HNA LGA – Clarence Valley 2025

Clarence Valley - LGA

Health Needs Assessment 2025 - 2028

Clarence Valley local government area (LGA)

An overview of the Clarence Valley local government area (LGA) health needs is provided. The Health Needs Assessment (HNA) process utilised a comprehensive, mixed-methods approach to collect and analyse data on the health and service needs of the North Coast region.

Key Information

Health Needs Assessment Clarence Valley LGA

The Clarence Valley local government area (LGA), located on the Traditional Lands of the Bundjalung, Gumbaingirr, and Yaegl Nations, spans 10,441 km², making it the largest LGA on the North Coast. Clarence Valley LGA is part of the Mid North Coast Local Health District and is part of the Clarence Valley SA3 however has some overlap with Coffs Harbour SA3. It encompasses a mix of coastal, hinterland, and mountain regions, along with rural towns and communities.

Grafton serves as the main regional centre, followed by the towns of Yamba and Maclean. Agriculture and the fishing industry are key sectors in the area’s economy. The Clarence Valley LGA maintains strong connections with neighbouring LGAs, including Coffs Harbour and Ballina.

The area’s demographic structure, geographic location and size presents specific health challenges, particularly in the areas of service access, healthy aging and chronic disease prevention and management.

Footnote: throughout this document ‘survey’ refers to the 2024 Better Health Community survey undertaken as part of the Health Needs Assessment 2025-28 consultation process

Key messages

DEMOGRAPHICS AND SOCIAL DETERMINANTS

  • Population 54,212 people, 10% of the North Coast population. Population projected to increase by 2% by 2031 (compared to 5% increase North Coast).
  • 27% aged 65 years or over, projected to increase by 11% by 2031 (18% increase North Coast and 29% increase NSW).
  • Population density: 5 residents per km2 (17 per km2 North Coast).
  • Median age 49 years (47 North Coast, 39 NSW).
  • 8% identify as Aboriginal and/or Torres Strait Islander (6% North Coast).
  • Nearly 1 in 5 children assessed as vulnerable in one or more areas of early childhood development.
  • 1 in 2 found it difficult to access a local GP for a child in their care.
  • Clarence Valley LGA has the second highest presence of post-natal depression in the North Coast. Double the North Coast average.

Opportunity: Work in partnership to improve education, support, community and peer-based services for children and families.

Fully immunised children rates:

  • 95% of 1-year-old children (94% in NSW and Australia)
  • 93% of 2-year-old children (92% NSW and Australia)
  • 97% of 5-year-old children (94% NSW and Australia).

• 62% of people aged 65 years and over have at least one long-term health condition. Highest in the North Coast.
• 3% population live with dementia (2% NSW and Australia). Higher than NSW and Australian rates and is expected to increase as the 65 years and over population increases.
• 66% of survey respondents reported the ageing population is one of the most serious health concerns in the community.
• 50% of survey respondents found accessing services for older people difficult. Challenges were lack of awareness of services and difficulty in organising services.

Did you know: Care Finders is a free service. It exists to support vulnerable people – who have no one else who can support them – to learn about, apply for and set up support services. 

Opportunity: Increase support and education regarding available services for people as they age and for ageing relatives or people in their care.

Healthy North Coast works in partnerships with Aboriginal Community Controlled Health Organisations to improve health outcomes for Aboriginal peoples, families and communities. Bulgarr Ngaru Medical Aboriginal Corporation provides services to the Bundjalung, Gumbaynggirr and Yaegl people of Clarence Valley, Richmond Valley, Kyogle and Tweed Heads LGAs. Clarence Valley clinics are based in Grafton, South Grafton, and Maclean and include outreach to Baryulgil, Malabugilmah, and Yamba.

  • 18% of people had an Aboriginal health check in Clarence Valley SA3

Connection to country and culture is key for Aboriginal & Torres Strait Islander peoples social and emotional wellbeing. Programs that Aboriginal peoples identified to help keep Aboriginal communities healthy and strong:

  • Exercise and fitness
  • Support with daily living / personal care
  • Training programs.
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  • 85 in every 1,000 people need assistance due to age or severe disability (75 per 1,000 North Coast and 58 per 1,000 NSW).
  • Median total personal income $578 per week ($652 North Coast, $813 NSW).
  • 7 per 1,000 people experienced domestic and family violence. Increased 82% from 2021 and is higher than North Coast and NSW rates (4 per 1,000).
  • Index of Relative Socio-Economic Disadvantage (IRSD) score 940, indicating greater disadvantage compared to the Australian average (1,000).

