AOP Current Situation

SWSAHS is one of 17 Area Health Services in NSW which are responsible for providing public health care services to a geographically defined population.

The primary purposes of an Area Health Service, as defined by the Health Services Act 1997, are to:

SWSAHS is administered by a Board consisting of members appointed by, and responsible to, the NSW Minister for Health. The role of the Board is to ensure that the Area fulfils its functions as defined by the Health Services Act and the Area’s Performance Agreement as negotiated and agreed with the Director-General of NSW Health.

The day to day management of the Area is the responsibility of the Area Chief Executive Officer and Area Executive Team. SWSAHS is comprised of Sector Health Services, each with a Sector General Manager. These are Bankstown, Fairfield, Liverpool, Macarthur and Wingecarribee.

SWS comprises the seven local government areas of Bankstown, Camden, Campbelltown, Fairfield, Liverpool, Wingecarribee and Wollondilly and covers an area of 6,237km².

Settlement varies from quite dense suburban residential development in Bankstown to scattered rural townships in Wingecarribee and Wollondilly. Parts of the Area are quite geographically isolated, particularly in Camden, Wingecarribee and Wollondilly and the western parts of Fairfield and Liverpool.

SWSAHS’s population is projected to grow by 13.7% from 731,615 in 1996 to 830,509 in 2006. SWSAHS comprised 11.8% of the total 1996 NSW population and will be the second most populous Health Service by 2006 with 12.3% of NSW’s population.

As well as overall population growth, the proportion of elderly people in SWSAHS is projected to increase from 9.1% to 10.7% of total population. This is significant as growth among the elderly is a key driver of hospital and health service activity and resource consumption. Rates of hospital usage for the 65-79 population is 4.6 times that of the average, while rates for the old elderly are 6-10 times that of the average.

The demographic characteristics of SWS indicate the residents have more social disadvantage than other areas in NSW:

Any population carries within it a level of illness or disability referred to as the burden of disease. Any population at any time has residents with pre-existing conditions (chronic diseases such as diabetes), with existing disabilities (eg those after a stroke), as well as those who are well and those who are at risk of becoming unwell.

On top of this, physical and mental harm can happen to any member of a population at any time. Some people’s chronic conditions can be kept stable for relatively minor cost (eg control of hypertension via drugs, control of diabetes via keeping blood sugars stable) creating relatively little burden on the health system. The burden of disease on society therefore depends on how well the illness or pre existing conditions are managed, as well as how well the health system responds to the episodic nature in changes in physical and mental health.

Low socio-economic status is associated with poorer health status. South Western Sydney (SWS) has factors such as relatively low income and higher unemployment which imply there will most likely be a sizeable burden of disease in the area.

While the tools for measuring this are limited to monitoring who uses SWSAHS services or those in other Area Health Services, part of the burden can be inferred from statistics regarding socio-economic status, as well as data collected by the Commonwealth Department of Health and Aged Care. For example, Health Insurance Commission data and Pharmaceutical Benefits Scheme data, can indicate better the number of people with diabetes or with hypertension who may not need the services of NSW Health but are cared for effectively by General Practitioners (GPs).

The 1995 SWSAHS Health Promotion Survey indicates that GPs were the main health service used once or more (87.2%), followed by dentists (41.5%), specialist doctors (36%) and hospital emergency or outpatient departments (14.1%). The 1997 NSW Health Survey report estimated that nearly 30% of SWS residents had seen a GP in the previous two weeks. It is apparent that GPs are a critical part of health services.

The information held by the NSW Health system is related to mortality and morbidity.

The principal cause of death in SWSAHS (1985-1994) was circulatory disease, accounting for more than 40% of all deaths. Cancer was the second major cause of death (approximately 25%), followed by injury/poisoning and respiratory disease. The principal individual cause of death for both sexes in the ten year period 1985-94 was acute myocardial infarction. Injury and poisoning causes were the most important contributors to premature mortality, followed by neoplasms.

The causes of death varied by age and sex. The primary cause of death in childhood (0-14 years) was accidents, while circulatory diseases and cancer were the predominant causes in middle (15-64 years) and old age groups (65+ years).

During the periods 1985-89 and 1990-94, age standardised death rates for English Speaking Background persons were substantially higher than those for Non English Speaking Background persons.

While hospital utilisation statistics refer to illness or injury requiring admission to an institution and are therefore not an accurate measure of morbidity in themselves, they do provide useful data on major cause of illness and injury. During the period 1990-96, hospital separations for SWS residents increased from 207 per 1000 population to 279 per 1000 population. Crude separation rates in SWSAHS were lower than the corresponding NSW rates.

Diseases of the digestive system, injury/poisoning and circulatory disorders for males and pregnancy complications and diseases of the genitourinary system for females were the main causes of separations in both SWS and NSW.

The Standardised Separation Ratios (SSRs) for infectious diseases, mental disorder, diseases of the nervous system, diseases of the respiratory system, musculo-skeletal diseases and injury/poisoning showed significantly lower rates in SWS compared to NSW.

SSRs for neoplasms, diseases of blood and blood forming organs, diseases of the skin, diseases of circulatory system and genitourinary disorders showed significantly higher rates of separation in SWS compared to NSW. Higher rates of separations for young children and the elderly reflect higher rates of illness in early and later life.

