Jenk Akyalcin: Welcome.  I am Jenk Akyalcin with the Primary Health Branch of the Department of Health.  I'd better get that right.  And my area is responsible for the home care patient strategy and also for integrated health promotion and with me today is the health promotion team, Sue Psalios and Katie Larking and Helen Dickson, she's at work today, and also there are others in the partnership team looking at other areas like service coordination, partnerships and so on. 

Great to see the numbers.  Can I just get a quick indication those of you who are from a government department, and those of you who are from the sector, if I can use that terminology?  Thanks very much.  That's terrific. 

This is the third of these lunch time seminar series, and the first one was on physical activities and the second one was on mental health, and we do have a recording of those sessions.  If you'd like to look at those, they're available on line.  Indeed, today, this session will be video recorded as well and it's really to assist our folk in rural areas who can’t attend during lunch times. 

Today's seminar is themed Health Equity, also referred to as Health Inequalities.  You all could be quite familiar with the term, but just to reiterate, the expression Health Equity is a shorthand way of describing both the fact that different people experience better or worse health depending on their life circumstances, and it's probably fair to say that for many the inequalities that are in fact preventable relate to income, education and living and working conditions. 

You may be aware that recently - in fact I think it was yesterday or the day before - that this particular document was released by the health minister, case studies on improving health for all, and the next lunch time seminar series we'll cover these sort of subjects [unclear] but it certainly relates to today's theme. 

I just really wanted to acknowledge the work of the sector, particularly Primary Care Partnerships, Community Health Services, Women's Health Services and others.  They're really making a significant contribution to reducing health inequalities and great pieces of work today as part of all that. 

Without taking any further time, if I can introduce to you Mark Boyd, who is the Director of the Cities for Safe and Healthy Communities, and Julie Watson, who is the Executive Officer of the Banyule Nillumbik Primary Care Partnership. 

Jenk: Thank you and welcome.

Mark Boyd: Good day, everyone.  Thanks a lot for coming along.  I will start it and then Julie will jump in, but before we begin I would like to acknowledge, on behalf of Julie and I, the traditional owners of the land that we are meeting on, and I pay my respects to elders working across Victorian communities today.

This presentation is about a trial we had about a year ago with Banyule Nillumbik Primary Care Alliance.  What we were looking at at the time was with Vic Health, doing the health inequalities role with them, and we produced People Places Processes, which was a resource for the sector. 

It is divided up into two parts.  The first part is a check list for the health promotion health workforce to be able to go through and look at some guiding questions that might help in the design of health promotion activities that they are going to be implementing at the local level.  The second half looks at the variety of approaches that health promotion can take, the whole population approach, targeted at interventions aimed at particular sub-populations, area based approaches that really look at using a defined geographical area, and then life forces approaches, which look at the particular stage in people's lives and sort of design their health promotion around that. 

Then what the resource does is it sort of weighs up when each one might actually help reduce inequalities and when they're not going to be that successful. I was just hearing from [unclear] there is some work being done within the Department of Health at the moment looking at program logic training for the workforce, and I think that the second half of that resource will lead into being useful for that work. 

Really what it is trying to do is say, okay, here's your outcome that you are trying to reach as far as the community wellbeing or community health outcomes, then using the evidence base, what's the logical process that will get there, because what quite often we attempt to do, and this just doesn't work with health inequalities, you sort of say, okay, here's the problem, we're going to throw some money or some resources at it and we're going to try to get this outcome, but, as has just been written about in - I think it's the Medical Journal of Australia, by Liz Waters and some others from her team, where they were talking about the health inequalities being one of those wicked problems, it's really difficult to solve.  There is a whole range of influences, and just when you think you've got a hold of that, it moves on to something else.  So it's really slippery as well.  It is sort of being really methodical about we're trying to achieve is really important.

The health inequality scene in Victoria in 2005, we had a bit of a policy vacuum - [Unclear] a joke. - except for the Vic Health position statement on health inequalities, so at the time that was about the only thing that was useful for the sector to talk about health inequalities.  It was like this really empty space.  With all of us working in the area, it was really difficult to sort of get a grip on, how do we actually turn the literature into what we need to do.

There's a couple of seats down here, there's three seats down here, and there's one over here.

Yes, as I was saying, a policy vacuum in 2005.  Then by 2009, where we are today, we've got a whole range of resources now available to us as a bit of a tool kit around health inequalities.  Sorry for the shadowing there.  It doesn't come up that well, does it?

Just to quickly describe then the tools that we have available to us within the sector now, it's a priority focus in our state plan.  For Vic Health, it still continues to be one of their overriding priorities within their strategic plan and within A Fairer Victoria health inequalities is a priority area.

The compendium of good practice that [unclear] just mentioned has been released.  It is a really guiding resource.  We may as well just look at that now.

Female: Sure.  I don't have it up, but anyway.

Mark Boyd: That's all right, we'll get them started.

Female: I'll do it.

Mark Boyd: So that sort of guides some of the ideas around what we can do at the practical level around health inequalities.  We also do have now State-wide equity indicators that have been developed, and so if you look on the internet at Fair Facts, I think I've got the web address later on in this, but it talks about the State-wide level health inequalities indicators that need to be mapped, and my understanding is that is now going to be an annual process to make sure that we're looking at that.  This is really tricky stuff. 

There was a report done by the federal Health and Community Services and Indigenous Affairs a couple of years ago which showed that social mobility over the last 50 years hasn't really moved that much for Australia.  So if you were born into a low income background, then you die in that low income, sort of access to resources as well, and so while there are the instances of the individuals coming out of that, and I used to use the crazy John example as being sort of one of those ones that just lie outside of that, but that's not even the case anymore.  There is still this really difficult work as far as trying to encourage a greater access to resources and potential for life amongst low income Victorians.

Also we have seen over the last few years a real increase in the Victorian population health survey and the analysis done through  an inequalities [unclear].  There is also an equity filter and a whole range of other resources, I understand, being used internally in the department to allow assessment of evidence to see whether or not it is contributing to how we design programs to reduce inequalities. I'm talking about the health promotion plan [unclear], so that's that People Places Processes sectors as they have been described.  That sort of helps guide discussions around how you would design a program. 

It really looked at the three types of inequalities that exist.  You have an inequity of access to services.  On the right-hand side there is a little triangle.  It is sort of saying that there is a role as far as inequitable access to the range of services that allow you to prevent ill health and also enhance your resources for living, but overall there is an inequity of opportunities for particular sub-populations in Victoria. 

There is a bit of difference between VHS and Vic Health as to how they describe those.  Vic Health, for example, recognises people on low incomes, indigenous residents of Victoria, migrants from a refugee background and people with disabilities.  If you actually look at the data, those groups consistently miss out on the equity of opportunity, so housing, employment, education, good jobs, good income, where people live, that sort of thing. 
Then there is the inequity of the impacts and outcomes.  One of our problems within the system is that we don't actually measure the differences in outcomes for a variety of people amongst our communities, and we see this all of the time.  I'm sure everyone here has been at a forum before where someone has presented findings about a research project, and then someone has asked, 'What does this mean for indigenous people in that area or who might be addressed by that', and the answer is, 'Oh no, well, we don't know, because the numbers were too small and we didn't analyse by that anyway.'  

I think what this is trying to do is actually say that that is not good enough, that we should actually be looking for those differential outcomes for those groups who miss out consistently, because if we don't, then we're still going to have the same [unclear] that we've always had, which is that inequality gap.

I will jump over to Julie now to describe her project that we ran.