Opportunity: Assist partnerships including community and social services to increase health and wellbeing supports. Targeted outreach programs and stronger partnerships with domestic violence services could help address the health needs of vulnerable populations in the region.

  • 3 in 1000 people experiencing homelessness (4 in 1,000 North Coast and NSW, and 9 in 1,000 Australia)
  • 4 in 1000 are at risk of homelessness (4 in 1,000 in North Coast and NSW and 7 in 1,000 Australia).
  • 29% single or lone households (25% NSW, 26% Australia) and 3% group homes (4% NSW and Australia).

Social isolation can increase health risks.

Key messages

PRIMARY HEALTHCARE NEEDS IN THE LGA

When you were asked…

What kind of programs would you like more of, to keep you and your community healthy and strong?

  • Exercise and fitness
  • Health screening services
  • Women’s health

Which do you see as the most serious health concerns in your community?

  • Mental health issues
  • Ageing population
  • Lack of access to healthcare services

  • Nearly 1 in 5 people have 2 or more chronic conditions.
  • The most common chronic conditions are osteoarthritis, anxiety, and depression.
  • Highest presence of Type I Diabetes in the north coast. More than 1 in 2 diagnosed are 65 years or older.

Opportunity: Strengthen and enhance preventative health programs, strategies, and care teams through partnerships, helping reduce the prevalence and impact of chronic conditions.

Cancer screening participation:

  • 42% National Bowel Cancer Screening Program (NSW 40%)
  • 64% BreastScreen Australia (NSW 50%)
  • 46% National Cervical Screening Program (NSW 46%).

The most diagnosed cancers:

  1. Urogenital cancer
  2.  Skin cancer
  3. Bowel cancer

The cancer with the highest death rate is respiratory cancer.

Shared experiences with mental health:

  • 1 in 10 people needed to access a mental health service but couldn’t
  • 4 in 10 people reported mental health as one of the most serious health concerns in the community
  • 2 in 3 found it hard to access a psychologist, counsellor or social worker.
  • 7 in 10 found it difficult to access a GP and psychiatry services. Higher than the North Coast average.
  • The top challenges to access mental health services included:
    • lack of services
    • difficult to organise appointments
    • Long way from home.

  • Clarence Valley SA3 rate of suicide deaths 22 per 100,000 population. This is double the rate of NSW.

Opportunity: In partnership, explore and implement innovative ways to strengthen treatment, prevention and mental health support programs suited to a rural area. This could include increased education, support and access for digital based services and community and peer support services. 

Did you know: Medicare Mental Health Centres can help you access the local mental health services and supports that are right for you. No referral needed, access by phoning 1800 595 212 or visit the website.

Grafton Base Hospital and Maclean District Hospital service the Clarence Valley region they are both rural community hospitals open all hours and providing emergency care and a range of medical, nursing and surgical services.

Community health centres Grafton Ambulatory Care, Community and Allied Health, Iluka Community Health, Maclean Community Health, and Yamba Community Health, provide a range of primary and allied health services.

  • 46 general practices
  • 14 general practitioners
  •  For every full time GP there are 1,429 people
  • 44 pharmacists
  • 13 pharmacies
  • 30 dentists

The distribution of GPs is unequal in the North Coast region, with the rate of GP FTE in Clarence Valley LGA among the lowest in the North Coast region.

Opportunity: Continue to work in partnership to support recruitment and retention of the healthcare workforce.

  • 75% of ED presentations are for lower urgency care (52% North Coast, 48% NSW).
  • After-hours GP use in Clarence Valley SA3 is 3% (Australia 17%). Access to after-hours GP services remains a challenge and may contribute to higher ED admissions.

Barriers to accessing primary care include: 

  • Long wait times for appointments
  • Difficulty getting an appointment
  • Lack of practitioners/services
  • Long distance from home
  • Cost
  • Difficult to organise appointments

Did you know: If you need medical advice and care, call Healthdirect for free, 24/7 on 1800 022 222 and speak to a registered nurse. 

HNC commissions a range of community-based services to address local health needs.

These include:

  • Aboriginal health
  • Alcohol & Other Drugs
  • Mental Health
  • Youth specific
  • Integrated Team Care

View more information about the services available in Clarence Valley LGA

Explore more: North Coast LGA Factsheets and information

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Byron - LGA

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Clarence Valley - LGA

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Coffs Harbour - LGA

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Kempsey - LGA

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Kyogle - LGA

View LGA Factsheet and key messages for the region.

