Health Needs Assessment
2025 - 2028​
Health Needs Assessment 2025 - 2028
Our needs assessment
The health needs assessment helps Primary Health Networks (PHNs) understand what health services their communities need by:
- assessing the community’s health status and health needs
- examining what health services are already available
- talking to people in the community and health service providers.
Through the health needs assessment, the PHNs identify the health needs for their local communities and possible gaps in services required to meet those needs. The needs assessment informs decisions to improve health in the local population by the PHN in collaboration with local partners.
The North Coast PHN, commonly known as Healthy North Coast (HNC), completed this assessment of health and service needs in 2024 to guide planning and commissioning for the three-year cycle 2025 to 2028.
Please note, in this website the term ‘Aboriginal peoples’ is used to refer inclusively to individuals who identify as either Aboriginal, Torres Strait Islander, or both Aboriginal and Torres Strait Islander.
Information from this website can be cited as: Healthy North Coast 2025-2028 Health Needs Assessment.
- The most common chronic conditions in general practice were anxiety, osteoarthritis, asthma, depression and osteoporosis. The North Coast has a considerably higher incidence of skin cancer than NSW.
- The percentage of lower urgency care presentations to emergency departments on the North Coast is higher than NSW and Australia. The rate of lower urgency presentations is higher than state and national rates for people aged 15 years and older, but the rate is lower for children up to 14 years old.
- There are disparities in accessing primary and hospital care services on the North Coast across geographical areas and communities. There is limited access to after-hours services in the region.
- Aboriginal peoples continue to experience considerable health disparities, highlighting ongoing gaps in access to healthcare, preventative services, patient experience and health outcomes.
- Children and young people, especially those from low socioeconomic backgrounds, that experience chronic health conditions or are neurodivergent, face considerable barriers in accessing health services.
- The North Coast continues to have lower child immunisation rates compared to both NSW and Australia wide.
- The North Coast has an ageing population, which has implications for the provision of community and aged care services and is challenged by increased care needs for people living with dementia.
- People on the North Coast experience substantial challenges accessing mental health services due to long wait times and barriers to access to appropriate services. This can exacerbate mental health issues.
- The misuse of illicit drugs and alcohol consumption remains highly prevalent in the North Coast. Factors contributing to drug and alcohol misuse may be insufficient services to match the demand for care, long wait times for treatment and cost.
- Some communities on the North Coast face increased vulnerabilities and barriers to accessing healthcare. The region has:
- high rates of domestic and family violence, with 575 domestic violence-related assault incidents per 100,000 residents, compared to 447 NSW wide
- increasing number of rough sleepers and clients of Specialist Homeless Services, with 8 people experiencing homelessness or at risk of homelessness per 1,000 residents
- high rates of people with need for assistance in in their day to day lives, with 75 people per 1,000 residents, compared to 58 in NSW and Australia wide
- people from LGBTQ+ communities continue to face challenges accessing safe healthcare services, affecting their health outcomes.
- The North Coast region is facing more frequent and severe climate disasters and environmental health challenges, which exacerbate the health needs across communities and in particular, vulnerable populations.
- The North Coast region is experiencing challenges with recruitment and retention of the health workforce.
Methods
Healthy North Coast’s 2025-2028 Health Needs Assessment (HNA) project was supported by a range of skilled contributors involved in 2 governance groups. The internal working group of Healthy North Coast staff provided practical support throughout the project. The external reference group provided expert advice and guidance, and included representatives from:
- Healthy North Coast Clinical Advisory Council
- Healthy North Coast Community Advisory Council
- Mid North Coast Local Health District
- Northern NSW Local Health District
- regional community health service providers
- people with expertise in health economic and survey design methods
- the Healthy North Coast executive leadership team
The HNA used a comprehensive, mixed methods approach using both quantitative and qualitative data from various primary and secondary sources.
Community engagement was instrumental in the assessment of health needs. The Better Health Community Survey (the ‘survey’) and community consultations provided qualitative data that supported and strengthened the findings from the quantitative data. Community engagement commenced with the survey and a continued with a series of community consultation events with community members, service providers and subject matter experts.
- The community survey, created in collaboration with Rooftop Social, was open for three 3 weeks in April 2024 and received 3,281 valid responses, surpassing the initial target of 2,200. Social media, radio, and printed materials were used to promote the survey, along with active outreach to Aboriginal Medical Services in the region to encourage and facilitate participation.
- The community consultations were conducted in August 2024 to gather deeper insights from people in the North Coast about their needs and experiences with health services. They used two 2 approaches: focusing on communities of interest and engaging the general population. These consultations built upon the Survey results to gather in-depth qualitative data.
- Communities of interest included Aboriginal and Torres Strait Islander communities, older adults, young people, LGBTQ+ communities, and those affected by mental health and alcohol and other drug issues. Subject matter experts provided valuable information on the specific health challenges for these communities.
- General population consultations were held through Community Conversations events in Kyogle, Grafton and Macksville as well as a virtual event region wide. These consultations used a combination of focus groups and one-on-one interviews, providing rich source of qualitative data to inform the project.
The quantitative data was obtained from sources such as:
- Australian Bureau of Statistics (ABS)
- Australian Institute of Health and Welfare (AIHW)
- NSW Government Planning
- HealthStats NSW
- Local health districts
- General practices
- Services commissioned by HNC
- Better Health Community Survey
The analysis of quantitative and qualitative data allowed the project team to identify a set of health and service needs for the North Coast population. Once the needs were known, a data triangulation process was used. This involved scoring each of the needs based on how evident they were in a range of datasets – public data, PHN Program data, general practice data and insights from the community engagement.
The data triangulation progressed to a prioritisation process to categorise the needs according to 7 defined criteria. A total of 31 stakeholders participated in the prioritisation process – Healthy North Coast staff and members of the HNA reference group and Healthy North Coast advisory councils.
View the Health needs we prioritised based on 7 criteria in our Methods approach.
While the health needs assessment aimed to be comprehensive, there were some limitations with data availability, particularly regarding specific populations and health concerns. To address these gaps, Healthy North Coast has established key partnerships to improve data sharing and understanding:
- Healthy North Coast has a Memorandum of Understanding with the Mid North Coast LHD and Northern NSW LHD. This agreement acknowledges our commitment to work together as a one system and help improve gaps in understanding. The aim is to achieve better health outcomes for North Coast communities.
- Healthy North Coast has established a Partnership with the Aboriginal Medical Services in the region aimed at ensuring that Aboriginal peoples have access to services that are prevention-focused, culturally safe, responsive to needs, equitable and free of racism. The Partnership is collaborating to develop Aboriginal data sovereignty principles and establish appropriate data-sharing agreements.
Priorities identified through the HNA were presented to members of the Healthy North Coast Joint Advisory Council, that includes the Clinical Advisory Council and the Community Advisory Council. Via roundtable discussions members identified key areas for deeper investigation in coming years and areas where further understanding is required on the role of Healthy North Coast contributing to better health outcomes.
The 5 priority areas for additional needs assessments are:
- Aboriginal health and wellbeing
- mental health outcomes
- children and younger persons’ health
- older persons’ health
- chronic disease prevention and management
The 3 areas identified for exploratory analysis are:
- health workforce
- social and environmental determinants of health
- digital health
Equity and health literacy principles will be incorporated in all needs assessments and exploratory analyses conducted by Healthy North Coast.
