RegionDubbo is a major inland city located 396km northwest of Sydney. In Table 24, regional population statistics are presented, including for the catchment of Dubbo. The 2006 population estimate by the ABS was 34,319 in the Dubbo Part A SLA and 3,525 in Dubbo Part B SLA. The Aboriginal population was estimated at 3,812 within the Part A SLA and a further 97 in the Part B SLA. However, the local AMS estimate is closer to 6,000.
Dubbo is a regional centre for the central Macquarie region and the broader North Western New South Wales Statistical Division. The Central Macquarie Statistical Subdivision which has 50,166 residents in addition to the Dubbo population, and an additional 4,172 Aboriginal residents. It includes towns such as Coonabarabran, Gilgandra, Wellington and Mudgee.
The North Western Statistical Division extends west and north to the Queensland border including towns such as Bourke, Brewarrina, Cobar, Collarenebri, Coonamble, Goodooga, Lightning Ridge, Nyngan and Walgett. In total (including Dubbo and the Central Macquarie Statistical Sub Division there are 111,230 people living in the Statistical Division and 14,265 Aboriginal people.
Table 10 – Regional population statistics (2006)
|Dubbo (C) Pt A (SLA)||1.95||RA2-Inner regional||957||34,319||3,812||11%|
|Dubbo (C) Pt B (SLA)||2.94||RA3-Outer regional||1052||3,525||97||3%|
|Central Macquarie Statistical Subdivision excl. Dubbo||50,166||4,172||8%|
|North Western Statistical Division NSW||9.38||RA4-Remote||111,230||14,265||13%|
Dubbo serves as a major regional hub and has a substantial range of commercial services available to the population, from entertainment to shopping to government services. In the northwest region of New South Wales there are no other regional hubs with the services that Dubbo offers, for this reason the town has a significant catchment area. Estimates of the population that Dubbo serves exceed 120,000. As mentioned the estimated resident population for the North Western New South Wales statistical division in 2006 was 110,000 people with an estimated Aboriginal population of over 14,000.
Due to the role of Dubbo in the region, there is a significant amount of travel that occurs between Dubbo and surrounding towns for commercial services. Transportation to Dubbo for general purposes is mostly through private vehicles. The city is situated on the terminus of the rail line from Sydney and there is no regular public transportation to more distant destinations. While Dubbo has good access from Sydney, highway is the only feasible option for onward travel. Top of page
Figure 7 – Maps of Dubbo SLAs, Central Macquarie Statistic Sub Division and North Western New South Wales Statistical Division, ASGC 2006
Dubbo (C) Pt A (SLA)
Dubbo (C) Pt B (SLA)
Central Macquarie Statistical Subdivision
North Western Statistical Division
Source: ABS 2011a
Dubbo is located 396km northwest of Sydney by road. It has a rail service to and from Sydney and regular commercial flights to Sydney.
In the 2006 Census 23.7% of the population usually resident in Dubbo (Part A and B SLAs) were children aged between 0-14 years, and 23.0% were people aged 55 years and over. The median age in Dubbo was 35 years, compared with 37 years for people in Australia.
Health service organisationTop of pageDubbo is located in the Western NSW Local Health District (LHD) within NSW Health system, which includes the North Western Statistical Division NSW, and extends south to include Orange and Bathurst. There are 40 hospital facilities within the LHD, many of which have been converted to multipurpose services over the last 16 years. Orange, Dubbo and Bathurst hospitals are the regional referral hospitals for the region, with Dubbo hospital the regional referral hospital for the North Western Statistical Division areas of the LHD.
Figure 8 – Western New South Wales LHD
Dubbo is serviced by the Dubbo Plains Division of General Practice, which has its main office located in the city. The Division covers a region similar to the Central Macquarie Statistical Subdivision. Currently there are 54 GPs in nine practices in the city of Dubbo, while the Dubbo Plains Division has approximately 100 GPs in 36 practices.
A new Medicare Local will be called Western New South Wales, compromising the Dubbo Plains Division together with the current Central West Division to the southeast and including the major cities of Bathurst and Orange.