Julie Watson: Hello, everyone.  We're really thrilled to have been able to be part of the work that Mark is progressing and I would like to tell you a little about that work. 
It really started just over three years ago when Helen Clough, who is the health planner at Banyule City Council, was looking to work with her partners on actioning the third year of their municipal public health plan.  She wanted a speaker that would inspire a group in developing their next big thing for the public health plan and invited [unclear] to come and present to the group.  As you can imagine, there was a lot of the same partners that belong to the BNPCA, so that the local government was engaged as well.  It was really quite a broad group.  She had good representations from police, housing services and other such groups, and at that session there was a real swell of interest in taking this concept and reproducing it in the next planning cycle.

At the time, the BNPCA was actually located within Banyule City Council, and so there was a deal of interaction between Howard and the BNPCA team, and at the same time we were preparing our 2006-2009 community health plan and the BNPCA decided to take this idea and put it in its plan.  I have to admit that it was included in very concrete ways.  I would have rather seen it more integrated throughout the plan, but at least it was in there.  That led us to some more intentional work.

There was a phase then when we weren't quite sure what shape that would take.  David talked about maybe being [unclear] for some work.  That didn't quite come off because of changes but then, co-incidentally and perfectly, Mark was doing some work with his tool and it transpired that we would use our PCP as a trial site.

Now, it was interesting to choose Banyule and Nillumbik.  I don't know whether you know much about that area.  It is north east of metropolitan Melbourne.  Nillumbik I think is the second most advantaged LGA in the State.  Banyule has two of the most advantaged suburbs in the northern area of Melbourne, Wivenhoe and Eaglemont, but it also has one of the most disadvantaged postcodes too in Heidelberg West, that old Olympic Village site, with a high percentage of public housing, a big Somali population and an identified neighbourhood renewal site.  So amongst seeming relative advantage, there was also this pocket of disadvantage, let alone that we do have an indigenous population of around 500, but we don't see them using our services much, people with a disability living in our catchment that we haven't been able to progress much work with.  So even though it might seem unusual, but we wanted to try and put forward the recognition that there were groups with distinct disadvantage that we weren't working with. 
Under the facilitation of Mark we have developed a working group, and it's great to have some of the members of that group here today.  There was Mark and myself; there was Anita, the health promotion planning officer from BNPCA; Howard from Banyule City Council; some other PCP representatives, Val Kay, from the Inner South East Partnership, Emma Brentnall from Campaspe PCP, one of our rule PCPs; Sue Psalios from Primary Health Branch; Stephanie Morris from our regional DHS department.  We've formed a working group to plan what we were going to do and initially we were working with Mark on looking at the tool he was developing and giving some suggestions to how it might be improved, and then we planned the three forums that we ultimately ran, and I would just like to talk you through those particular forums.

For the first forum we were going to try and encourage a wide representation, so we didn't want to put people off by using health promotion language that was going to disengage our representatives that may not come from that particular background.  It was a bit like a health promotion 101 and introducing the idea of focus determinants of health.  It might have bored some of the health promotion professionals, but at least we felt then we were getting those groups on an even playing field.

Mark introduced the tool to the group and then they were given the task of picking something from their work.  It was said right from the start that it was going to be action orientated.  They weren't just coming to learn.  There was going to be work to be done.  I actually think that's what got so many people in.  We ended up with about a group of 30.  So we were really thrilled about that.  They had to pick something from their work.  It could be a policy, a program or a project.  A program would be long-term, something that was funded for [unclear] or a project might have been a shorter term aspect of the work, and then matrixed over that was it could be in the planning phase, the implementation phase or the evaluation phase.  After the first forum they were to go away and pick something from their work.

At the first session we also allocated a mentor to each of the participants and they worked on the working group that was planning the session.  Between the first and the second forums the mentors followed up with their selected representatives and talked about what piece of work they might be thinking.

Then we came back to the second forum.  At that second forum we started off by sharing with each other the piece of work they were going to apply the tool to. It was really quite astounding the mix we got, because we were a bit concerned it might be heavy to one thing or another, but it actually proved to be quite a good distribution, without any intentional engineering of that.  Then Mark went on to talk about how to apply the tool and we used a local example of a 'walking together' group as an example of the tool being applied.  The group left and the evaluation showed that they felt confident in applying it to their piece of work.

We had about two months between the second and the third forums, and so that was when they applied the tool to their particular interest.  Mentors signed up with them and a lot of the evaluation said how useful that mentoring was, because it challenged them to really sit with the questions that they might have just dismissed.  So we would say that that mentoring facility that we developed really paid dividends and was a really worthwhile part of the process.

We also tried to set up a new learning system through group e-mail, but ultimately only Mark and I used it.  So that didn't quite work like we'd hoped, but I think in Mark's evaluation he talks about that maybe we were just a little bit too early, not to dismiss it as a possible learning technology, but maybe our timing was a little bit out.  This was all happening at the start of 2008, about 12 months ago.

The third forum was a massive evaluation forum.  It was just incredible because we were trying to not only get feedback on the outcomes for them in applying the tools to their piece of work, but also their experience with the tool and their experience of the forums.  We were asking lots and lots of questions, but it was really fascinating getting the response.  Even those that couldn't attend, we managed to gather their experiences as well and include that in the results as well.

Have we got time, Mark, just to go through some of the experiences?

Mark Boyd: What's on the list again?

Julie Watson: No, we probably haven't.  We will go on to the next one. 
There was great momentum created by the forums in our PCP, and I've had individual contact with people that participated in the process, saying how they often think back to the tool and what they learnt from that and applying it to other situations, and we want to keep that momentum going, but the tool did heighten equity discussions. 
What came out of it for the PCP was a challenge to us to help our agencies create those links to other sectors that they don't feel that they were connected with, so housing services and disability services and agencies that work specifically with a cultural group, helping them to form those links. 

They also found the bit of training that we did in that first forum really informative if they hadn't had much experience of health promotion concepts, and they were wanting that to be available to them so that they could share it with other staff teams.  I am thinking particularly here of a lady from a heart program at Austin Health who was just blown away by this concept of working earlier, and the challenge for her in the client group that their particular program were working with.  That's the sort of discussions and ideas that were going on.

Thank you.

Mark Boyd: I might just add a couple more comments as well around this sort of thing.  I think one of the things around partnerships that people found really difficult was that we do say it, we do know it, but then how do we make it real.  A lot of the agencies there were from mainstream or from service deliveries and they still had difficulty, even though they had identified that they wanted to engage with the Somali population, for example, in the area.  When they actually then ran the project, they did have all these outcomes, they didn't have that high level Somali participation that they had actually been looking for, and so there is this whole extra level of engagement that we still need to work out how to get around some of those complexities, but people were talking about working with disability services, for example.  [Unclear] they identified that that was one of the areas that they wanted to do, but still at the end of the day the project didn't actually engage [unclear] for other people with disabilities. 

It is really great that they did.  Julie was telling me earlier about how that has now been embedded into the Banyule Nillumbik Primary Care Alliance, but we are really working to build those partnerships in [unclear] in stronger ways, and the same with the health in the wider service sectors.  I think what we saw even is that there's a little bit of a drop-off.  At the first one the employment services and a couple of others came on, but a couple of those didn't make it all the way through to the end because of other competing pressures.  If there are ways to try to get the wider service sectors to work together, that would be great.

