaboration using the ABCD approach and tools to monitor the impact of CQI on clinical management and community prevalence of sexually transmitted infections. 

Abbreviations
ABCD		Audit of Best Practice in Chronic Disease
ACCHS		Aboriginal Community Controlled Health Service
ADSCA		Alcohol and other Drugs Services Central Australia
AFNT		Asthma Foundation NT
ALPA		Arnhem Land Progress Association
AMI		Acute Myocardial Infarction
AMSANT	Aboriginal Medical Services Alliance Northern Territory
ANFPP		Australia Nurse-Family Partnership Program
ANZDATA	Australian and New Zealand Dialysis and Transplant
		Registry
AOD		Alcohol and Other Drugs Services
ASH		Alice Springs Hospital
ASeCP		Advanced Shared electronic Care Plan
BOLD		Better Outcomes for Lung Disease
CA		Central Australia
CAAC		Central Australian Aboriginal Congress
CAD		Chronic Airway Disease
CATI		Computer Assisted Telephone Interview
CCNT		Cancer Council NT
CCPMS	Chronic Conditions Prevention and Management Strategy
CDMP		Chronic Disease Management Plan
CDN		Chronic Disease Network
CDU		Charles Darwin University
CKD 		Chronic Kidney Disease
COPD		Chronic Obstructive Pulmonary Disease
CQI		Continuous Quality Improvement
CVR		Cardiovascular Risk 
DBE		Department of Business and Employment
DCF		Department of Children and Families
DCM		Department of Chief Minister
DEEWR	Department of Education, Employment and Workplace
		Relations – Australian Government 
DET		Department of Education & Training 
DGPP		Division of General Practice
DLGHRS	Department of Local Government, Housing and Regional
   		services
	DoH		Department of Health 
DOJ		Department of Justice
EHSDI		Expanded Health Service Delivery Initiative
ESKD		End Stage Kidney Disease
GPNNT		General Practice Network Northern Territory
HFNT		Heart Foundation NT
HIA		Health Impact Assessment
HLNT		Healthy Living NT
HSAK		Healthy School Age Kids
HUK5		Healthy Kids Under 5
IHD		Ischaemic Heart Disease
JCU		James Cook University
JLF		Jimmy Little Foundation
NATSIHS	National Aboriginal and Torres Strait Islander Health Survey
NATSISS	National Aboriginal and Torres Strait Islander Social Survey
NGO		Non Government Organisation
NHS		National Health Survey
NT		Northern Territory
NTAHKPI	NT Aboriginal Health Key Performance Indicator
OATSIH	Office of the Aboriginal and Torres Strait Islander Health 
PCAC		Per Capita Alcohol Consumption
PCD		Preventable Chronic Disease
PCIS		Primary Care Information System
PFES		Police, Fire and Emergency Services 
PHC		Primary Health Care
PIRS		Patient Information Recall Systems
PHN		Public Health Network
QIPPS		Quality Improvement Program Planning System (QIPPS)
RCT		Randomised Controlled Trial
RDH		Royal Darwin Hospital
RHD		Rheumatic Heart Disease
SDOH		Social Determinants of Health
SEHR		Shared Electronic Health Records
TE		Top End	

Appendix 1 -  Table of data sources used for the profile of chronic disease in the NT

Data source
	Type	Time Series	Frequency	Coverage & Population	Age Group	What Data 	Comments	
NT Division of General Practice Program (DGPP)
	Medibank data
Survey
Administrative 
	Yes (for some)	Annual 	NT urban non-Indigenous	All ages	DGPP Prevention 1
DGPP Chronic Disease Management 1	Data quality variable across indicators. Only limited amount can be used. 	
ABS National Health Survey (NHS)	Survey Data	Yes	3 yearly
’01, ’04, ‘07	Australian-wide
Not applicable in NT 	All ages – Children to adults	Australian Prevalence on a number of Health Conditions, Risk Factors; Psychological Distress	Data not applicable in NT
Self-reported 
Lag time between collection & reporting
In 2011, will be incorporated into the Australian Health Survey (AHS)
	
ABS Australian Health Survey (AHS)	Survey Data	Possibly	First time 2011 
?Continue 	Australian-wide
Some component may be applicable in NT	All ages -Children to adults	Include 4 components:
-	NHS
-	NATSIHS
-	Nat. Nutrition & Physical Activity Survey (NNPAS)
-	National Health Measures Survey (NHMS)
	Core content NHS & NATSIHS, with a subset undertaking NNPAS, and voluntary participation in (NHMS).

