Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common childhood neurodevelopmental disorder, affecting approximately 6–10% of Australian children. Without timely treatment, ADHD can lead to lifelong impairment, including increased risk of substance use, poorer educational and employment outcomes, and reduced social and emotional wellbeing.
Within the Healthy North Coast region (Northern NSW and Mid North Coast Local Health Districts), lengthy wait times for paediatric ADHD assessments have created significant access inequities, particularly for vulnerable families. These delays in diagnosis and treatment increase the complexity of ADHD management and place added pressure on specialist services.
The Henry Review (2020) identified inefficiencies in specialist-led stimulant prescribing and recommended alternative care models. In response, the NSW Ministry of Health introduced key reforms:
These reforms aim to reduce wait times, improve access to assessment and treatment, and strengthen ADHD care delivery across NSW.
On 1 November 2024, Northern NSW public paediatric clinics transitioned to a co-management model for stable ADHD patients, with Mid North Coast clinics following in November 2025.
Under this model:
• Paediatricians confirm diagnosis, initiate treatment, and provide detailed medication and monitoring plans to the patient’s GP.
• GPs assume responsibility for ongoing prescribing, review, and monitoring in accordance with the specialist’s recommendations.
• Both clinicians ensure prescribing remains under a single prescriber at any given time.
The ADHD CNC Co-Management Coordinator, Bel Davis (nnswlhd-adhd@health.nsw.gov.au | mnclhd-adhd@health.nsw.gov.au, 0427 940 980), plays a pivotal role in supporting GPs to safely co-manage ADHD patients. The role includes GP education, facilitation of communication between primary and specialist care, transition planning to adult services, and oversight of clinical initiatives aimed at reducing wait times and improving outcomes.
Project Components
1. GP Training and Support
– Education sessions on ADHD assessment, prescribing, medication titration, SafeScript use, and PBS authority processes.
– Access to HealthPathways for localised clinical guidelines and referral pathways.
– Ongoing collaboration between GPs, paediatricians, and the ADHD coordinator.
– Promotion of appropriate MBS item use to ensure sustainability.
2. Co-Management of ADHD Care
– Shared care between GPs and specialists for stable ADHD patients.
– Regular medication reviews, monitoring, and documentation of treatment response.
– Integration of non-pharmacological interventions, including behavioural therapies, school supports, and allied health input.
3. Improving Access and Reducing Wait Times
– Reduced demand on specialist paediatric services by shifting stable management to primary care.
– Expanded GP and nurse roles, enhancing professional development and workforce capacity.
– Timely follow-up and continuity of care for children with complex needs.
Supporting Resources
HealthPathways
• ADHD in Children and Adolescents
• ADHD Medication Co-management for Children and Adolescents
• Non-Acute Paediatric Assessment
Useful Links
Continuation Prescriber – NSW Health
https://www.health.nsw.gov.au/pharmaceutical/doctors/Pages/adhd-management-prescribes.aspx
Explains the new Continuation Prescriber arrangements, eligibility, and authority requirements for GPs continuing ADHD medication prescribing.
SafeScript NSW Education and Training – NSW Health
https://www.health.nsw.gov.au/pharmaceutical/safescript/practitioners/Pages/education-training.aspx
Provides practitioner training and resources for SafeScript NSW, the real-time prescription monitoring system.
Clinical Guidelines – ADHD (AADPA)
https://aadpa.com.au
Access the Australian Evidence-Based Clinical Practice Guideline for ADHD, detailing national standards for assessment and treatment across the lifespan.
NSW Health / University of Sydney – Brain and Mind Centre ADHD Training
https://short-courses.sydney.edu.au/class/ADHD-1
An online e-learning course developed by the Brain and Mind Centre, funded by NSW Health, to upskill primary care practitioners in ADHD management.
Covers diagnostic pathways, pharmacological and non-pharmacological management, and collaborative care models. The first 500 enrolments are free.
Medication Information Sheets – Choice and Medication (Hunter New England Health)
https://www.choiceandmedication.org/hunternewengland/printable-leaflets/
Download clear, printable information sheets for patients and families explaining ADHD medications, side effects, and safe use.
Agency for Clinical Innovation (ACI) – ADHD in General Practice
https://aci.health.nsw.gov.au/projects/adhd-in-general-practice
Outlines NSW system-wide initiatives supporting general practice involvement in ADHD management.
Therapeutic Goods Administration (TGA) – Medication Shortages
https://www.tga.gov.au/safety/shortages/information-about-major-medicine-shortages/about-shortage-methylphenidate-hydrochloride-products
Provides current updates on ADHD medication shortages, expected resupply timelines, and prescriber guidance.
Autofills
Pre-filled clinical note templates designed for integration into practice software, enabling GPs and practice staff to efficiently document ADHD co-management reviews. These can be adapted to individual practice workflows.
Please contact your HNC Regional Manager or the ADHD Co-Management Co-ordinator on 0427940980 or at NNSWLHD-ADHD@health.nsw.gov.au or mnclhd-adhd@health.nsw.gov.au for further information
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.
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.
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.
Strategic Priority Area: One team
Empowering aged care teams to deliver safer, more consistent care.
The Deteriorating Resident Triage Tool (DRRT) supports aged care staff to confidently recognise and respond to signs of resident deterioration. It enables timely, evidence-based decisions, strengthens communication with health services, and promotes early intervention and effective care planning, helping residents receive the right care, at the right time, in the right place. By doing so, it reduces unnecessary Emergency Department presentations and improves resident outcomes.
Developed in collaboration with a specialist geriatrician and informed by input from Residential Aged Care Managers, NSW Ambulance, GPs, and clinical experts across the Mid and North Coast Local Health Districts, the DRRT is practical, relevant, and aligned with contemporary best practice.
Aligned with the Strengthened Quality Standards:
Strategic Priority Area: No one is left behind
Care finders is a free service to assist older adults connect to aged care services and supports. Care finders support older people who experience significant barriers to accessing services, and walk alongside their clients at their own pace, to understand their individual situation and support them to work through the steps to address their needs. Care finders assist people with access to other supports in the community. They can provide connections both with accessing services for the first time, and with changing or finding new services and supports if their needs change.
Care finders can:
The care finder program has been extended to June 2029 and is provided by the following organisations. Each (Lismore, Coffs Harbour, Clarence Valley, Richmond Valley, Port Macquarie-Hastings, Kempsey, Nambucca and Bellingen) and Footprints (Kyogle, Tweed, Byron and Ballina).
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.
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.
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:
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.
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:
These objectives will contribute to achieving the following intended overarching outcomes of:
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
Wellbeing Flexible Funding Criteria & Eligibility
| *Team Size (Total staff and contractors) | Funding Available |
| Small (1-5) | $500-$1500 |
| Medium (6-20) | $1500-$4000 |
| Large (>20) | $4000-$5000 |