That leads into this final point about creativity training.  I don't want creativity training to be seen as something that we do with resource underdeveloped, places that don't have enough resources to run properly.  We give them creative training to make their work more effective, given that they don't have any resources.  I'm not talking about that, but it's more about how do we really make this sort of work come alive, but it's really tricky stuff. 

For example, in the actual check list response the questions are around how many fast food outlets are available in the local area and how many alcohol outlets and how much tobacco is sold in your local area, and some of the comments from people filling in the check list were, 'Oh, this isn't really relevant to me, this sort of question', and yet they're working in community health services.  You'd think they've just got the diabetes support groups running, why wouldn't you look at that sort of information, and then think, given that this is the environment that's available, we don't have fresh fruit and veg supermarkets, but we do have Subways and McDonalds and all the rest, how do you actually use that sort of stuff to then design your diabetes support group session so that they are actually relevant?  There's no point sort of telling people at your local diabetes support group what they should be eating, blah, blah, blah, when that's not available in the local area.  So maybe it's about how you use a little bit of Subway or use some other stuff that is locally available and make the best menu choices from that even. 
Some of those sorts of creative links weren't quite happening.  Another one that seemed to come up in the questions was when we asked about, 'How does your health promotion project link to say employment and education opportunities', and people were saying, 'Look, that's not the primary objective of our health program', and yet the person coming to that health program may be coming because their health issue is impacting on their employment opportunities.  So for the person coming into the service, employment is actually the main game for them.  It's just that health is getting in the way.  So trying to expand our thinking in really realistic ways would be helpful around that.

There are a range of other examples and other recommendations for Vic Health as far as continuing the tool because it was found to be really useful for the Primary Care Alliance and then for DHS more generally.  I just want to talk about four suggestions that I have got, for what it's worth.

First of all, I think one of the things that has been really tricky around all of this work, and it really came up in the talk, is that we don't actually have a pie graph of the contribution of the various causes of health inequalities to Victoria or Australia, or internationally even.  So I just made this up.  Don't take the cycle of the graph as being relevant, although I would say that probably it pretty much is.  For example, in a research, particularly for New Zealand, it talks about place effects being about 10 per cent of the influence on health inequalities, and then I've actually had a look at the avoidable social outlooks for health for Australia.  You can sort of divide up the low income populations and their access to health services, and if you do that, you get about a third of the health inequalities in Victoria are due to inadequate access to health services.  So even without thinking about a creative link to the wider influences of health, there is a lot we can just do within our health service delivery, especially for this audience in primary care.  In fact, if we do some of that work, maybe that's got some real potency then and some value to employment services and all the rest in saying, 'Look, this is how we got our backyard together.  These are the sorts of tools or influences you need in your work', so that we're actually adding value to the other sort of sectors as well.

I won't go through the rest of those because they were the two that really stood out for me, but we need that sort of map because at the moment people are saying that the check list is okay.  We have identified five areas that we haven't thought through.  How do we then prioritise those areas, if we have identified there is an education gap and there is a place impact because of the high level of fast food and alcohol and all that sort, you know, whatever they've identified, but then how do you actually prioritise which ones you should address first, because that's going to create the greatest gains in reducing inequality.  This work would help inform that, if you get me. 
Second, what we really need to then translate is State indicators, reduce that download, so [unclear] does help static downloads [unclear], but then how do we actually drill that down into program outcomes.  One of the difficulties for the workers during the trial was that, yes, they were big believers in what we were talking about around reducing health inequalities, but their funding guidelines were talking much more about throughputs, about the number of people who use the service, not whether those were the right people or the people with the greatest need.  So there was sort of this disconnect sometimes.  If we actually operationalised these State indicators into our program models, then you would actually drive them to force this thinking around health inequalities a bit more.

Third of all, for Vic Health the check list was found quite useful.  It was really in draft stages and because of our time limit we were rushing through it a bit, so there is some sort of professional wordsmithing that could be done, there is some editing to make the questions a little bit simpler, and also maybe just some sort of ordering of them so that they are going from, say, an individual centre focus to the program service deliveries, the wider influences on health or something, and sometimes it jumps around within the various questions, but overall it was found that it really did enhance discussion. 

The quote on the cover of the report talks about how frightening one service found it to be because they hadn't considered any of this stuff and they realised that their programs were probably being delivered to those who didn't have access to money, a car, had good stable housing, employment and all of the rest already.  Then you could actually build a discussion to fit around it.  You've got the tool, but for Vic Health, maybe they could look at how they raise this at a staff working group sort of thing and work through it and raise discussions in that way and all of the rest.  I've noticed Vic Health recently, they've got their anti-discrimination program and they've just moved that into having a training course attached to it and all the rest.  So maybe there's a structure where they could do something similar with health inequalities.

Finally, there is the need for further tool kits and resources.  [Unclear].  One thing that I think is really encouraging will be - in a way to do that creative training thing and build the relationships between health and wider service sectors - will be if there were a few more multi-sectoral funding programs, and it's really tricky, but it's the only way to get us out of our silo thinking I think.  Primary Care is actually doing this, I understand, with the Department of Justice where there is a problem gambling program the Department of Justice is funding via Primary Care, but even if there were just more, it doesn't need to be huge and all of that sort of stuff, but if there were some more examples of those sorts of ways of working across government agencies to just sort of build up those sorts of links and get us thinking a bit outside the box sort of thing. 
The State-wide program intervention planning tools.  One of the works that Shelley and I were doing together with Kelly Horton and Dave Trudinger and Michelle [Pavey] on the day when we were doing all of this, one of the ideas then was also looking at if there is in the evidence base what a successful intervention is to reduce inequalities, how do you design a program logic based on the needs that are showing in the Fair Facts report, plus the best of what we do know about how to reduce inequalities and then how do you design a program at a State-wide level that way.  That sort of work, I understand, is still continuing.  There is still that need.

One of the other areas that came up to the Primary Care Alliance was that yes, it was great that workers were doing this but they still needed that senior management buy-in to actually give their work credence at the local level and also encourage the senior managers to be negotiating the funding arrangements that do embed equity into the performance indicators of what they say they are going to work with.  I understand Daniel, again, has been running some forums with senior managers to try to align that a bit better and, again, that needs further work.  I have also mentioned the training course for Vic Health or someone like that.  I mean definitely what people wanted in the three forums that we held, the first two, if that could be packaged up as either a self-paste presentation or something that could be an ongoing thing. 
I think that is it for our one, because we only got half an hour, and I think we have probably gone over that already.

Jenk Akyalcin: Thanks very much, Mark.  Thank you, Julie.  It was very illuminating.  Probably the highlight for me really was how to implement this practically.  I think [unclear], using this is a great opportunity, how can it be an opportunity through partnerships [unclear] available in a non-threatening way.  I think the thing that came out to me is about the mentors and you can increase the value [unclear] a health promotional background and I always struggle to access further information for professionals.  So I think [unclear] means that this work can be taken forward to the people who come from that world and I think that is really important.  So thank you very much for that presentation and we certainly encourage the Primary Care Partnership and the department agencies to continue this sort of thinking and to make use of these sorts of resources that are available.

Our next presenter Olive Aumann and Olive is the Health Development Manager at Whitehorse Community Health Service in Melbourne.  One of the things that this presentation will show perhaps is how to get a [unclear] approach to [unclear] documents and, Olive, if you are ready, over to you and welcome.