Specialist servicesSpecialist services are delivered through a combination of public (staff specialists) and private practitioners. Many of these specialists visit from Sydney or other large centres as it is challenging to recruit specialists to locate in rural communities. This has led to a situation where the demand for a full-time specialist service is demonstrable but cannot be met from local sources. Specialist services have tended to be ad hoc rather than driven by demand. Some private services are carried out part-time without Commonwealth or state funding and consequently depend on Medicare and patient revenue. Public services are funded through the operating budget of Dubbo Base Hospital (DBH). The hospital would prefer full-time staff or VMO services but have been unable to attract suitable applicants. The range of permanent specialist services is presented in Table 25 (not comprehensive). Other specialist services are provided on a part-time visiting basis.
Table 11 – Resident specialities in Dubbo
|Specialty||Number||Provides outreach to catchment (describe)|
|Surgery||Mudgee, Cobar, Walgett, Wellington|
|OB/GYN||4||Visit Walgett, Bourke, Coonamble, Wellington, Coonabarabran, Cobar|
|Paediatrics||3||Bourke AMS, Nyngan|
HospitalThe main hospital in Dubbo is Dubbo Base Hospital, which is in the category of hospitals between 100 and 200 beds. It has an emergency department and provides acute, rehab and subacute services. Admissions for the hospital are listed in Table 12. Lourdes hospital is also located in Dubbo and is a third schedule facility that provides sub and non-acute services, including rehab and palliative care.
Table 12 – Admissions to Dubbo Base Hospital 2009-10
|Same day admissions||Overnight admissions|
Specialist mental health
|Source: MyHospitals website|
The specific services that are provided through Dubbo Base include:
- coronary care unit
- dialysis unit
- ear, nose and throat surgery
- eye surgery
- general surgery
- gynaecological surgery
- orthopaedic (bone) surgery
- urological surgery
- other elective surgery
- emergency department
- intensive care unit
- oncology unit
- outpatient services
- paediatrics unit
- psychiatric unit/ward.
Aboriginal Medical ServicesDubbo has one public AMS in the city, the Thubbo Aboriginal Medical Co-operative, which provides services to the local community as well as to people from the wider catchment (including from other AMSs). The Thubbo AMS has associations with the National Aboriginal Community Controlled Health Organisations (NACCHO), Aboriginal Health Medical Research Council of New South Wales (AH & MRC) and the Bila Muuji Aboriginal groups. The AMS employs one full time and three part time general practitioners. Funding acquired through Commonwealth support allows the clinic to stay open until 9pm, thereby enhancing public convenience.
Thubbo is the largest AMS in the region as determined by the number of patient contacts, with around 80 per cent identifying as Indigenous. Due to the role of Dubbo as the major hub for the region, a larger population is served by Thubbo than a typical AMS. Many patients who come to Thubbo live within the boundaries of other AMSs. For this reason, when patients from other areas access services through Thubbo AMS, there is an attempt to inform the home AMS and get transfer files over as appropriate.
OptometryDubbo itself is well served for optometry, with ten optometrists working in the town. Seven provide outreach services.
Travelling into DubboDubbo is a major hub for the region and many people travel into the city from the catchment to receive medical services. As an example, a visiting neurologist who worked for two and a half days over a two month period had 26% of the patients travel in from outside of Dubbo. The actual means of travel is generally through private transport although this may be funded by the Isolated Patients Travel and Accommodation Assistance Scheme (IPTAAS) program. Some Indigenous and elderly patients do use alternative forms of transport to get to Dubbo, including buses (one arrival/departure per day) and other community transport. The Thubbo AMS does provide some community transport within Dubbo as well as providing limited support to patients travelling in from the catchment. In some special circumstances the AMS will cover additional travel arrangements, including into Sydney.
It was pointed out that for many Aboriginal patients the main motivation for travel to Dubbo is commercial (government services, banking, shopping) with medical attention regarded as optional if time permits. Lower priority is given to medical appointments, even where an appointment was pre-arranged. Some patients cannot or will not travel except in an emergency. Dubbo may be up to six hours from a patient’s home. At those distances, travel is a major barrier, especially for older people and those living in difficult socio-economic circumstances. Consequently, increasing access to medical services requires better transport links.