Arising from the National Health Ministers’ annual conferences has been the identification of National Health Priority Areas (Coronary Heart Disease, Diabetes, Mental Health, Injury, Cancer, and Asthma). Asthma has recently been identified as the sixth National Health Priority Area.

From this SWSAHS has identified its own high priority areas. This has been on the basis of the National agenda, the State agenda and the local health needs in the South West of Sydney. Eleven (11) Advisory Committees have been convened to advise the Area on priorities for health improvement and long term directions for health outcomes and health improvement strategies. This will involve a number of tasks such as advice of best practice, appropriateness of current utilisation, suitable indicators to enable measurement, opportunities for networking and priorities for action.

SWS residents had higher rates of mortality from CHD compared to NSW and is a major cause of death in SWSAHS. SWS residents had higher hospital separation rates for CHD diagnosis, left heart cardiac catheterisation and coronary angioplasty (males) procedures than NSW.

SWSAHS has developed a Strategic Plan for Improving Health for Coronary Heart Disease that has the goals of:

Risk factors included: inadequate rates of physical activity in SWSAHS were significantly higher; overall rate of smoking was slightly higher in SWSAHS, rates for overweight and obesity significantly higher in SWSAHS.

Cardiology and cardiothoracic surgery and bypass service streams are significant outflows for SWSAHS.

Medical oncology has high outflows and demand and relatively low self sufficiency.

In 1994, 32 males and 51 females died of diabetes. The relative number of deaths from diabetes for both males and females in SWS was higher than for the NSW population, and in the case of females, significantly higher (almost 15% higher for males and almost 40% higher for females). The annual change in death rates over the last 12 years is slightly negative for males (-2.08%) and slightly positive for females (0.90%).

Diabetes incidence increases with increasing age and is higher in ATSI and NESB populations. Diabetes is a significant health problem for the population of SWS, as highlighted in the Diabetes Strategic Plan, Diabetes Health in South Western Sydney, Strategic Plan for Improving Health 1997-2002.

Stroke is a significant illness, causing approximately 400 deaths a year in SWS. One third of all people who experience a stroke die from the condition and a further third are left with a disability. Many of the risk factors for cardiovascular disease (including stroke) are modifiable. These include: high blood pressure, smoking, poor diet, obesity and physical inactivity. To the extent that these risk factors are modifiable, many cases of stroke can be prevented.

High blood pressure is the single most important risk factor for stroke. It is not known whether SWS residents’ experience of high blood pressure is higher or lower when compared with other populations. However, assuming that 10% of the population has high blood pressure, based on other population studies, this would equate with 73,000 residents.

Stroke: A Strategic Plan for Improving Health 1999-2002 was released in April 1999 and begins to address this health priority area.

Falls from playground equipment are the most common cause of childhood injuries and a significant cause of trauma amongst children 0-14 years of age. Approximately 18,000 children are taken to hospital each year in NSW for playground related injuries, of which 3,000 are serious enough to be hospitalised (NSW Health Department, 1993). In SWS in 1995/96 falls in the 0-14 year age group accounted for 915 injury admissions to hospital. Figures from the NSW Health Department (1993) indicate that school playgrounds (39%) have the highest number of falls from playground equipment, followed by community playgrounds (27%).

NSW Fire Brigades statistics show that fatalities are twice as likely to occur in houses without smoke detectors. Most fatalities are due to smoke inhalation and not the actual fire.

During 1997 there were 6,240 reported motor vehicle accidents in SWS. Of these 62 were fatalities with 485 people admitted to hospital and 1,414 treated for an injury. The majority of fatalities were car occupants followed by pedestrian fatalities. Four of the seven LGAs in SWS recorded the highest number of motor vehicle controllers involved in fatal accidents for the State: Campbelltown 20, Fairfield 16, Liverpool 10 and Bankstown 8. 50% of fatalities in SWS were involved in crashes in which the speed of the vehicle was 60 kilometres or less. In all crashes in SWS speeding accounted for 18% of fatalities.

Data from the 1994/95 health promotion surveys indicate that the self-reported rate of episodes of injury occurring in the last 12 months was similar for both residents of SWS and residents of NSW. These episodes included those requiring hospitalisation.

The report Mental Health and Wellbeing: Profile of Adults, Australia, 1997 (Australian Bureau of Statistics) indicates that 18% of the Australian population met the criteria for a mental disorder in the previous 12 months (anxiety, affective and drug and alcohol disorder). Young adults aged 18-24 years had the highest prevalence of mental disorder with a rate of 27%.

Given the relationship between mental health problems and social disadvantage, it is assumed that SWS residents have higher rates of mental health problems than other more socially advantaged areas of NSW.

By taking a broad view of mental health in SWS, opportunities exist to work with communities to reduce isolation, improve community support structures and connect people to services and to each other. In addition, issues such as suicide prevention in young people, domestic violence and child protection, can be addressed and better integrated through this broader view of mental health. Development of partnerships and community health are important parts of this type of approach.

The adequate provision of mental health services is an important issue for SWSAHS as the percentage of NSW resources allocated to SWSAHS for mental health services has never approached the levels of funding provided to other Areas.