Olive Aumann: I guess, moving away from the more theoretical perspective that Mark and Julie have provided, it is drilling down into what we do when the clients [unclear] and that's I guess where I'm coming in, and, unfortunately, at the time when we identified our population groups to work with, we didn't have the benefit of this tool of Mark's [unclear].  So that's fantastic. 
I am from Whitehorse Community Health Service and the program I am talking about is a health promotion initiative that is based on our health promotion plan, our [unclear] health promotion plan and it is named by the residents Residents Making a Difference.

Just giving you a bit of a snapshot about Whitehorse for those of you who don't know Whitehorse.  The local government area is only about 15 kilometres east of Melbourne, so it is not very far away from the city.  It has got around about 145,000 residents.  It is quite a small geographical local government area, quite tiny really if you look it on the map.  So the people are kind of captive a little bit.  It has got very much an ageing and an older population.  It has actually got one of the oldest age profiles, if you like, in Melbourne, quite a lot of diversity, particularly from Chinese speaking backgrounds, overall similar to Nillumbik and [unclear] local government areas, ten on the scale of [unclear] local government areas, but within that like Nillumbik and Banyule, similar pockets of disadvantage.  In some neighbourhoods in the local government area they actually have a super score as low as any of the super scores in the statistics around the Melbourne metropolitan area.  So obvious disadvantage and obvious subsequent health inequalities, but the challenge always is to find out who they are and where those people are. 

Back in 2004 we were starting to look at this work really seriously about reducing health inequalities.  In 2003, those of you who are in community health and primary care partnerships sectors will recall that we had a minimum process for integrated health promotion plans and implementation reporting that DHS had - I was going to say imposed, but I shouldn't say that because it is a fantastic [unclear] strategy, but it had applied to us as part of our funding, so it really required a lot more rigour and a lot more ability for us to be able to look at some evidence of what we were doing, not just - I guess why we were doing what we were doing, as well as the outcomes.

When we started to think about who should we be working with in the local government area, because we don't want to increase the gap in health, we realised that we really had very little data about the health of our community.  What we did have were lots of demographic data, but that was before a lot of - there has been a lot of research over the last few years on community indicators for a whole range of things, but this was in the very early days of the Victorian population health survey.  I think there had been two Victorian population health surveys in the two preceding years, and that survey was terrific, but it didn't - it showed the State-wide data [unclear], and obviously in that State-wide data there were a whole lot of differences for different populations and it didn't highlight the inequities, but we really liked the population health survey and we wanted to apply it to our local government level. 
So after probably 18 months of negotiation and toing and froing and looking for funding, and at one point being told that if we did that we would lose our health promotion funding, if we stepped [unclear] and all sorts of things [unclear].

At that time it was really trying to develop the understanding that we needed this data [unclear].  So in 2004 we undertook a population health survey down at the Whitehorse local government level, and that survey was applied to a 0.5 per cent sample size in Whitehorse, and we had done our research to find out that that was a good representative sample of a comparable [unclear].  We copied exactly the methodology of the State-wide survey.  We had full partnership with the Public Health Branch [unclear] survey and getting an extra course in, putting up a brief to get extra social research people to apply the survey, because it is actually a computer assisted telephone interview.  It is a 20 minute long one [unclear] randomly pick out some and try and match them up with addresses and [unclear] very effectively and very much out of the realms of what the staff could do.  So we did that research.

Towards the end of the process of doing the data collection, we partnered with the Department of Victorian Communities [unclear], and particularly the research manager, Jeannette Pope, was incredibly supportive and instrumental in this [unclear] and she felt that such an important piece of work [unclear] that she actually funded a little office for us, which was [unclear] report.

Just to give you a snapshot, one page of the report does give a snapshot, and I don't know who clear this screen is to people at the back.  What we did with the sample is we actually - as I said, we had [unclear] sample size - we wanted to make sure we had a good representation of people on low incomes and we wanted to make sure that we had a good representation from Chinese people, people from a Chinese speaking background.  The reason for that is because often [unclear] we had been experiencing in the State-wide Victorian population health survey to that point, the experience is that you often miss those groups.  (a) They don't have Chinese or they don't answer Chinese or they don't want to be involved in those kind of surveys over the phone or they have got silent numbers, or in terms of the Chinese, they don't speak the language.  So part of our brief to the social researchers is that they had to get a minimum of 100 of each of those.  Out of the 870 we had 200 from those two groups.  That gave us a really good sample. 

If you just look along at the two different columns, on the left we have got the State-wide average.  So we were able to compare our results with the previous Victorian population health survey.  Then we have got the Whitehorse average, then we have got the Whitehorse low income and then we have got the Chinese community population results.

Olive Aumann: The other thing, on the right-hand side then we have got, you know, what jumped out within those particular samples as then other groups, [unclear] groups.  You will see that there is a little time bomb symbol next to the other risk groups and you will see that the time bomb symbol appears through that table.  Essentially that was alerting us to some real problems in terms of some of the data and for some of the population groups, and if you look at the low income group, you will see that, no surprise, there are time bombs against almost everything.

I won't go into any more of that, but if anybody would like a copy of that or would like further discussion about that, I'm happy to, but I would also say at this point that it's very heartening to see the Public Health Branch has now actually changed the way that they're doing the population health survey and they're doing it to provide enough of sample sizes at a local government level to provide this sort of information.  So that's fantastic.  [Unclear] that fits in with our next planning cycle.

Just a snapshot, by way of snapshots, about the health inequalities in Whitehorse that we identified through this population survey was that there was a clear relationship between health status and income - surprise, surprise; that there is a socio-economic gradient in six out of the 10 cardiovascular disease risk factors; and the highest risk factors were found to be in public housing residents, unemployed people and those unable to work.  That takes into account the indigenous third category as well.  Very high risk factors for Chinese residents, particularly around the issue of anxiety and depression, and part of the population health survey was actually applying the Kessler rating scale that some of you may be aware of, but it is actually a tool that is used to diagnose or identify depression in people, and 30 of the Chinese people who responded in the survey were identified, adding the scores, as having an undiagnosed depression, which was very concerning.  Also low screening rates and low dental care rates for that group.

There were other population groups with very high rates of psychological distress as well, and just one that comes to mind was carers of people with those issues.  Very high levels of asthma and other respiratory diseases, and in fact the highest in the State, would you believe, experienced by some population groups more than others.  That raises all sorts of interesting questions as well, particularly around looking at things like transport [unclear].  There are some major, major intersections in Whitehorse with lots of cars stopped at lights for periods of time, railway crossings over roads and things.

Then certain population groups were also not able to get health alternatives.  So part of the population health survey was also [unclear] some of that [unclear] work around social capital, and it was quite clear the population groups that were having trouble in that social capital area. 
We had to make some decisions about what we did with that information and we identified that we would work with public housing residents in Whitehorse.  There aren't very many public housing areas in Whitehorse and they are certainly nothing like the inner part of Melbourne where there is high-rise and really large numbers of people living in public housing.  Our public housing tends to be small pockets in quite nicely set up areas, newer stocks of housing, tenants can be moved into that kind of thing, apart from the fact that there are houses dotted right throughout the local community and in the neighbourhoods that are attached to estates, as we term it here, but we had some discrete areas that were public housing estates, and to be quite frank, it was easy and a good place for us to go.  It was a group of people who we knew were likely to have worse health and were likely to have increasing worse health for all the wrong reasons, economic and social, and there they're all together.  So that was really a driver for us.

In 2003 as part of our Youth Day health promotion planning process we did a consultation with residents in three of those public housing estates.  Two of the estates are predominantly older residents, and, again, that reflects, I think, our LGA demographic that we have a much higher older demographic.  The other estate was a more mixed family demographic from sort of baby to 90 plus, but with 35 different core groups represented in there as well, so quite complex.