Travelling out of DubboPatients have to travel out of Dubbo to receive a significant number of services that they need. Medical services that patients have to travel for include many in-patient services, complex outpatient diagnostics (e.g. PET-CT), thoracic surgery, spinal injuries, mental health and sub-specialty services. (A full discussion of gaps is provided in the next section.) Traveling out of Dubbo is however a significant challenge for much of the population. Barriers to travel include time, local commitments, money and the desire to avoid the city. For example, if someone is taking care of a sick or elderly family member, they cannot leave their home to travel to Sydney to receive services. Other people will not attend a service to avoid the metropolitan areas. Lourdes hospital staff brought our attention to the fact that the hospital is often responsible for patient travel costs for patients that need transfer to services that the hospital does not provide. This creates a significant, and at times unnecessary, expense for services that could be available in Dubbo.Top of page
Visiting specialist servicesVisiting specialists are common in Dubbo, funded both through MSOAP and through other arrangements, including those employed in the public sector. As can be seen in Table 19, most of the visiting MSOAP services are administered through private locations. The arrangements for these services are mainly through the use of existing rooms at specialist medical centres in town. Often the centre will arrange and manage patients, take care of paperwork and perform the other administrative tasks needed for the specialist to provide services at the location. One interesting case is that of a dermatologist, who after receiving MSOAP funding for many years purchased a property and set up a secondary practice in Dubbo that he visits two days per week. While he still receives MSOAP for his travel expenses, he is able to provide a more comprehensive and integrated service to residents through his purchase of a local property.
Table 13 – MSOAP services to Dubbo
|Program||Specialty||No. of visits||No. patients||No. of ATSI patients||Where delivered|
|MSOAP||Physician - Cardiology||8||218||1||Private|
|MSOAP||Physician - Cardiology||24||457||29||Private|
|MSOAP||Physician - General||22||485||27||Private|
|MSOAP||Physician - Neurology||24||115||11||Private|
|MSOAP||Physician - Palliative||10||34||4||Lourdes|
|MSOAP||Physician - Rehabilitation||4||21||1||Lourdes|
|MSOAP||Physician - Respiratory||24||782||48||Private|
|MSOAP||Physician - Rheumatology||22||437||21||Private|
|MSOAP||Psychiatry - General||50||59||6||Private|
|MSOAP||Psychiatry - Geriatric||24||12||0||Lourdes (need provider)|
|MSOAP||Surgery - Gastroenterology||6||6||0|
|MSOAP||Surgery - Neuro||6||73||0||Private (consultation only)|
|MSOAP||Physician - Nephrology||2 (2010-11)||Hospital|
|MSOAP||Physician - Neurology||1 (2010-11)||Private (in the air)|
|MSOAP||Surgery – Oral & Maxillo-Facial||1(2010-11)||Private|
|MSOAP-ICD||Chronic respiratory disease, Respiratory physician||12(2010-11)||AMS|
|MSOAP-ICD||Cardiovascular Disease - cardiology||12(2010-11)||AMS|
Numerous other specialists not covered by MSOAP visit Dubbo, many of which have a high turnover. There are several different arrangements through which these specialists coming to Dubbo. The first is specialists who have decided to provide services in Dubbo as a personal choice, business reasons or both. In these cases the visits are not supported by any outside source and the costs of providing the visiting services must be covered by payments from patients. The second type is public visiting services that are supported by the state health department. These services are provided at or through the public hospitals. The specialists generally come from other public hospitals or private providers under contract to provide services. Finally, it appears that there may be some specialists who visit and provide a combination of public and private services to patients. A list of these other visiting services is in Table 14.
Table 14 – Visiting services to Dubbo not supported by MSOAP
|Type||Specialty||Number of visiting specialists|
|Public||Anaesthetist||Up to 3|
|State/private (to hospital)||Oncologist||1|
|State/private (to hospital)||Haematologist||1|
|State/private (to hospital)||Radiation Oncologist||2|
|Private||Nuclear Medicine Physician||1|
|Private||Oral and Maxillofacial Surgery||1|
|Private (small amount public)||Orthopaedic Surgery||11|
|Private||Reconstructive Cosmetic Surgeon||1|
|Private||Thoracic Physician/ Sleep Medicine||1|
Services delivered outside Dubbo to the wider catchment population are provided through MSOAP (Table 15), Dubbo Base Hospital specialist (Table 25) and specialists in private practice (Table 16).