Provide in-depth analysis on nutrition and physical activity; Objective measures of Blood Pressure and BMI; biochemical measures
 	
ABS National Aboriginal Torres Strait Islander Health Survey (NATSIHS)
	Survey Data	Yes	6 yearly
‘02, ‘08 	Aust Indigenous
NT Indigenous
(urban & remote)	Ages 18+	NT Aboriginal Prevalence of health conditions; risk factors, psychological distress
	Self Reported 	
ABS National Aboriginal Torres Strait Islander Social Survey (NATSISS)
	Survey Data	Yes	6 yearly
’04, ‘10	Aust Indigenous
NT Indigenous (urban & remote)	Ages 15+	NT Aboriginal prevalence on psychological distress, risk factors	Self Reported	
ABS Census of Population and Housing	Census	Yes	5 yearly
’01, ’06, ‘11	Australian-wide
NT Indigenous & non-Indigenous
	All ages	Total population, education, income, employment, housing	Population estimates for each State, Territory & Large Geographical Areas. Also data for Small Geographical Areas & population groups
	
Computer Assisted Telephone Interview
(CATI)
	Survey Data
	No	2 CATI 
’00, ‘04
(SA & WA)	NT urban Non-Indigenous	Ages 18+	Prevalence of health conditions, risk factors, psychological distress, mental health

	Self Reported 
Unrepresentative of Indigenous population	
NT and National Hospital Morbidity Database	Administrative Data	Yes	Continuous collection
Annually by AIHW	Australian-wide
NT Indigenous & non-Indigenous	All ages	Hospitalisations, prevalence of health conditions	Information bias – Coding issues, different pattern of hospital or diagnosis
Indigenous identification adequate in NT	
NT and National Mortality Database	Administrative Data
	Yes	Continuous	Australian-wide
NT Indigenous & non-Indigenous	All ages	Mortality data	Information bias - death certificates
Lag time between actual deaths & reporting
	
NT and National Cancer Register	Surveillance Data	Yes	Continuous
Reports by AIHW & HGPU	Australian-wide
NT Indigenous & non-Indigenous	All ages	Cancer incidence and mortality	Mandatory reporting by every State and Territory - hospitals, pathology, radiation oncology, cancer centres, nursing homes
	
Australian and New Zealand Dialysis and Transplant Registry (ANZDATA)	Surveillance Data	Yes	Continuous
Annual reporting by ANZDATA	Australian-Wide
NT Indigenous & non-Indigenous	All ages	A range of data on End Stage Kidney Patient requiring dialysis or transplant
 	Annual collection from all renal units
Good data quality: methods for data validation	
National Perinatal Data Collection	Pooled from administrative & surveillance data	Yes	Continuous
	Australian-Wide
NT Indigenous & non-Indigenous	All ages	Low birth weight, smoking during pregnancy	Quality assessment in 2007 – NT Indigenous status data good & suitable for trend analysis
	
National Drug Strategy Household Survey (NDSHS)	Survey data	Yes	3 yearly
’07, 10	Australian-wide
NT urban Non-Indigenous		Prevalence of smoking

	Self-reported 
Response rate ~50%
Issues with NT coverage	

Appendix 2: Kessler 10 (K10)

K10 was developed to provide a brief and valid measure of anxiety and depressive disorders in the population.  It uses a 10 question scale to determine the level of psychological distress and the 10 items are summed to give scores ranging from 10 and 50.  It is not a diagnostic tool, but an indicator of psychological distress.  There is no agreed method of determining the cut-off score for low, medium and high levels of psychological distress.  Most of the scoring methodology employed in the studies used in this report employed the scoring cut offs below:

  Table 12 – Kessler 10 Level of psychological distress 
K10 Score	Level of Psychological Distress	
10 – 15	Low	No Psychological Distress	
16 – 21	Moderate		
22 – 29	High	Psychological Distress	
30 – 50	Very High		

The exception is for The National Aboriginal and Torres Strait Islander Social Survey (NATSISS) 2008 who collected responses to five of the K10 questions, producing outputs for what will be referred to as a K5. 