Part of that consultation process consisted of an actual written survey, just a really quick and dirty written survey that was happened delivered to people, so that people could be assisted to complete it if they wanted assistance [unclear].  It also consisted of [unclear] and just exploring some of the things that  [unclear]. 
What they identified back in 2003 that were barriers to their health were: lack of access to appropriate physical activity opportunities; poor access to public transport; and lack of control over the area of the estate, their actual environments, the gardens, parklands, when trees were cut down, when they weren't, that sort of thing. Back in 2003 it was a bit of a revelation to us that the community had such a broad view of their health, probably for all the wrong reasons, things like nutrition and that sort of thing. 

We have been working with those three public housing estates since 2003 and I am going to talk to you a little about one of them and hopefully show you a bit of a photo story, which will mean you don't have to listen to me for very much longer, so you actually get to see some of what's being done. 

Some key strategies in that housing estate have been that whole thing about developing trust and rapport and respect for relationships with community members, and I can't emphasise enough how important time is to that.  It takes a long time to get to that point where you can actually get some meaningful participation, and the need to respond to community issues.  So like I said, I think when we started to think about working with these communities and we were looking at some population health data [unclear] risk factors, we were thinking in terms of getting some exercise groups happening, doing some stuff on food and very, very quickly found that that was not on anybody's agenda.  So we had to really take a step back and respond to what the community issues were.  We started to form or the community started to form some groups.

Olive Aumann: They named themselves Residents Making a Difference.  Some of the groups that they started to form were [unclear] by lack of opportunities for physical activity.  It was more around the fact that they were a group of older people.  The opportunity that they saw for physical activity was more about walking and walking in their local neighbourhood, and yet walking in their local neighbourhood was really problematic, and perhaps people will see that a little bit later on in the photo story, just in terms of the way that footpaths are and roads are and lack of crossings and that sort of thing. So there was a neighbourhood walkability walking group formed, there was a public transport working group formed and a sort of 'deliver social events' kind of working group formed give power to the people, and certainly one of the strategies that they have looked at establishing is establishing a bit of a social focus, having monthly meetings that all the residents were invited to, and to bring along lunch and having a little bit of a meeting focus to that as well. 

Part of the strategies were about helping residents to take on roles, so getting residents involved in doing neighbourhood walkability audits, so that the walkability working group - you know, our staff [unclear] the National Heart Foundation helped by signing walkability audit tools and came back and worked with the residents to go out and do more of the walkability audits, where they were able to identify what were the important routes to many of them, whether they would want to walk and what were the barriers to them being able to use those routes. 

It takes a strong mediation role in then bringing a partnership together, because obviously community health services can do nothing about most of the [unclear], so we needed to make sure that the people that could do something about that were on board, and of course council were critical, the Office of Housing for the purposes of housing stock; the tenants advocacy organisation agency continued their engagement anyway; local fitness centre just to provide a bit of an added, I guess, string to the bow in terms of physical activity; and the local neighbourhood house.

We also [unclear] the community up to the peak body, so the National Heart Foundation, as I said, used their Healthy By Design audit tool, and they were very interested in the fact that we had got residents to actually use the tool.  [Unclear] it was a new tool and so they were quite keen about that.  We were actually able to invite them out to the community to talk to residents about their experiences in that, and in fact the residents were able to feed back to the National Heart Foundation about some problems with the audit tool and they subsequently made some adjustments.

Also, the Planning Institute of Australia, had been working with National Heart Foundation on that tool.  They came back a few times and provided, I suppose, some pro bono advice about some issues in the housing estates that the residents could then take up with the Office of Housing and Kinect Australia, just in terms of some of the staff working more on their access to help with some of the things that were being done.

I guess all of those strategies were really aimed at supporting residents to advocate and model for change on their own behalf.  This is just a picture taken of a group of residents at Eastbridge housing estate it's called.  There's about 54 residents at the estate.  As I said, it's mainly an older person's estate, with quite high levels of chronic disease and disability amongst the residents.  The community, when we went into it in 2003, was a very divided community.  There was a community hall there that was an Office of Housing hall that was not used a lot.  Someone had the key but nobody wanted to ask the person to come and unlock the hall, and there was a lot of division and a lot of no speaking, some problems, new people, old people, all sorts of things. As you can see - I think this was taken about 2006 - all of that has been just broken down incredibly. 

That is actually three of the ladies.  One of the things that they did in the [unclear], I think it was in 2006, is they decided that they wanted to put on a Christmas party for the partnership group and they wouldn't let us have anything to do with it and they said, 'No, you just come on the day', and they provided some entertainment [unclear].

If I can get a bit of help to access the photo story, that would be all right.  I will close this down.

Sara Edwards: I’m going to go around and we’ll go in order of the questions, and I’m going to look for some feedback and then I’ll probably add some things as well. There’s no right or wrong around these pictures. It was just again as I said to create conversation, and also one of the key factors for this programme is collaboration. Collaboration with agencies, collaboration with schools, collaboration with families and the young people as well. So question number one, which table had? Yes, so what three pictures did you feel could have been key partners in Players United?

Female speaker: We thought this one so maybe some sort of sporting sort of co-branding or sponsorship.

Sara Edwards: Absolutely, yes.

Female speaker: So that’s one. The schools obviously are key partners in contributing and participating in the programme, and then we thought maybe some sort of corporate sponsor like Milo…

Sara Edwards: Absolutely, yes, and I mean it’s been key. What we tend to find is the – one of the things that we’re struggling with is that – I’ll do a government thing. Sport will solve a lot of problems, yes, and we can link young people into sports clubs. The thing that we’re going to struggle with is our young people have no money, and that hasn't changed in the last 12 years and I don't think that that’s going to change. So it’s finding alternative ways of bringing sport messages in, which have really great roles around the issue and around community kind of concepts, and this was one of the reasons why this programme started.
Australian Rules football and cricket, even though our young people aren’t particularly focused on that, they tend to run fantastic sessions and I know that I can always ring them up and they’re always there. The other thing that schools are going now is bringing local people, so we had African drumming into the school. It’s not just restricted to sport. It is around that person coming in and being a role model to the young people. The young people interview them as a guest speaker, and then they go and they demonstrate an activity. So it could be juggling, it could be anything, and the young people then participate and we’re encouraging them to take the skills that that facilitator had, and obviously practice it by running sessions for primary school students.
Number two was pictures that represent objectives the Players United programme wanted to achieve for their young people participating in the programme. Who had number two? Yeah, what did you get?

Female speaker: We had books that represent people learning.

Sara Edwards: Absolutely.

Female speaker: So the whole thing’s focused around the learning of some description. African drums we picked because we had insight that you were going to say that. It represented to us the fact that you were trying to develop an appreciation and understanding of cultures, different cultures and bringing kids together on that. This was kids coming together, working together, hands together, sharing a task and a job and learning through doing that. This was similar in creating of mateship and an understanding of one another, and this one here was…

Female speaker: Overcoming fears and developing confidence.

Female speaker: Yes, through leadership and leadership strengths.