Table 15 – MSOAP services to Dubbo catchment
|Program||Specialty||No. of visits||No. patients||No. of ATSI patients||Location|
|MSOAP||Physician - Addiction Medicine (Drug and Alcohol)||8||8||8||Bourke|
|MSOAP||Surgery - General||5||98||37||Bourke|
|MSOAP||Physician - Addiction Medicine (Drug and Alcohol)||12||12||12||Walgett|
|MSOAP||Physician - Cardiology||11||62||20||Walgett|
|MSOAP||Physician - Respiratory||11||35||12||Walgett|
|MSOAP||Physician - Sexual Health||2||8||1||Walgett|
|MSOAP-ICD||Diabetes team||4 (2010-11)||Lightning Ridge, Goodooga|
|MSOAP-ICD||Chronic respiratory disease||6 (2010-11)||Coonamble|
|MSOAP-ICD||Chronic respiratory disease||6 (2010-11)||Wellington|
|MSOAP-ICD||Cardiovascular disease||6 (2010-11)||Wellington|
|MSOAP-ICD||Cardiovascular disease||6 (2010-11)||Coonamble|
|MSOAP-ICD||Chronic respiratory disease||6 (2010-11)||Bourke|
|MSOAP-ICD||Chronic respiratory disease||6 (2010-11)||Brewarrina|
|MSOAP-ICD||Chronic respiratory disease||6 (2010-11)||Walgett|
|MSOAP-ICD||Cardiovascular||5 (2010-11)||Lightning Ridge|
Table 16 – Non-MSOAP specialists from Dubbo visiting Dubbo catchmentTop of page
|Specialty||Location||Number of specialists|
It is clear that there are different roles that visiting specialists play in the health service delivery framework within Dubbo. The success of the services would appear to be related to the need that the visiting service is responding to. However, in general, the view was expressed that the visiting services were not meeting the needs of the community. However, this did not necessarily reflect the quality or quantity of services being provided, rather, the significant need that exists in Dubbo.
At Dubbo Base Hospital most of the visiting specialists were there to provide services that could not be provided by resident staff. Some of these services are most likely best provided through visiting services due to the level of demand for them. However, many of the visiting services that are provided into Dubbo Base (mostly through the state) are there to make up for recruitment shortages for full time staff. Significant workforce and recruitment issues exist at the hospital, which leads to chronic understaffing (for specialists) that have to be supplemented with visiting services. The issue is magnified in the catchment area where fewer services are available to begin with. A compounding factor on the staff shortage at the hospital are acute cases from Dubbo and the catchment that may have been prevented through better availability of primary and secondary services. For these reasons, the hospital currently uses and views visiting services as replacement services for staffing shortages.
The Lourdes hospital, which provides sub and non-acute services to mainly elderly patients, uses visiting specialty services to supplement the clinical staff that they already have. While there are also significant recruitment and staffing issues for specialists, the need is not as significant as at Base Hospital. When a visiting specialist comes to Lourdes they function mostly as a consultation service, providing input on challenging cases, setting up medication or care plans and providing education and upskilling services to the clinical staff. This role for visiting services appears to be very successful as it is well integrated with the services that are provided by the full time staff at the hospital.
Visiting specialty services in the general community play several roles: making up for services that are not being provided by the market, providing services that would not normally be available and the provision of high level services. The rates that a specialist can earn in the city are equal to or greater than the rates in Dubbo, the support/education network is smaller and the major cities are a more popular location of residence for specialists. To overcome the marketplace barriers, specialists can receive extra funding (i.e. MSOAP) or make a personal choice to provide a visiting service for non-tangible benefits.