Appendix 3:  Partnership between the health sector and other government departments

Name of Partnership	Departments involved	Primary purpose of partnerships	Example Of activities	Status of partnerships	Planned outcomes of the partnership	
Early Years and Youth	
Early Childhood Steering Committee (ECSC) 
	DET, DOH, DCF, NTPFES, DHLGRS, DCM
	To guide the development and implementation of an NT wide Early Childhood Development Plan that will seek to improve early childhood development outcomes by identifying priority strategies for more coordinated cross-agency activities, and by delivering high quality services and programs for young children and their families. 
	(i) NT Early Childhood Development (NTECD) Plan that provides greater coherence of existing and new identified initiatives and strategies. 

(ii) Integrated universal child and family services in the 20 Territory Growth Towns, including joint funding arrangements to build the capacity of the related workforce.	On-going	• Identify the developmental needs of children in Northern Territory, and the programs capable of delivering measurably improved outcomes for all children, and to reduce the existing disparities in children’s health, developmental and educational outcomes.

• Build system effectiveness and capacity and address gaps in order to develop improved early childhood development services by 2020, in accordance with the National Early Childhood Development Strategy.

• Enable the effective integration of preventative and targeted universal services for young children between DET, DHF and other relevant agencies to develop streamlined governance and administrative arrangements, funding agreements and reporting mechanisms.

• Build policy coherence among stakeholder agencies.

• Oversee the implementation of more effective universal preventative and early intervention responses for vulnerable children.
	
Integrated Children and Family Centres	DET, DoH, Police, DCF,
PFES 
	To determine child and youth programs to run from integrated centres in five NT communities	Healthy Under Five Kids Program	Recently established (one year) - ongoing	Best quality, evidence-based Child and Youth Health programs to run from integrated centres in each community
	
Alice Springs Transformation Plan - Early Childhood Project	DET, DoH, DCM, DEEWR,  CAAC Anglicare, Tangentyere.	To develop an evidence-based ECD initiative in Alice Springs (in development)	Abecedarian pilot in Alice Springs	Currently being established.	To be defined.	
Australian Nurse Family Partnership Program
	OATSIH, CAAC, ANFPP Support Service	To establish in Alice Springs a Nurse Family Partnership Program site.	Sustained nurse home visiting	Ongoing - established in 2008.	As specified in Project documentation.	
Youth Health Policy	DCF, DoH	To develop a Youth Health Policy for the NT	Collaborative consultation meetings	Recently established (six months)	Youth Health Policy for the NT with accountable outcomes
	
Education	
Indigenous Early Childhood Development National Partnership -Element 2	DoH & DET	To increase provision of sexual and reproductive health services to Indigenous teenagers.	Education resources mapped against the NT Curriculum Framework.
• Planning with regional sexual health and educational services regarding a training calendar for 2011.
• Ongoing sexual health promotion and education through NT schools and health centres.
	Ongoing - commenced July 2009.		
Jimmy Little Foundation (JLF) Education Resourc	DoH, DET, Jimmy Little Foundation (JLF)	To support the school curriculum in the area of healthy lifestyle.	Advising on the development of a teaching manual aimed at primary school aged students including nutrition, physical activity, oral health, hygiene information
	Establishing formal agreements with JLF	Inclusion of a set of healthy lifestyle messages consistent with national guidelines.	
Childhood Healthy Weight Project	DoH, DET	To promote healthy weight and prevent weight gain	Joint development of a Canteen Nutrition and Healthy Eating Policy for NT Schools
	MOU	Indicators not yet established	
Royal Darwin Hospital (RDH) Community engagement project	DoH, DET 	Liaise with DET to establish a pilot program with RDH staff and Dripstone High School in 2011. 	Engagement with secondary school students on careers in health	Time-limited
	 	