Mental Health recurrent funding is allocated from a separate pool. A Mental Health Resource Distribution Formula has been under development by NSW Health for some time. It has been estimated by SWSAHS (on a per capita basis) that there is a budget deficiency of over $17 million if equity is applied to the distribution of mental health resources across NSW. The 1999/00 mental health budget for SWSAHS is $22.895 million.

Planning has occurred for acute adolescent inpatient and day services at Campbelltown and Liverpool; expansion of adult inpatient services at Liverpool; and the overall development of services for Fairfield-Liverpool.

The United States Centre for Disease Control and Prevention described tobacco smoking as the single greatest cause of disease in the developed world (US Department of Health and Human Services, 1994). Excessive alcohol use is attributable to a number of health related illness, accidents and violent behaviours.

Groups at risk in SWS include some NESB groups (such as Vietnamese men), Aboriginal people, young people and people of low socio-economic status.

Based on the SWS Health Promotion Survey Report 1994/95, the smoking rate for SWS residents is 25.1%, slightly higher than the NSW rate of 24%. However, between population subgroups and geographical areas there were differences in smoking rates. For example, smoking prevalence was high in Liverpool (32%), Campbelltown (27.9%) and Fairfield (25.5%) and lower in Bankstown (22%) and Wollondilly/Wingecarribee (20.9%).

Information from the NSW Health Promotion Survey on smoking prevalence among Aboriginal and Torres Strait people indicates that 42% were current smokers with rates of 47% among males and 36% among females.

The Trends in Adolescent Health in SWS report indicated the following trends in relation to smoking for young people:

It is estimated that, in SWS in 1990/91 up to 2% of all hospital separations could be attributed to the effects of alcohol. The Trends in Adolescent Health in SWS report indicated the following trends in relation to alcohol:

Of the illicit drugs, heroin is of major concern in SWS, and specifically the local government area of Fairfield, where 47% of all recorded offences for trafficking in narcotics in the state occur. Research into heroin-related deaths in SWS indicates a 120% increase in deaths from 1992 (20 deaths) to 1995 (44 deaths). Over half of those who died in 1995 resided outside SWS.

24.4% of SWSAHS’s population is aged 0-14 years. Infant Mortality Rates (IMR) have tended to decline in all SWS LGAs during the period 1987-1994. Over the period 1987-1994 the IMR for SWS residents was similar to that for NSW residents (7.6 and 7.5 respectively).

Late diagnosis of hearing loss (not detected until a child was over one year of age) was 48.3% (mean) in SWSAHS compared to 36.3% (mean) in NSW over the period 1990-1993. Late intervention impacts directly upon the overall development of affected children including the development of speech and language and their overall psycho-social development.

Over the period 1987-1994 SWS residents experienced a significantly higher rate of low birthweight babies (at term) compared with the rate for NSW. Two factors which account for this higher rate of low birth weight babies are smoking in pregnancy and a high proportion of mothers from Asian countries who tend to have smaller babies. The proportion of SWS women who smoked during pregnancy for the period 1993-1994 was similar to those in NSW, however some LGAs such as Campbelltown, Wingecarribee and Camden were found to have higher proportions of women smoking.

During 1994/95 Department of Community Services data indicate that SWSAHS had the highest notification rate of child abuse (children aged 0-17 years) of any of the Sydney metropolitan Area Health Services (30 reports per 1000 population).

Data from the Adolescent Health Survey, conducted across 34 Government schools in 1992 indicate that young people aged 11 and 15 years partake in high levels of smoking; high levels of alcohol use; low levels of physical activity and often experience feelings of being lonely. The rates of smoking and alcohol use reported in SWS were no higher than NSW rates.

There were 20 deaths attributed to suicide in those aged 10-19 years during the period 1990-1994 in SWS, and of those 14 were males, the ratio of male to female deaths being 2.3 to 1. The number of deaths rose markedly in the 20-29 years age category with 81 reported deaths, 68 occurring in males. The rates of suicide in SWSAHS are similar to the NSW rates.

Cancer and injury and poisonings accounted for 20% of deaths of SWS residents aged 0 to 14 years for the period 1990-1994. There were no significant differences in the death rates experienced by SWS residents when compared to NSW residents.

Outflows for paediatric and perinatal services are significant. While outflows for tertiary services are appropriate, it is considered that most children in SWS should be able to access non tertiary care locally.

The Perinatal Services Network (PSN) has reviewed the bed requirements for neonatal services in SWSAHS. The PSN is the state expert group. The PSN has suggested that SWSAHS requires 58 level 2 beds, which is an increase of 6 beds. The PSN has also suggested that 4 of these additional beds should be located at Liverpool Hospital. The current configuration at Liverpool Hospital is 5 level 3 ventilator beds, 3 level 3 non ventilator beds and 15 level 2 beds.

The PSN has recommended that the Liverpool Neonatal Intensive Care Unit requires 1 additional level 3 ventilator bed. This will require a transfer of resources from an existing NICU as no additional level 3 ventilator beds are required statewide. The process of transfer is still to be advised by the Department of Health.