A second type of service being provided in the community is a specialist service that does not receive sufficient demand to support the service being permanently located in the town. In this case the visiting service either receives additional funding or has to be sustained through the payments received through the provision of services. Finally, a visiting service can provide expertise and connections that could not exist in the town that the service is being provided in. For example, if a cardiothoracic surgeon from a major hospital in Sydney provided consultations in Dubbo, the specialist could bring expertise from their colleagues in Sydney as well as a personal relationship with patients who needed to travel to Sydney receive further treatment.
Visiting services to the AMS are culturally sensitive, affordable and integrated with the other resources at the AMS. The first aspect is critical in that many mainstream services are not culturally sensitive to Indigenous communities and therefore members of these communities do not feel comfortable accessing them. Many mainstream specialist services also usually have significant costs associated with them. Services provided through AMSs bulk bill or have low fees and therefore are more accessible. The importance of integration of specialist services with an AMS is that Aboriginal Health Workers and GPs in the AMS can develop relationships with the specialists. These relationships increase attendance rates and allow for better communication between levels of care for the patient.
Gaps in specialist servicesSignificant gaps in specialist services exist in Dubbo. These are critical to service delivery for the region as Dubbo is a major hub. Some of the major specialties identified as gaps include: radiation oncology, rheumatology, endocrinology, respiratory, neurology, ophthalmology, ENT surgery, angiography (coronary, cerebral, renal), orthopaedics, psychiatry, child psychiatry, dentistry and dermatology. Indigenous gaps are greater as there is a lower level of access to mainstream services from the Indigenous population. At the AMS, ear grommets for children were identified as a major gap. In addition, many services, even if they are available in Dubbo have significant waiting lists, are available only through private practices, or both. This means that the gaps in services are greater for certain populations.
Assessment of needThe assessment of need in Dubbo is led by the Dubbo Plains Division of General Practice, acting as a sub-contractor to one of the fundholders in New South Wales - the Rural Doctors Network. To manage the need in the area, the Division develops and manages MSOAP proposals. The process that they pursue to develop new services includes feedback from GPs, surveys of specialists, analysis of service and health data, and meeting with stakeholders who want to have input. For the last few years, the Division has mostly continued existing services and only with MSOAP-ICD were they able to add new services.
Many stakeholders in the region feel that they have not been fully engaged in the process of the assessment of need and the development of visiting services. The relationship between the AMS and the Division is somewhat divisive, where the Division does not feel the AMS can get services up and running efficiently and the AMS does not feel fully engaged in developing new services. The hospitals do not feel fully engaged in the assessment of need, where changes in available services are not acknowledged, with continuing services being prioritised over new and urgent needs.
There is no indication that services that are being provided are not needed. However, they are not necessarily the highest priority services. There is significant evidence that there is not comprehensive engagement of the various local stakeholders to develop a comprehensive needs assessment and visiting services plan for Dubbo. All of the stakeholders do have an idea of their need and want to be engaged. The services appear to be based as much on need as they are on other logistical factors associated with setting up services. The challenge with this approach is that the services are more ad hoc and are not able to most efficiently address the community needs. One challenge that was raised to providing a more comprehensive assessment of need was that the administrative cost in time to create a plan for visiting services is not provided for in budgets.
The success of visiting services is dependent on patient access to the services and integration of care between the visiting service and other service providers.
Referrals in Dubbo mostly occur through standard referral pathways as would occur in a major city. The Division maintains a list of specialists, both visiting and permanent, that provide services to Dubbo. The list is mostly up to date and does provide contacts for referrals, including secure electronic communication. Many of the providers in Dubbo do appear to know the other specialists in town or a person to contact if a referral is needed. There was some feedback that at times it can be challenging to know which specialists are available and who is still visiting. However, challenges in accessing specialist services has more to do with availability than lack of knowledge.
Management of referrals and patients is done almost exclusively by the visiting specialist or by the site hosting the specialist. At the AMS there are significant administrative efforts that go into referrals and managing patient lists. Currently, they are in the process of developing case management services for their patients, which they see as critical to improving access and utilisation of services.
Notifications for new visiting services are often provided through the Division. New services are sent out through a weekly e-mail that goes to GPs, allied health professionals and nurses. In addition, a specialist health directory is also released. Despite the efforts of the Division there was still a sense that stakeholders (AMS and Dubbo Base in particular), were not fully aware of all of the visiting specialist services.