Employment	
Aboriginal Health and Community Services Workforce in the NT (Project)	DoH, DBE, DEEWR
	Encourage and coordinate system change relating to education pathways	Working Group	To commence in 2011		
Food Security	
Partnership with Outback Stores	DoH, Outback Stores	To facilitate increase the supply and demand for healthy food choices in remote communities	Share information, including sales data, plan and implement healthy food promotion

	MOU	Improved food security.	
Market Basket Survey

	DoH, Katherine West Health, ALPA	To conduct an annual monitoring of prices, quality and availability of a basket of foods in remote community stores	Monitor price, quality and availability of food in remote community stores	Non formalised	Improved food security.	
Others	
Climate Change
Symposium	DoH, DCM, CDU
	To organise and deliver a climate change symposium in October 2011.	Keynote speakers and session on health and chronic conditions. 
	Meeting on a monthly basis to progress.	Ongoing relationship with DCM re: Health and climate change	
Healthy Homes Working Group	DoH, DCF, DLGHRS FACSIA, Centrelink, Power and Water Corp	Development of a management plan by place, initially in the fifteen Remote Service Delivery priority communities, aimed at improving coordination in the provision of services that impact on Housing, Tenancy and Life Skills support that will address the increased support needs in the roll out of additional public housing.

Identify the effectiveness and limitations of current Territory and Federal Government strategies and services to address the skills required by Aboriginal people in maintaining a healthy home.	 	Established late 2010	Monitor, and provide advice to the Remote Service Delivery Board of Management on improvements to service coordination in the fifteen priority communities. 

Develop a framework for the provision of services that impact on Housing, Tenancy and Life Skills support that will address the increased support needs in the roll out of additional public housing. 

Develop a framework to improve the communication, information-sharing, and working arrangements between all organisations involved in service planning, provision and reform. 
	
Improving Water Management of Small Water Supplies	DoH, DLGHRS, Power and Water Corp, National Water Commission	Help Outstation and Small Water Suppliers to prepare Water Management Plans	Workshops and Training for Resource Centres and Shires	Continuation of Earlier Project. July 2008 - July 2010. Current Project from late 2010
	Improve drinking water management in small supplies to protect public health.  
Build capacity in the field.	

Asbestos Steering Committee	DoH, DLGHRS, FAHCSIA	Working to address the issue of asbestos in the 73 NT communities with Asbestos Registries through the Asbestos Management Project	Monitor the overarching progress, outcomes and achievements of the agreed objectives for the Project against the Scope;
Review major innovations and suggestions from the Senior Project Manager, where these require Government approval;
Report, and provide information to departmental senior executives and ministers;
Provide feedback to the Senior Project Manager from departmental senior executives and ministers; 
Provide Operational Status reports from line Agencies; 
Take corrective action where required.	Established early 2009 ongoing until project completed in approx June 2011	Removal and replacement of all asbestos containing material (ACM) that requires removal in ‘Less than 12 months’ as defined in the 73 Asbestos Registers.	

ALPA		Arnhem Land Progress Association
ANFPP		Australia Nurse-Family Partnership Program
CAAC		Central Australian Aboriginal Congress
CDU		Charles Darwin University
DBE		Department of Business and Employment
DCF		Department of Children and Families
DCM		Department of Chief Minister
DEEWR		Department of Education, Employment and Workplace Relations – Australian Government 
DET		Department of Education & Training 
DLGHRS		Department Local Government, Housing and Regional Services,
DoH		Department of Health 
JLF		Jimmy Little Foundation
OATSIH		Office of the Aboriginal and Torres Strait Islander Health 
PFES		Police, Fire and Emergency Services 

Appendix 4: Supplementary Data Tables and Figures

i)	Number and proportion of Aboriginal staff employed within the Department of Health