Sara Edwards: Programmes mapped into the English curriculum, and this is schools mapped in, so part of the programme is that they do assessment tasks and they do journal writing. So whatever they learn they do, they write. If we want young people and a number of young people that we are working with, who are struggling with literacy, if they’re writing about things that they’re doing they’re more likely to want to participate.
We also found that journal writing became quite a positive avenue for young people to talk about other things as well, and so the schools putting a number of strategies in the welfare teams, because things were coming out that we actually hadn’t heard. So there was a real side product there that teachers went I hadn't quite thought about that, but a young man up there talking about what he – when he thought it was going to be English – then also when he could actually take it. He didn’t realise he was doing English, but it just came in another vehicle and that’s really important for our young people.
Number three, how do you think Players United was then able to make the programme sustainable in such a highly disadvantaged area? Who had number three? Yes.

Male speaker: …mathematics, doing things in the curriculum and not just English.

Sara Edwards: Yes, fantastic, yes.

Female speaker: …I’m guessing that it’s teachers and training organisations and support of those…

Sara Edwards: Yes, fantastic.

Female speaker: …apply the different ways…

Sara Edwards: Yes, that’s fabulous.

Female speaker: Collaborative…

Sara Edwards: And over here is a manual and there is a written manual that goes with this programme, and what we were trying to do was funding in all of our sector is crazy. It’s no different for any other agency, and so we didn’t want intellectual knowledge to leave if one of us left. That’s probably about 200 pages. It’s taken us forever to write it. It is word perfect with all the assessment tasks et cetera, et cetera. So that certainly for us is sustainability, so that people can pick up the programme and run that. It can be a little bit more complicated than some programmes, so it looks simple but you’ve got teachers that are teaching English, all of a sudden having to run a bit of sport and then it kind of moves across and it has a welfare component.
So the team teaching from our agency has been quite important, but also the relationships that we’re creating with the school, with the teacher, and then those [unclear] come back into community health around us linking in our psychologists, social workers and different other sources of family support that we’ve naturally provided.
I’m going to go what has been a consistent roadblock in the implementation of Players United? So that’s number four.

Female speaker: That’s us.

Sara Edwards: Yes, what did you think?

Female speaker: So four of the young people we chose that, not interested, don’t want to listen.

Sara Edwards: Absolutely, yes.

Female speaker: And we also picked this one, because no one else wanted it.
[Over speaking]

Female speaker: …it’s not cool to be in this programme…school agencies probably share the same sort of roadblocks, which is financial, so money, and also having the infrastructure to be able to implement new programmes.

Sara Edwards: The turnover of staff in schools has probably been a thing that we’ve – as we skill up and go away the skill resources and the community agencies will resource it well, but we can’t retain staff. So every year we have to train up at least another – out of six staff in Toowoomba we’d have to train another four. That has been the same over four or five years. It’s not going to change. And also agency staff, because we have very high turnover of agency workers, just because the pay’s not really wonderful and so they flick around. And also they’re not core funded, so you know, your programme starts and finishes.
So they’re just ongoing things. For young people, Year 9 or in a community VCAL, I find at the beginning of the programme, because we’re not giving them the answers, it’s like pushing a truck up hill. I can’t think of anything better to describe. It keeps unpacking on us all the time, but we know that in week six when they go out and they run the private school programme and we haven't skilled them up as well as they would like, they always come back and the first thing they say is they didn’t listen to us miss. We couldn't work out how to get these children to pay attention and you go oh really.
So [unclear] it’s been sequenced well, it maps into a Level 1 coaching course so it’s coaching principles. It’s mapped into the VCAL and [unclear], which is the personal development. So as far as looking at core programmes across a number of different areas, it ticks off those as well. So I’d like to say thank you very much for having me today. There is some written material that goes along with this programme. Like I said there’s lots of manuals and things and you’re very welcome. If you feel there’s ever an opportunity for a school or a community that would like to participate in a programme like this, I’m really happy to share that as well. So thank you.

Facilitator: Sara, thank you for that and thank you for such an innovative way to actually share your work with us. I’m sure we all enjoyed that. I’d like to now introduce Chris Scanlon and Julie Arnell to you from Barwon South West regions at Barwon Health, and they’re going to talk to us about Read the Play, which is about increasing mental health literacy.

Chris Scanlon: Whilst Julie’s gathering things from the other side of the room, thank you for sharing your lunchtime with us. It’s fantastic. I’m very privileged. It’s great. Yeah, as introduced, I’m Chris Scanlon. I’m a social worker. I work with Barwon Health obviously in Geelong. My actual position is mental health promotion officer to the Barwon South West region, so [unclear] you can get from Geelong…

What we wanted to present today is the bookends, I suppose, of a community based programme called Read The Play that we’ve introduced in Geelong. And more recently it’s actually running in Portland as well, so it’s the Barwon South West stuff. I’m going to provide the dry boring stuff. Julie is going to get the fun part, and [unclear] games and activities and stuff. The bar’s up here somewhere. That’s great. So I’ll try and get through the background and some of the more dry stuff as quick as well.

Read The Play, I’ll look at giving a brief intro. I’ll look at the objectives behind the programme, look at the history of it, I guess, in terms of development. Look at what we actually provide in transit training, and also as a surplus look at what we’re providing transits for, for those people that have trained up. I’ll look very briefly at evaluation, because like all community projects and health promotion strategies they need to be evaluated, so we do have evaluation as a component. And then it’ll be over to Julie to look at the games and the fun bit. But just before that, I’m saying I’m from Barwon Health. Julie is not from Barwon Health. Julie is from…

Julie Arnell: Headspace.

Chris Scanlon: So Headspace Barwon and Headspace are one of our partners in this project. Just to set a little bit of context, I suppose, and again won’t take a long time to do this, but just in terms of young people. I think we all know some of the demographics around the fact that we do have a high incidence of – or a high frequency of mental health problems in our young people population. And I probably don’t need to preach to the converted in terms of we look at one in seven for children between 4 and 17 and then one in four for 18 to 24 year olds, as is coming through Victoria statistics and the new reform document around mental health matters.
So what we were trying to do – we’re all aware of that and we’re all aware of treatment services, but treatment services alone are not going to lessen the burden, I suppose, or make big inroads into sorting out the mental health issues of our young populations. Mental health promotion is important and mental health promotion strategies are making a difference, and I think increasingly making a difference in terms of impact and improving the quality of life of our young people.

There’s a number of different programmes out there and as we all know, a lot of them are perhaps school based or based in other more institutional settings. We were looking at targeting and running a programme in sports clubs. So looking at the gatekeepers of our young people and training up the gatekeepers as in the adult people in our sporting clubs, to capacity build their knowledge of mental health and mental illness. And get them to intervene early and act early in terms of guiding young people in their sports club into the service system, and hence into Barwon Health and our mental health service and [headspace] and other community based services in Geelong.

So hence we ended up with a programme called Read The Play. So what we are actually doing and I’ve sort of already had a bit of a look around, already making you aware of that. We’re looking at increasing the knowledge and awareness of mental health and drugs and alcohol. We’re looking at educating people at the sports clubs around what the local service provision is for young people, and how we can get them into those support services. We’re also looking at improving attitudes and stigma. We need to de-stigmatise mental health. We need to mainstream mental health in terms of illness and disease, and in terms of there’s good treatments out there and that aspect as well. And of course with the people who we’re training up, we want to increase their confidence in dealing with young people, that rapport, that relationship, and actually doing the work around guiding that person into the mental health service.

So let’s have a look and we can sort of run quickly through the development of the programme. We’re talking about a programme that started back in 2006. The initiation of the programme came from a guy by the name of David Langley, one of the senior managers at Kempe Engineering. And the Kempe Group and David approached us a mental health service to say we think we need to do more around our young people and mental illness. Can’t we do something in the sports clubs?