This will require consideration of the capacity of Liverpool Hospital NICU to accommodate the additional beds.

Based on the 1996 Census, Aboriginal and Torres Strait Islander people constitute 1.2% of the population in SWS. Because the number of Aboriginal and Torres Strait Islander people is comparatively low, and due to the inaccuracy in coding of Aboriginality in data collection systems local quantitative data on their health status is incomplete and/or unreliable. Thus national data are often used as a proxy.

Nationally, Aboriginal people have a death rate approximately double that of the total Australian population, they have a life expectancy almost twenty years below that of all Australians, and Aboriginal and Torres Strait Islander babies die at three to four times the rate of all Australian babies. Most Aboriginal and Torres Strait Islander residents of SWS live in urban or peri-urban communities and may not have the same health status as that of Aboriginal people nationally, however their health is probably substantially worse than non Aboriginal people in SWS.

A study of admissions to Campbelltown Hospital indicated that Aboriginal children reported lower levels of immunisation (44%), experienced higher rates of hospital admission for vaccine preventable diseases; higher rates of children who were low weight (13%); low height (12%); shorter duration of hospital stay (mean length of stay 2 days); and higher levels of readmission with 19% admitted twice and 52% admitted greater than two times.

Overall, people from non-English speaking background have lower morbidity and mortality rates than the NSW population as a whole. However, for some health issues some groups have higher or similar rates. People born in Oceania and the Middle East have significantly higher hospitalisation rates for cardiovascular disease, and males born in USSR higher death rates.

Women born in South East Asia had significantly more new cases of cervical cancer, however deaths rates for cervical cancer were similar to those for all women in South Western Sydney and NSW.

Females from North East Asia and Eastern Europe had significantly higher death rates for suicide than NSW as a whole. People from all other countries had significantly lower or the same rates of morbidity and mortality from all causes of injury.

For diabetes, the death rate is higher for males and females from Southern Europe, Middle East and North Africa; higher for males from Southern Asia; and higher for females from Oceania/Micronesia/Polynesia.

For NESB residents, health status and service utilisation are likely to be affected by pre-migration experiences, the migration process and factors associated with settlement, such as English language skills, social support and satisfaction with life in Australia. A study of recently arrived immigrants to Australia examined self-reported physical and mental health status and utilisation of health services, six months post-arrival. On each of the health status measures used the study found that humanitarian entrants scored the poorest, with age-standardised ratios tending to be significantly higher than the next group, in most cases Preferential Family entrants.

It also found that those proficient in English reported better health and less use of medical services than those with poor or no English language proficiency, and the authors concluded that English language fluency appeared to have an independent effect on the health status of immigrants.

This is particularly relevant to SWS, which has a higher proportion of people with poor English language skills than NSW overall (in 1996, 25.3% of SWS residents who spoke a language other than English at home spoke English not well or not at all, compared with 20.4% for NSW.

The study also found that those employed had the highest rate of good self-rated health and a lower rate of reported long term conditions; and that women reported poorer health on each of the health status measures used.

With regard to the health of refugees, studies have shown that they have significant mental health problems (approximately half of all refugees) and physical health problems. SWS has significant numbers of residents who are refugees or are from refugee-like backgrounds. Data for 1996/97 indicate that 39.1% of humanitarian entrants to NSW settled in SWS. This figure does not include those from "refugee-like backgrounds" ie those coming from situations of war/civil unrest/fleeing discrimination or persecution etc, who may technically arrive under Family migration categories.

In SWSAHS in 1998, nearly 62% of all notified diseases were due to Hepatitis B and Hepatitis C. This compares to 44% for NSW. SWSAHS accounted for 17.8% of all notifications for Hepatitis B and Hepatitis C in NSW. Hepatitis B and Hepatitis C are common in the 15-24 year age group and continue to be prominent in the older age groups. In particular, the SWSAHS rates for Hepatitis B are much higher than NSW rates for all age groups.

These rates are a concern due to the implications of mother to newborn transmission and longer term morbidity and mortality associated with cirrhosis and cancer of the liver.

In 1998, the greatest proportion of notifications was for residents of Fairfield, followed by residents of Bankstown and Campbelltown. Notification rates were highest for residents of Fairfield and Bankstown.

Asthma is a chronic respiratory condition, usually beginning in childhood. Its effects may vary from mild, with occasional acute exacerbations, to severe. It is an important public health problem in Australia, with prevalence rates amongst the highest in the world (Report of the Chief Health Officer 1997).

In 1998 there were a total of 3,916 Emergency Department (ED) presentations for a primary diagnosis of asthma. Asthma accounted for 2.2% of all ED presentations in SWSAHS compared to 1.8% for NSW. The proportion of ED presentations for asthma are greatest in the 0-14 year age group for both males and females. The presentation rates for SWS residents are particularly higher for the 0-4 year age group compared to NSW rates for the 0-4 year age group.

Just over 80% of all presentations by SWS residents for asthma were to SWSAHS hospitals. The majority of ED presentations were to Liverpool, Bankstown and Campbelltown. The 0-14 year age group constituted the greatest proportion of asthma presentations to Campbelltown and Bankstown Hospitals.