Figure 24 - Classification levels of Aboriginal staff in the Department of Health (DoH) and the Department of Children and Families (DCF) in 2010

ii)	NT Aboriginal babies with low birth weight 2006 – 2010

Table 13 –  Trend in public hospital liveborn low birth weight (LBW) babies, by financial year and Aboriginal status
 
Year	Aboriginal	Non-Aboriginal	
	Total	LBW	(%)	Total	LBW	(%)	
2006*	1424	208	(14.61)	1601	122	(7.62)	
2007*	1452	201	(13.84)	1532	103	(6.72)	
2008*	1379	180	(13.05)	1628	81	(4.98)	
2009*	1462	188	(12.86)	1598	94	(5.88)	
2010*	1402	202	(14.41)	1698	130	(7.66)	
							
Notes:‘Not Stated’ Indigenous status were excluded from analysis. Babies born before arrival with an intended hospital of birth were included in analysis. 
** 2006–2010 data obtained from A2 2 - 2009_10 data.pdf
Figure 25 - Trend in the proportion of NT liveborn low birth weight babies by Indigenous status

iii)	Chronic Disease Management

Figures 26 – Number and Proportion of clients with Type 2 Diabetes who have a chronic disease management plan in 2010.

Figure 27 - Proportion of clients with Type 2 Diabetes who have had an HbA1c test in the last 6 months in 2010

Figure 28 - Proportion Diabetic clients with proteinuria treated with ACEi and/or ARB
iv)	Medical Specialist Outreach Assistance Program (MSOAP) 
Table 14 - Number of clinic sessions of specialist outreach program for people with chronic conditions in 2010 
Specialty	Top End	Central	Total	
Physician	96	89	185	
Cardiology	36	38	74	
Renal	178	17	195	
Respiratory	16	0	16	
Psychiatry	84	74	158	
Total	410	218	628	

v)	Access to General Practitioners and Primary Health Care Professionals

Table 15 - Ratio of Medicare claims by Allied Health Professional to GP services and breakdown of service Iitem

	MBS Item No	NT	National	
NT RATIO of AHP ITEMS to GP ITEMS		1: 6.6	1:7.8	
TOTAL Allied Health Professionals Items		84,497	13,161,020	
TOTAL GP Items		555,618	102,432,922	
Allied Health Professional Services	
Services by Aboriginal Health Worker or Practice Nurse 	10986, 10987 10988, 10989	10,179
(12%)	37,212
(0.3%)	
Services by Practice Nurses
	10993, 10994, 10995, 10996, 10997, 10998, 10999	60,130
(71%)	7,542,001
(57%)	
Services by Clinical Psychologist 
	80000, 80005, 80010, 80015, 80020	2,617
(3%)	1,087,169
(8.3%)	
Services by Focused Psychological Strategies / General Psychologists	80100, 80105, 80110, 80115, 80120	6,143
(7%)	1,869,203
(14%)	
Services claimable by Occupational Therapists	80125, 80130, 80135, 80140, 80145	2
(0%)	34,194
(0.3%)	
Services claimable by Social Workers
	80150, 80155, 80160, 80165, 80170	292
(0%)	162,081
(1.2%)	
Additional MBS items by Allied Health Professionals
	10950 – 10954, 10956, 10958, 10960, 10962, 10966, 10970, 10978	5,134
(6%)	2,429,160
(18.5%)	
All Allied Health Professionals TOTAL		84,497
(100%)	13,161,020
(100%)	
GP Items	
GP A1 Professional Attendance Items		553,301	98,540,565	
GP A2 Professional Attendance Items		2,317	3,892,357	
TOTAL GP Items		555,618	102,432,922	

vi)	Electronic Care Planning and Recall System 

Table 16 - The number and proportion of general practices within the Division using practice register/ recall/ reminder systems to identify patients with a chronic disease for review and appropriate action 2009/10

Practices using electronic system	Practices using manual system	No register/ recall/ reminder system	Number of practices for whom data available	Number of practices for whom data is unavailable	Total practices in the Division	
Number 	58	9	52	119	1	120	
Percent 	48.33%	7.5%	43.33%	99.17%	0.83%	100%	

Appendix 5:  	Number of community education/health promotion/social marketing activities to promote quitting and smoke free environments.