Kempe Engineering in Geelong were already supporting junior football and junior netball, so there was that opportunity to perhaps work on that. Kempe have provided significant funding amongst others as well. In fact, Kempe are still a significant partner in terms of funding and David still holds the position on the committee as the chairperson.

Chris Scanlon: The managing committee goes a lot broader than Barwon Health, Headspace and Kempe. We’ve got the government on, we’ve got the significant representation from three football and netball leagues, so they are on our committee of management. We also have league networks, which are the key community coordinating body around junior sports in Geelong. We’ve got the police as well. It was important to get the police on board with it as well there, and the Barwon Health Foundation as well. So as well as our clinical service we’ve got representation from our fundraising arm as well.

What initially happened was that we were wanting to set this programme up, make sure it’s evidence based, make sure it’s got an evaluation strategy around it. Initially we went to talk to people at Orygen Youth Health and in the first instance they developed the programme with us, in conjunction with [unclear] and it’s been changed a little bit. And Orygen are still involved but – well not directly involved but we certainly acknowledge them as on examination of our key partners, particularly in the development of it.

Our first programme rolled out in 2007, and then we followed that up in 2008 and we are currently rolling the programme now in 2009. In fact, tonight I’m doing session two of our three sessions tonight, and importantly they’re actually finishing session three tonight. So we’ve kind of consolidated our programme, and we think it’s still moving forward and looking good.

So what is the training? What are we talking about when we’re talking about our Read The Play training? We are targeting young – well, we’re training up club representatives, a significant person in that club who might already have a relationship with the young people. Some clubs are putting up people on the committee. Other clubs are putting up maybe captains of some of the more senior teams, who have an affiliation and association with the junior clubs. So we’re looking at someone who’s significant in that club, who’s already got some rapport and association with the younger members.

Under 16 football, under 15 netball across three leagues in Geelong – we’ve got three leagues there and a total of about 33 clubs I think. The training is 8.5 hours duration. We do that over three evening sessions, and then [unclear] call it a fourth session that is actually club based back at the club. This sort of stuff that Julie’s going to demonstrate is what we are teaching our trainers or our mentors to do, back in the club and you’ll have a bit of experience of how to do all that.

As a service, as a mental health service and some of our community based mental health services as well are providing clinical workers and other community workers. To play a further association with these clubs so we can continue on a longer term basis to support them in terms of information, in terms of changes in service system, in terms of giving them a contact with the [particular] system.
Evaluation – there’s been two – just to flip back sorry – just with the three sessions, just to briefly go over the three sessions just very quickly. We give an introduction around youth mental health and the health promotion approach, if you like. We then start to look at the different mental illnesses, the low prevalence and also high prevalence. So we’re looking at depression, we’re looking at anxiety, we look at psychosis substance use. We talk around suicide as well, and the best approach around that and we talk about eating disorders. So they’re the areas that we look at.

[Unclear] back, we train up the people to be able to provide and engage young people and learn about mental health, through something that’s a better learning experience and more engaging for the young people themselves. I just mentioned that where the primary care partnerships come in as well, is that we did get some funding and as part of a partnership arrangement we got some drought relief funding. Because again, the three leagues do cover a fairly geographically area so drought is impacting. And what we were doing and proposing was that we give what we call a wristband, but it’s got a USB stick on it. And it’s got Read The Play on it and the website, and on the stick itself there’s only one file on this, so then the kids can use it for their own purposes, for study or for school or whatever. Then on it is where to go for help, just one slide, really quick, short, sharp and that’s on that, so all the kids get that as part of their training, along with other stuff in a show bag.
So back to the evaluation, we have done pre and post-tests in the first two years and the indicators tell us that the people we are training and the club representatives, are getting an increased knowledge around mental health and mental illness. There’s an improved around local service and where to actually refer or where to guide young people into the service system. And also they’re telling us anecdotally that they are getting more confidence in terms of building that rapport, building that relationship and being actually open to guide young people and help them.

What we’re focusing on in the groups that we’re training this year, is to look at a six month follow up so we can see whether that knowledge has been retained and look at further sustaining Read The Play as a programme.

Chris Scanlon: So contacts, that’s me and that’s Tony, who is Julie’s boss at Headspace and we do have the website to refer to as well. That’s the dry stuff. Let’s do the fun.

Julie Arnell: My charter was to develop an interactive and engaging way of communicating the mental health message to young people. And my first response was well they’re playing football and they’re playing netball because they love to play. They just do. And the previous DVD that we watched, showed us that the young people appreciated the fact that that leadership programme was conducted in such a way that it was interactive and that they were engaged and they had something to do. And they didn’t just have somebody telling them what they should be doing in order to be a good leader.

So along that same line what I decided to do was develop an interactive games evening. Now they need a score chart as all people who work with young people know, they’re very competitive by nature and they want to know who’s where and when they’re winning et cetera. So on this part we actually have the score chart for – oh I put them on the wrong side – they’re on the netball court when they should have been on the footy, which is on the other side. Never mind, that doesn't matter.

And on this side if you pop it over, if you turn it over for me Chris, there’s the football oval. They should have been on there. So you start off with this at the beginning of the evening. You explain to them that there is a method of actually scoring. They have football that’s of the colour of their team. So they’re sitting around tables, they have a particular colour for their team and every time they score in a game, there are three, two and one points to be won by the particular team and they move from player to player according to the numbers that are actually on here. And eventually they get up to the top here and then they say yay, we won. So that’s the way that they know how they’re actually going.

The whole message throughout all of the games is giving young people permission to say. So I took it one step further, Read The Play, know what to say, because for a number of them the inhibiting factor is just being uncertain about what is the right thing to say to a mate or somebody else, whom you are worried about. You think there might be an issue or whatever, what do you say? And the fact that you don’t have the words and you don’t have the knowledge can stop you saying anything at all.

So it’s a similar message that’s actually being given to the trainers. We’re giving them the information to know a bit more about mental health, and then they feel more comfortable actually going out and communicating with the young people because they feel that they know what is the appropriate thing to say.

There’s a series of games in here and a series of games, focuses every time on what it is that you’re actually going to say. So what we’re going to do is we’re actually going to play just a couple of the games right this very moment.

Chris Scanlon: And before you do that Julie, I just might run through – just to give you an idea what some of the games kind of look like, this might be a bit rushed, which it will be. But this is what – on the third night that we’re training all the club reps, we facilitate this with them so that they know what to do back at the club. People in our service and Headspace actually parallel with the people from the clubs, to then run the junior people through this sort of stuff. So it’s a series of game, which will…

Julie Arnell: So this supports the delivery by the trainer to the young people, and at certain stages along the way it actually tells them that they’re up to the next particular game to play. Because another thing that we need to reinforce is the fact that not everybody is a teacher, so they’re out there, they’re willing, their heart is in it, but they don’t necessarily consider themselves to be teachers. So they wanted as much support as I could give them in the delivery of the programme. So they’ve got this and at the same time as this is actually running and they’re clicking through it…there are places along the line where they’re actually seeing that they need to stop, and go onto the game.

So what does good mental health play say? In the background there is music that’s actually playing that gives them to a clue to what they need to be coming up with, so that’s the first game that they actually play. And they put their heads together around a table and say well I reckon, you know, it means something like – and what we’re hoping that they’ll get out of that the music believe it or not says I get knocked down, I get back up again, you know that.