The overall rate of hospital separations (per 1,000 presentations) for males and females were similar between SWS residents and all residents of NSW. Compared to NSW, both male and female residents of Campbelltown and female residents of Bankstown had higher standardised separation rates (SSRs). 85% of hospital separations were from hospitals in SWSAHS with Campbelltown and Liverpool having the highest proportion of 0-14 year age group separations (64% and 58% respectively) and Bankstown and Fairfield having larger proportions of separations in the 55+ year age group.

The death rate from asthma in NSW has been declining gradually since 1989 while the hospitalisation rate has been relatively stable in recent years. There were a total of 152 deaths from asthma in SWSAHS in the period 1993-1997. In SWSAHS for both males and females, the age standardised mortality was no greater than that for NSW.

NSW Health’s Asthma Improvement Project has identified the following goals: reducing the prevalence of asthma; improving the health of people with asthma; and optimising the clinical management of asthma.

Public sector health services in SWS are provided by hospitals, community health centres, nursing homes and specialist centres providing services such as rehabilitation, mental health and family and child. A range of other health services is also provided by private, government and non government organisations.

There are six acute hospitals in SWSAHS. There has been significant capital investment in facilities in SWSAHS over the past 5-10 years. The major redevelopment associated with Campbelltown and Camden Hospitals is estimated to be complete in 2003.

Liverpool Hospital is the principal referral hospital for SWSAHS and a major teaching and research hospital for the University of NSW.

Liverpool provides a range of sub specialty services, primarily at role delineation levels 5 and 6, in medicine, surgery, critical care, aged care, mental health, drug and alcohol, obstetrics and gynaecology, neonatology and paediatrics (Level 4).

Liverpool has 551 average available beds and provides Area and Statewide tertiary referral services and also district level services to the Liverpool LGA.

Bankstown-Lidcombe Hospital is a major metropolitan hospital providing services, primarily at role delineation level 5, in medicine, surgery, critical care, aged care, rehabilitation, mental health, obstetrics and paediatrics.

The Hospital has 404 average available beds and provides services to the Bankstown and Lidcombe LGAs.

Campbelltown and Camden Hospitals operate under a common executive management structure. Campbelltown is a district metropolitan hospital providing a range of services primarily at role delineation level 4 in medicine, surgery, critical care, obstetrics, paediatrics, mental health and drug and alcohol. As part of the Macarthur Sector Strategy, 81 additional beds and upgrading of services to mainly level 5 will be achieved by mid 2003.

Camden is a district metropolitan hospital providing medical, surgical and obstetric services mainly at role delineation level 3. Camden also has specific roles in palliative care and aged care and rehabilitation for the Macarthur Sector. The facility is being upgraded as part of the Macarthur Sector Strategy.

The two hospitals have 263 average available beds and deliver services to the residents of the Campbelltown, Camden and Wollondilly LGAs.

Fairfield Hospital is a district metropolitan hospital providing services, primarily at role delineation levels 3 and 4, in medicine, surgery, critical care and obstetrics.

The hospital has 185 average available beds and delivers services to residents of the Fairfield LGAs. Fairfield Hospital is developing a role as the centre for elective orthopaedics for the Liverpool-Fairfield Sectors.

Bowral Hospital is a rural district hospital providing services mainly at role delineation level 3 in medicine, surgery, critical care and obstetrics.

The hospital has 73 average available beds and delivers services to residents of the Wingecarribee LGA.

Hospital	Total Beds		Average Beds Available in 1998/99
Hospital	Built	Ave Available	Acute	Rehabilitation	Mental Health
Liverpool	680	545	519	20¹	26
Bankstown	454	404	314	60	30
Fairfield	244	185	185
Campbelltown²	313	231	185	16	30
Camden²	84	32	32
Bowral	75	73	71		2
Total	1,850	1,470	1,260	96	88

Role delineation is a process that determines that the support services, staff profiles, minimum safety standards and other requirements are provided to ensure that clinical services are provided safely and appropriately supported. There are 8 clinical support services that are primarily hospital based and are essential to the successful provision of 49 major clinical core services. There are up to 7 levels of service (0-6) in increasing complexity.

The role delineation of acute hospitals in SWSAHS is provided in Appendix B. The role levels for Campbelltown and Camden are those approved as part of the Macarthur Sector Strategy.

As indicated in Table 2, there were 35 operating rooms (including procedure rooms) in 1997/98 in acute public hospitals in SWSAHS.

A combination of surgical activity of 28,625 Episodes of Care (EOC) and endoscopy procedures of 6,118 EOC resulted in a total supply of surgery/endoscopy within SWSAHS during the 1997/98 period of 34,743 EOC. Detail of the activity is provided in Appendix C.

Dividing this operating room activity by the number of funded sessions per year of 9,820 (assuming 2 sessions a day and a theatre year of 10 months duration), results in a per session workload of 3.5 cases.

The current unused physical capacity of SWSAHS theatres is 104.5 sessions per week or 4,180 per 10 month year. Applying the per session caseload capacity of 3.5, it is estimated that SWSAHS has the theatre capacity to do an additional 14,630 EOC.