List of current or completed research projects by Menzies on tobacco control
•	Monitoring tobacco consumption using tobacco wholesale data: 
o	Following a project by Menzies in 26 remote communities involving monitoring tobacco consumption using wholesale data from all tobacco outlets, the NT Department of Justice has made ruling that tobacco wholesale data is a condition for a new NT Tobacco Retail Licences. This will enable the monitoring of trends and impact of new policies and programs.
o	In addition, it also led to 1) collaboration with the Nutrition Researchers that showed no impact of the introduction of Income Management on tobacco sales and 2) collaboration with Nganampa Health Council in examining tobacco sales on Anangu Pitjantjatjara lands that showed low daily tobacco consumption in six remote Aboriginal communities.
•	Healthy Starts Study: An international Randomised Controlled Trial which aims to test the efficacy of a family centred tobacco controlled program about second-hand smoke to reduce respiratory illness in Indigenous infants in Darwin and Maori infants in New Zealand. 
•	Maternal and household smoking behaviours during pregnancy and post partum: findings from the Northern Territory Pneumum Study: Prospective cohort study to describe the trends in maternal and household smoking behaviours of Indigenous women in the NT from their last trimester in pregnancy to seven months post partum.
•	Cochrane systematic review of incentives to prevent smoking in children and adolescents (ongoing) which aims to assess the effect of incentives on preventing children and adolescents from starting to smoke.
•	Talking about Smokes: A Commonwealth funded project, Menzies commenced the Establishment Phase of an ambitious national longitudinal study of Indigenous smoking in partnership with ACCHS and leading tobacco control researchers in 2010. It is based on the influential International Tobacco Control Policy Evaluation Project, which has projects in 20 countries around the world and has the potential to transform the evidence base and how tobacco control policies work to reduce Aboriginal Smoking.
•	Impact of the 25% increase in the tax on tobacco, which examines the impact of the increase in tobacco excise in May 2010 on tobacco consumption in 18 stores in remote Aboriginal communities. 

List of publications by the Menzies Tobacco Researchers in 2010, Preventable Chronic Disease division
•	Brimblecombe J, McDonnell J, Barnes A, Dhurrkay JG, Thomas DP, Bailie R.  Impact of income management on store sales in Northern Australia. Med  Aust 2010; 192: 549-554.
•	Butler R, Chapman S, Thomas D, Torzillo P.  Low daily smoking estimates derived from sales monitored tobacco use in six remote predominantly Aboriginal communities.  Aust NZ J Public Health 2010; 34:S71-5
•	Johnston V, Thomas DP. What works in Indigenous tobacco control?: the perceptions of remote Indigenous community members and health staff. Health Promotion Journal of Australia 2010; 21:45-50.
•	Johnston V, Thomas DP, McDonnell J, Andrews R. Maternal and household smoking behaviours during pregnancy and postpartum: findings from an Indigenous cohort in the Northern Territory. Medical Journal of Australia, in press.
•	Johnston V., Walker N., Thomas D., Glover M., Chang A., Bullen C., et al. The study protocol for a randomized controlled trial of a family-centred tobacco control program about environmental tobacco smoke (ets) to reduce respiratory illness in indigenous infants. BMC Public Health, 2010;10(1):114.
•	Thomas D, Johnston V. Incentives for preventing smoking in children and adolescents (Protocol). Cochrane Database of Systematic Reviews 2010, Issue 8. Art. No.: CD008645. DOI: 10.1002/14651858.CD008645.
•	Thomas DP, Glover M.  Smoking and Aboriginal and Torres Strait Islander and Māori children.  Journal of Paediatrics and Child Health 2010; 46: 516-20.
•	Thomas DP, Johnston V. Lessons for Aboriginal tobacco control in remote communities: an evaluation of the Northern Territory 'Tobacco Project.’ Australian and New Zealand Journal of Public Health 2010;34(1): 45-49.