Lismore - LGA

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Nambucca Valley - LGA

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Port Macquarie-Hastings - LGA

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Richmond Valley - LGA

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Tweed - LGA

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HNA Homepage

View Health Needs Assessment Homepage

HNA LGAs Map

View Health Needs Assessment LGAs Map

HNA Priority Areas List

View Health Needs Assessment Priority Areas List

Our regional partners

  • Local Health District partners in our footprint: Mid North Coast Local Health District (MNCLHD) & Northern New South Wales Local Health District (NNSWLHD)
  • Aboriginal Medical Services (AMS)
  • The Royal Australian College of General Practitioners (RACGP)
  • Australian College of Rural and Remote Medicine (ACRRM)
  • Rural Doctors Network (RDN)
  • Rural Clinical Schools & Regional Training Hubs
  • General Practitioners
  • Registrars and International Medical Graduates
  • North Coast Allied Health Association (NCAHA)
  • Local Councils
    Pharmaceutical Society of Australia (PSA)
  • Universities including: Charles Sturt University (CSU), University of New South Wales (UNSW), Southern Cross University (SCU)

Aged Care Disaster Management Planning

Strategic Priority Area: One team

North Coast is identified as the region most likely to be impacted by climate change in Australia and also forecasted greatest growth in those 65+.

Healthy North Coast takes a lead role in ensuring the older population and the sector that supports them are prepared for, can respond to and recover from disasters and other emergencies.

We have led eight regional disaster management capacity building workshops, bringing together SES, community organisations and the aged care sector.

We have also developed disaster preparedness tip sheets for both residential and community aged care providers.

Voluntary Assisted Dying

Strategic Priority Area: One team

In May 2022, the NSW Parliament passed the Voluntary Assisted Dying Act 2022. Effective from Tuesday, 28 November 2023, eligible people have the choice to access voluntary assisted dying. 

Healthy North Coast has developed a webpage for both health professionals and consumers, with links to available information and resources.

Living with Dementia resources

Strategic Priority Area: No one is left behind

Healthy North Coast has worked with people living with dementia, their families and local service providers to develop an information booklet that will help them connect with local and national supports along their journey.

Highly regarded by a range of professional supporting those on or starting the dementia journey, the booklet includes commonly asked questions for people to ask their GP and/or specialist.

“It’s a fantastic resource and I give it to everyone on their first diagnosis. Its easy to read, so well planned and thought through and has lots of really useful information, tailored to the region.
I also find it very helpful when educating clinical staff.”

−Geropsychiatric Nurse Practitioner, Mid North Coast.

The resource is available in digital and printed copies, with more than 5,000 distributed across the region. An e-version is available to clinicians via the Dementia and Cognitive Impairment HealthPathway.

Deteriorating Resident Triage Tool Pilot

Strategic Priority Area: One team

The Deteriorating Resident Response Tool (DRRT) has been developed to guide RN’s in Residential Aged Care homes (RACHs) to better understand, anticipate and make clinical decisions responding to the deteriorating health of residents.

The objective of the DRRT is to give RACH staff clear information to triage and provide appropriate care for a range of residents’ health conditions, and, in turn, prevent unnecessary presentations to ED.

The tool has been designed together with a specialist geriatrician, consulting with stakeholders such as Residential Aged Care Managers, NSW Ambulance, GPs, and experts from Mid and North Coast LHDs.

The pilot commences in March with four participating RACHs. Evaluation measures will include effectiveness in building RN confidence and reported reduction in unnecessary hospitalisations. Findings will inform a future planned, region-wide implementation.

North Coast Care Finders Program

Strategic Priority Area: No one is left behind

The Care Finders program is a free region-wide service to support vulnerable older people who have no-one else to help them, to learn about, apply for and set up support services.

Care finders can help people understand what aged care services are available, set up an assessment, and find and choose services. They also help people with access to other supports in the community, both accessing services for the first time and changing or finding new services and supports.

On the North Coast, Healthy North Coast has commissioned four organisations to provide this important service: EACH, Carexcell, Lifetime Connect and Footprints.

icon with person and hands

Psychological services in residential aged care homes

Strategic Priority Area: Improving Lives Now

Healthy North Coast commissions two service providers to deliver psychological therapies and supports for older people with, or at risk of developing, a mental illness and who are living in residential aged care homes (RACHs).