Sector Health Service	Theatres	Sessions Funded	Possible Sessions Total per 5 day week	Capacity
Bankstown	8	50.5	80	29.5
Camden	2	15	20	5
Campbelltown Main Theatres Day Theatres	2 2	12 14	20 20	8 6
Fairfield	4	25	40	15
Liverpool	11	83	110	27
Wingecarribee	2	20	20	0
Total	31	219.5	310	90.5
Bankstown	2	14	20	6
Liverpool	2	12	20	8
Total	4	26	40	14
Grand Total	35	245.5	350	104.5

Braeside Hospital is a third schedule hospital managed by Hope Healthcare and is located on the Fairfield Hospital campus. There are 72 beds available for palliative care (20), rehabilitation (36) and aged care psychiatry (16).

Karitane provides support, guidance and information to families experiencing parenting difficulties, to health professionals and to the community. Karitane is located at Carramar and provides the following services: education unit; a 24 bed pre/post natal depression residential unit; volunteer home visiting; Family Care Cottages; and a 24 hour care line.

There are community health centres at Narellan, Campbelltown, Rosemeadow, Tahmoor, Bowral, Bankstown, Liverpool, Cabramatta, Carramar, Prairevale, Ingleburn, Yagoona, Moorebank and Hoxton Park.

The major service types, target groups and the activities provided by SWSAHS community health services include:

In 1997/98, there were 44,729 separations of SWS residents in the private sector. Consistent with the generally lower case mix in the private sector, this was equivalent to 30,006 cost weighted separations. SWS residents used 93,584 bed days.

263 beds are available in the following private hospitals: Bankstown Private (66), Greenacre; Macarthur Private (52), Campbelltown; Southern Highlands Private (64); and Sydney Southwest Private (81), Liverpool. There are four day procedure centres located in Fairfield Heights, Bowral, Moorebank and Liverpool. There are 2,395 beds in 28 nursing homes.

There are 975 General Practitioners across the south west of Sydney with 60% consulting in a language other than English. These are organised into five Divisions of General Practice – Fairfield, Liverpool, Bankstown, Macarthur and Southern Highlands.

Hospital	Staff FTE¹	Available Beds	Seps	% Same Day to Total Admissions	% Surgical Same Day to Total Surgery	Occupancy Rate	Average Length of Stay	NIOOS
Bankstown	1,053.2	404	27,978	31.7	35.9	86.6%	4.5 days	357,116
Camden²		32	5,739	38.1	50.9	71.7%	3.6 days	81,083
Campbelltown	750.2	231	22,513	33.0	53.9	90.9%	3.2 days	329,886
Fairfield	490.4	185	15,850	21.9	33.0	77.8%	3.3 days	395,094
Liverpool	2,004.1	545	49,815	46.4	31.2	94.4%	3.7 days	657,000
Wingecarribee	183.9	73	7,139	38.1	48.7	78.7%	3.0 days	73,122
Total	4,481.8	1,470		34.9%	42.3%	83.4%	3.55 days	1,893,301

Hospital	Cost per Weighted Separation	SWS Peer Group Cost per Weighted Separation	Hospital Comparison Book Peer Group Cost per Weighted Separation
Bankstown	2,259	2,200	2,146
Camden	2,112	2,100	2,409
Campbelltown	2,031	2,100	2,146
Fairfield	1,966	2,100	2,146
Liverpool	2,195	2,400	2,537
Wingecarribee	2,032	2,100	2,409

Table 5 – 1998/99 Activity and Cost Data for SWSAHS Non Acute Health Services

Health Service	Staff FTE	Available Beds	Admissions	Cost per Separation	Occupancy Rate	Average Length of Stay	NIOOS
Brain Injury	70.7	24	145	$32,182	70.4%	33.7 days	7,706
Braeside	172.6	72	1,500	$7,089	87.3%	14.8 days	9,830
Carrington	87.0	94	78	$59,987	99.8%	433.4 days
Karitane	62.9	24	1,359	$2,588	81.9%	5.1 days	33,524
Queen Victoria	90.9	100	132	$42,763	95.8%	292.8 days	1,355
Total	484.1	314	3,214				52,415

Service	Emergency OOS	Emergency Diagnostics OOS	Emergency Services $’000	Ave cost per OOS¹	Mental Health OOS	Mental Health Services $’000	Ave Cost per OOS
Bankstown	30,679	24,031	$2,309	$75	19,892	$3,174	$160
Campbelltown	32,452	16,817	$2,022	$62	17,429	$373	21
Camden	11,811	3,574	$824	$70	0	0	0
Fairfield	27,395	13,692	$2,053	$75	429	0	-
Liverpool	52,508	29,555	$6,082	$116	51,562	$6,452	$125
Wingecarribee	17,137	28	$934	$54	5,675	$820	$144
Total			$14,244	$75		$10,819	$114

Service	Outpatient OOS	Outpatient Diagnostics OOS	Outpatient Services $’000	Ave cost per OOS	Primary & Comm Based OOS	Primary & Comm Based Services $’000	Ave Cost per OOS
Bankstown	80,610	31,718	$9,059	$81	117,158	$7,807	$67
Campbelltown	113,888	10,366	$5,742	$46	98,297	$8,770	$89
Camden	12,751	6,108	$1,399	$74	36,320	$3,879	$107
Fairfield	45,933	26,060	$3,274	$45	272,261	$11,788	$43
Liverpool	363,165	41,907	$22,259	$55	102,571	$20,332	$198
Wingecarribee	11,781	81	$1,962	$165	36,706	$2,891	$79
Total			$43,695	$59		$55,467	$84