Communication between visiting services was cited as a key aspect of successful visiting services to Dubbo. Having specialists provide letters and records to local providers is seen as an important part of the services that they provide. While there was some feeling that this process could be improved, the main complaint, from Dubbo Base, was that the fragmentation of services and communication due to visiting services.
The issue that Dubbo Base Hospital had was that visiting specialists were not part of the referral pathway for their hospital. What this means is that patients that require inpatient services at some point after receiving visiting specialist services would enter a separate pathway. The change in pathway can significantly hinder communication between Dubbo Base, the specialist and the hospital Dubbo sends patients to (RPA). This leaves a significant burden on Dubbo base to manage acute patients who are seen by a specialist outside of their typical pathway.
MSOAP and VOS impactsThe impact of MSOAP was seen as positive by all service providers in Dubbo except for Dubbo Base Hospital. Improvements due to MSOAP were harder to quantify because of loss of permanent services within the community and the high level of unmet need.
Lourdes Hospital and Thubbo AMS had the opinion that services had increased access significantly, where specialists provided through MSOAP were seen as providing services that would not exist without the program. At Lourdes they particularly valued that MSOAP specialists could provide education and expertise that would not otherwise be available. At the AMS, they felt that the services that MSOAP provided both met a need and provided a service that might not have been otherwise accessed.
The Division felt that MSOAP provided an invaluable service, but did not have a significant impact because other services had decreased during the time that MSOAP has been in operation. However, they were of the opinion that if the program was not in operation that services would be significantly worse.
BenefitsThe main benefit of MSOAP was seen as improved access to services in Dubbo and the catchment area. The additional benefits are increased utilisation of services by patients and money savings through reduced travel. Through the consultations it became clear that there are significant barriers, emotional, social, psychological and economic that prevent people from accessing services. When the services are easily available to them they are much more likely to access them. This is seen as the kind of benefit that cannot be quantified because there is not an alternative service that a visiting specialist can be compared to.
The Division felt MSOAP provided specialists with exposure to Dubbo, leading to the creation of new and sustainable services. Multiple groups cited the expertise of specialists from MSOAP as being a major benefit, including the relationship that they bring with major hospitals in capital cities.
Areas for improvementThe current program could be improved through a better process of assessing need and creating service proposals. It was felt that more people need to be brought together to discuss need and develop priorities for the community. The situation in Dubbo is constantly changing and therefore the needs of the community are shifting through the course of a year. Services were provided more on a polling basis than through creating a plan to address the need in Dubbo.
Flexibility was seen as a major issue for the Division, where the planning and budgets of service plans were too rigid given the realities of service delivery on the ground. They felt that if funding was more flexible and services were paid for on a fixed price basis, administration would be simplified and more services could be provided in an efficient manner. A second aspect of flexibility is an increase in the inclusion of teams in the delivery of service, including care planning and other support for the specialist (similar to MSOAP-ICD). The efficiency of the specialist could then be significantly improved through distribution of unnecessary work away from the specialist.
The area that was seen as being the most critical area for improvement was the level of payments for administrative support to the specialists. Currently, organisations involved or specialists are coming out of pocket to provide the support that specialists need to deliver their services. This includes taking appointments, following up with patients, dealing with patients on the day of service, writing up and sending letters to GPs and other tasks such as sending lab results back to the specialist. Everyone agreed that these services were critical to the success of the service, but due to the level of administrative payments the support is not sustainable. A related issue that was raised is that the payment and billing process was seen as overly burdensome to the specialists and their staff. It is already a challenge to deliver visiting services, the extra work creates stress and less incentive to participate.
There were some specific ideas raised for improving MSOAP:
- create more connections with groups that can source doctors to fill need (i.e. specialist colleges, large hospitals, health networks)
- increase marketing and advertising
- keep payment levels in line with inflation
- encourage multiple day clinics over single day visits
- provide higher payments to some specialties to encourage them to participate
- get more registrars to participate (get relationships with training programs)
- focus on sub specialty services.Top of page