The aim of the program is to both provide direct support to residents and their families and carers, as well as upskill the RACH workforce to respond to the needs of residents presenting with mental health concerns.

Healthy Towns. Healthy Communities.

Strategic Priority Area: Securing a Healthier Future

Connection and a sense of belonging are protective factors for both individual and community health and wellbeing. Evidence highlights that the social determinants of health play a critical role in addressing many of our regions health challenges.

That’s why Healthy North Coast has long been committed to supporting communities to strengthen and to build social health. Our initiatives, including contemporary ‘Social Prescribing’, help people to connect to activities, supports and each other, and assist communities to integrate services and bridge gaps.

icon with person and hands

Telehealth in Residential Aged Care

Strategic Priority Area: Improving Lives Now

The Royal Commission into Aged Care Quality and Safety identified several critical areas affecting aged care residents and our health system. Key challenges include:

  • Limited access to general practitioners (GPs) and allied health professionals in aged care facilities.
  • Difficulties accessing out-of-hours services

Telehealth offers valuable opportunities to enhance support for residents living in aged care homes. Funded by the Commonwealth Department of Health and Aged Care, this initiative provides telehealth equipment and staff training as part of the response to the Royal Commission’s findings.

By improving access to primary care clinicians, specialist services, and other service providers through telehealth, we can significantly enhance health outcomes for residents, reducing unnecessary hospital transfers and emergency department visits.

The selection of telehealth equipment was guided by our Healthy Ageing Strategy (HAS), a comprehensive digital discovery questionnaire, and consultation workshops with various stakeholders. These efforts included interviews with residents to understand their attitudes toward telehealth, ensuring the initiative meets their needs and preferences.

icon with person and hands

Greater Choice at Home Palliative Care Program

Strategic Priority Area: Improving Lives Now

Aims to provide people who have life limiting conditions the opportunity to exercise choice and receive high quality care at home, harnessing improved and better coordinated supports and services that meet their individual needs.

Program objectives:

  • Improve access to palliative care at home and support end-of-life care systems and services (in primary health care and community care)
  • To enable the right care at the right time and in the right place (to reduce unnecessary hospitalisation)
  • Generate and use data to support continuous improvement of services across sectors
  • Use available technologies to support flexible and responsive palliative care at home, including in the after-hours.

These objectives will contribute to achieving the following intended overarching outcomes of:

  • Improved capacity and responsiveness of services to meet local needs and priorities
  • Improved patient access to quality palliative care services in the home
  • Improved coordination of care for patients across health care providers and integration of palliative care services in their region.

Education & training funding elibility

Funding is open to all primary care providers within disaster affected communities across the Healthy North Coast footprint.

Workforce Locum support and R&R funding criteria

  • Available to primary care services in disaster impacted communities within the Healthy North Coast footprint.
  • Available to support short-term workforce coverage, allowing clinicians to rest and recover.
  • Workforce-support funding in total is capped for each site, over a 12-month period:
    • $10k for GPs and/or
    • $5K for nursing and/or
    • $5k administration support and/or
    • $5K allied/pharmacy and other.
  • Funding is not to be used to fill gaps in staffing that have not been able to recruit to and not to replace existing staff.
  • Healthy North Coast will assess requirements and approve available funding directly with the service requesting support.
  • Priority will be given to sites that have immediate, short-term workforce support needs.
  • Requests will be reviewed and supported on a case-by-case basis.
  • Program funding administered via RCTI Agreement (Recipient Created Tax Invoice) to be paid monthly, or on completion of the placement (whichever comes first).
  • Practices will be required to complete a request for payment form monthly, or on completion of the placement (whichever occurs first).

Wellbeing Flexible Funding Criteria & Eligibility

  • Open to all primary care providers within disaster affected communities across the Healthy North Coast footprint.
  • Activity must be purposeful, with the aim of increasing the wellbeing of your team.
  • Requests will be assessed on a case-by-case basis, with funding allocated based on team size.*
  • Following approval by Healthy North Coast, funding will be administered via RCTI Agreement (Recipient Created Tax Invoice) upon providing proof of expenses.
  • Funding cannot be used for the purchase of alcohol, or any other goods or services where the vendor cannot quote their Australian Business Number.
  • Planned activities must occur prior to 30th June 2024.
  • Funding will not be available for retrospective activities.
*Team Size
(Total staff and contractors)
Funding Available
Small (1-5)$500-$1500
Medium (6-20)$1500-$4000
Large (>20)$4000-$5000

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