Service	Rehab & Extended Care OOS	Rehab & Extended Care $’000	Ave cost per OOS	Total OOS	Total $’000	Ave Cost per OOS¹
Bankstown	54,090	$8,811	$163	358,178	$31,160	$93
Campbelltown	15,648	$287	$18	304,897	$17,194	$60
Camden	14,574	$1,454	$100	85,138	$7,556	$93
Fairfield	9,581	$2,140	$223	395,351	$19,255	$50
Liverpool	49,012	$6,528	$133	690,280	$61,653	$93
Wingecarribee	5,469	$624	$114	76,877	$7,231	$94
Total		$19,844	$133		$144,049	$81

In addition, 7,882 Rehabilitation and Extended Care OOS were provided at Braeside at an average cost of $134 per OOS; Karitane provided 27,634 Primary and Community Based Services OOS and 3,774 Mental Health OOS; and Queen Victoria provided 604 Primary and Community Based Services OOS and 4,661 Rehabilitation and Extended Care OOS.

There were 244.2 FTE staff employed in Mental Health services in Bankstown, Campbelltown and Liverpool in 1998/99. There was 823.04 FTE staff employed in Community and Allied Health services in all Sectors in 1998/99. This compares to 202.7 FTE staff employed in Mental Health and 665.8 FTE in Community and Allied Health services in all Sectors in 1996/97.

It should be noted that there has been some variation in cost centres over this period and direct comparison is not possible.

With ongoing resource constraints and limited numbers of 24 hour medical clinics and GPs who bulk bill, it is expected that people accessing care through the Emergency Departments (ED) will increase and the unplanned to planned admission ratio will increase.

There has been a 10.7% increase in weighted ED attendances since 1996/97. This is important as EDs are a key entry point into the hospital system. Over the same period there has been a 5.3% increase in admissions from ED to hospital. This would suggest that some of this growth in attendances is appropriate as the patient has gone on to be admitted.

There are some variations across the Sectors. Weighted ED attendances have increased at Liverpool (17.3%), Bowral (22.1%) and Campbelltown (12.1%) with associated increases in admissions (Liverpool 15.1%; Bowral 28.4% and Campbelltown 7.8%). There has been reductions in both attendances and admissions at Camden (-5.1% and -11.1% respectively). Attendances have increased at Fairfield (3.4%) and Bankstown (7.4%) while admissions have decreased (-1.2% and -3.6% respectively).

Th variation in the Macarthur Sector is related to the changes in inpatient beds and decanting at Camden and therefore shifts of activity to Campbelltown.

Of total hospital admissions in 1997/98 and 1998/99, 37.9% and 38.5% were from the ED. As a statewide benchmark, generally about 33% of total admissions are from the ED.

Monitoring of waiting lists commenced in March 1995. There are a number of targets in relation to waiting lists and there have been a number of strategies aimed at reducing the waiting time for patients, particularly for those waiting longer than 12 months.

Figure 5 indicates the total utilisation of acute services by SWS residents over the period 1994/95 to 1997/98. This includes public and private sector activity, residents treated within SWSAHS and those treated outside SWSAHS. This shows:

1 in 4 SWS residents access care outside SWSAHS. In 1997/98, more than 50% of SWS residents accessed tertiary services outside the Area Health Service. Figure 6 demonstrates the inflows and outflows in 1997/98. Central Sydney, South Eastern Sydney and Western Sydney Area Health Services and the new Children’s Hospital are the four main areas where SWS residents access care outside SWSAHS.

There has been a significant reduction in tertiary outflows since 1995/96 that is expected to have continued in 1998/99. Non tertiary overnight and same day outflows have remained basically the same or have slightly increased.

In regard to outflows by Sector Health Service, there have been slight reductions over the period 1994/95 to 1997/98. Bankstown Health Service is the main source of outflows from SWSAHS with 34% of all outflows from this Sector. This is followed by Fairfield and then Macarthur Sector Health Services.

As indicated there are varying levels of outflows and self sufficiency by individual service stream. It should be noted that while there may be high outflows for some services, self sufficiency may in fact be high. For example, while Obstetrics is a high volume outflow, 88% of SWS residents receive obstetric care within SWSAHS.

The top 10 tertiary outflows by SRG account for 85% of all tertiary outflows from SWSAHS. The top 10 non tertiary overnight outflows by SRG account for 66% of all non tertiary overnight outflows. The top 10 same day outflows account for 74% of all same day outflows. Figures 8-10 indicate these flows.

In the years 1994/95 to 1997/98, there has been an 11% increase in inflows to SWSAHS. Reflecting the increased availability of higher level services within the Area, there has been an 18% increase in case-weighted separations. Central and Western Sydney Area Health Services are the main sources of inflow.

Net flows, that is the differential between outflows and inflows, is one of the indicators used to determine the Area’s budget. Over the period 1994/95 to 1997/98, there has been a reduction in net flows as outflows from SWSAHS have reduced and inflows have increased. However, overall the Area continues to have large net outflows.

In 1997/98 SWSAHS total activity grew 7.16% compared to 1996/97. This corresponded with an injection of funds to Liverpool and other sites. Flow reversal was evident in the clinical disciplines where services were developed or expanded, for example, cardiothoracic surgery. Tertiary self sufficiency increased by 10% from 37.6% in 1996/97 to 47.4% in 1997/98. Despite this, for some services outflows increased (for example, in orthopaedics) and equity worsened, with more patients having to travel outside SWSAHS for care.

Activity increased 2.73% in 1998/99. As much of this was driven by funding for the Priority Access Strategy, some of the growth has been aimed at lowering existing queues and creating better access. However, some flow reversal is anticipated.

SWSAHS has historically been under funded in relation to its RDF share of the available funds for health services. Currently SWSAHS has 96.1% of its 2001 funding share. This share excludes funding for SWS residents who receive care outside SWSAHS, that is, the share is based on existing flow patterns. If SWSAHS achieved its 2001 target share, this would be equivalent to an additional $18 million based on the current pool of funds which is available.

Activity currently occurring somewhere in the NSW health system is funded activity. If activity related to SWS residents can be reversed and managed within SWSAHS, then the estimated flow reversal that is considered achievable would deliver $47 million (at $2,300 per cost weighted separation) to SWSAHS by 2001.

The main Area Health Services affected by this flow reversal are Central, South Eastern and Western Sydney Area Health Services. It is estimated that the impact is in the order of $10-$15 million, although this is being reviewed as part of a more detailed flow analysis.

SWSAHS Program Shares have changed over the period 1995/96 to 1999/00 as shown in Figure 13. There have been significant budget enhancements since 1995/96 for a wide range of services including the development of new services at Liverpool, Wollondilly and Rosemeadow Community Health Services, a range of mental health Initiatives, community based services and waiting list reduction.

An increasing percentage of the budget is being directed to Primary and Community Based, Outpatient and Rehabilitation and Extended Care services.

The total SWSAHS budget has also increased by 31% over the period 1995/96 to 1999/00. The Government subsidy by Program is shown in Table 7.

Program	1995/96 $,000	1996/97 $’000	1997/98 $’000	1998/99 $’000	1999/00 $’000
Population Health	3,405	3,517	4,690	5,276	5,396
Primary and Community Based	27,580	35,113	47,678	51,000	53,088
Outpatient Services	16,521	15,016	28,927	29,897	31,315
Emergency Services	20,702	21,872	28,769	29,896	29,939
Acute Inpatient Services	214,809	224,773	240,241	251,483	249,576
Mental Health Services	15,779	16,919	22,131	22,862	22,895
Rehabilitation and Extended Care	33,042	34,410	43,193	44,845	45,066
Teaching and Research	5,327	5,397	4,416	4,397	4,754
Total:	$337,165	$357,017	$420,045	$439,656	$442,029

This has enabled SWSAHS to both increase overall activity as well as make progress in treating more SWS residents locally, thus reversing outflows.

SWSAHS has an enviable record in the development of innovative service models and clinical practice. Whilst to date some of this innovation has been driven by resource constraints, given the patient and clinician benefit which has resulted, this should continue to be promoted and supported.

SWSAHS has also achieved overall efficient provision of services, although there is still room for some improvement. SWSAHS has demonstrated the ability to both respond to increasing demand for services from residents, as well as reversing outflows.

When the Macarthur Strategy is completed, the overall condition of SWSAHS’s physical assets will be good. It is acknowledged that there is a need for further work at Liverpool and Bowral in particular, but the base for future modification of assets to meet service needs is strong.

There has also been a rapid expansion in the number of staff within the Area. This provides a significant opportunity to further develop and enhance the skills of people to achieve and respond to changes in health service provision. There has also been significant progress in relation to research recently with the establishment of the Ingham Research Institute and Simpson Centre.

A weakness of our current position is the inequity in access to services, as well as skilled staff. It is a major objective to ensure that SWS residents have equitable access to the health services they require.

It is also difficult to determine the effectiveness of our current services. This is important in making decisions about the relative allocation of funding between programs and within programs, and ultimately to individual service streams.

Resource constraints are likely to continue and will mean that SWSAHS will need to look to its own resources in the first instance to develop and enhance services that are considered a priority.

Table 8 summarises the current performance of SWSAHS in relation to a number of key indicators.

Indicator	Measure
Beds Available	1,470 beds
Bed capacity potentially available	536 beds
% of same day activity as proportion of total admissions	34.9%
% of same day surgery as proportion of surgery	42.3%
Acute self sufficiency in 1997/98 Total Tertiary Non tertiary Day only	75% 47.4% 81.5% 68.9%
Average length of stay in SWSAHS in 1997/98 Tertiary Non tertiary	11.5 days 4.4 days
ED admissions as a % of total admissions	37.9% in 1997/98 and 38.5% in 1998/99
Hospital admissions per FTE	29.3 in 1998/99
Average cost per NIOOS (1997/98)	$81
Average per cost weighted separation	$2,099