So Chris came up with that and said let’s play that music and then he listened to the actual verse instead of just the chorus at the end or whatever, and we thought we’d just better stick with the verse. We’ve just got the verse playing nicely in the background, and the idea of course being that if you’re knocked over by these life issues or whatever, you need to get back up again and there are people around that can support you in actually getting back up again.

Chris Scanlon: So we hope the young kids will come up with a theme around resilience rather than I have a whisky drink and…

Julie Arnell: So that was…and we hope they’ll have a bit of fun and they’ll actually laugh through the whole thing. So in this one the game that goes with this, is that the teams actually have an arrow. We have the fractional cards out the front and they have to decide how prevalent they think it is. Is it one out of four, is it one out of eight, is it one out of ten or whatever? A simple game. Next one. Can you say it is or it isn’t? They have a chart in front of them and a whole host of illnesses listed on the charts. They need to decide whether it goes in – is it a mental illness or is it just a general illness. So where does glandular fever go and where does depression go…

Chris Scanlon: And where’s mental retardation if it’s not a mental illness, so we try and get some of those myths over…

Julie Arnell: And the idea was just to create the dialogue and get young people talking. Give them permission to talk about it. Give them permission to ask questions about it and on and on it goes. So each one of those is a game. Now, just for fun, you get to experience some of the games. The games I try to develop in different ways to appeal to different learners, because not everybody’s a writer but this one is a writing one.
So in your teams at the table there will be a time limit that is set on this. You actually get a squiggly man. Here is the squiggly man, and the message is can you say how you feel? So how is this bloke who is experiencing anxiety, actually feeling? So you look at it and see whether you can label it, and they label it as fast as they can and tender their results in and then there is a slide up there that actually tells them the answers

Chris Scanlon: Nathan Thompson. Thanks Julie, and we’ve really got tight time constraints so thanks again. Look, just in conclusion now, our reach into the clubs if you like, we’ve got 33 clubs across the three different leagues. We’ve been involved in 25 of those clubs, and I think we’ve trained up more or less just about 100 people within the clubs. And we’ve probably reached about 2000 young kids in the training back at the club, so that’s Read The Play. Hopefully you’re impressed with Read The Play and hopefully – and we’re confident that we’ll be able to keep rolling the programme out, not just in Geelong and Barwon South West, but broader as well. Okay, thanks very much for your time and thanks Julie.

Facilitator: I’d just like to ask you to join again in first of all congratulating these people on this fantastic work that you’re all pursuing. I think it’s just fantastic work and thank you for taking the time to come and share with us today…and I’m just going to finish with an ad, because I know time is…but as I said earlier this is the second one of these. Our next one is due on August the 20th, I think, if I’ve got that correct and the theme for that one will be about [unclear], so please pencil that in your diary if you haven't already done so. I know that this crowd is not huge, but I am mindful that we do put these on [unclear] and I know our rural colleagues are very appreciative of the fact that it gives them access to that, which they can actually stream from off the web. And obviously the case studies will also be available on the information website. So thank you all for coming. I enjoyed it, I think the work is great and I’m sure everybody here feels that too. So thank you all for coming.

From my point of view, I guess it’s a real pleasure to be providing the seminar series. I do think that IHP, or Integrated Health Promotion, as we’ve come to understand it, which is a major piece of work as part of the PCP strategy, in some ways has been seen as the poor relative of the PCP strategy.

I think that I find myself more and more drawn into conversations around service coordination. That certainly has been a significant focus in IHP, where I think the work has really matured and been a significant player. [Anthony has had his profile] so I’m really pleased to be launching the seminar series today.

I guess it would be useful to reflect on when I first engaged with the PCP strategy, which started in 2000. We all know that health promotion, while it was being practised widely and some of it was very good, we certainly did have a sense that it needed to be more robust in terms of going forward.

We certainly felt that it was very fragmented in terms of what was being delivered. We certainly felt that there was scope to consolidate our efforts and come together in partnership. Certainly, that’s what we had sought to do through the IHP strategy. We’ve certainly seen some of the benefit of that work going forward.

I would like to also acknowledge that we are making some real headway in this space. I want to acknowledge the work of Public Health in working with us in Primary Care in terms of supporting the sector in terms of skill development; and also in helping us shape the IHP kit and some of the resources along with that. That has been a fundamental part of the reform going forward.

And I would also like to reflect on the work of the sector itself in terms of taking on the IHP framework, working that framework through, and certainly delivering what I think is a much more robust set of health promotion interventions. It’s useful to note that we’ve just recently completed an evaluation on IHP across the state. The full report of this work is available on the web.

But you can see here just from this slide that one of the questions asked in that frame was how people – and when I say people, I’m talking about practitioners out in the sector. The question asked what they felt about the robust nature of the health promotion activity that was being delivered.

This is a question which reflects about in relation to pre and post. As you can see there, we’ve got significant improvement in the way clinicians rate their practice in this space. I think that’s really exciting, and I want to acknowledge the work of the sector, as I said, in embracing the IHP framework and working in that space. We’re going to hear some really good examples of that in practice very soon.

At the end of today’s session, I hope that you develop a greater understanding of health promotion and how it improves the health and wellbeing of Victorians, particularly disadvantaged and hard-to-reach populations. We are certainly very much interested in the primary health space in our branch in those communities that actually do need tailored approaches. These are people who are not empowered and who will not take on health promotion messages easily.

We are also hoping that you’ll have discovered the impacts that have been achieved from investment in community health, private partnerships and mental health promotion work. I hope that you gain some knowledge about primary and secondary prevention as well as disease management and tertiary prevention.

Thank you. I usually have a buddy, who is an 81-year-old chap called Ron Topp. He is the President of the University of the Third Age in Pakenham. The University of the Third Age is one of the four partnerships of organisations that we’re involved in. It’s community learning partnership. He did a fantastic little rolling photo show which was part of our evaluation.

Unfortunately he has got his AGM today, and the AGM is more important. I don’t know whether he wants to be re-elected or not, but I think the rest of them are hoping that he will because he’s a very, very active person for his age. I think you’ll notice that he’s pretty computer savvy too. One of his main areas of teaching is computers.

Just a bit of background about community learning partnerships. Working for community health – and I work for Cardinia-Casey Community Health Service – we hadn’t really done anything very much in particular with the Neighbourhood House network, even though we have got Neighbourhood House networks that are quite formal in both Cardinia and in Casey.

Just through one of the projects that I was working with in relation to a community garden, we approached a community centre that was just becoming established in Pakenham. Their history had been in working with people with disabilities. The centre is called Outlook Incorporated. They started a community centre to try and provide integration opportunities for people living in that Pakenham catchment area.

Because of the project that I was involved with in relation to a community garden, we thought it was really important to integrate it with the disabilities in terms of new opportunities across sector activities. So our relationship with this Outlook Community Centre evolved.

In the last two years that I’ve been involved with two different projects with this community component, I’ve learnt so much about how education runs in the community; the non-threatening type of education where people can do TAFE accredited training without being intimidated by having to sit in a normal, formal classroom environment.

So if I have learnt anything myself out of all of this work that we’ve been doing in partnership, it’s just what fantastic opportunities there are for people to learn informally. If you look at the social determinants, by offering education opportunities it just gives people so much scope for expanding into such good things in terms of employment, employability; in terms of their housing; in terms of improving their whole lifestyle.

So if you want me to explain my basic social [unclear] I think it should be education. I know we always talk about employment, but I think [inaudible]. I guess what I wanted to say today – I’ve got these six slides. I don’t really know what’s on them, but I’ll follow through. At the end of last year, we had to report on the success or the challenges of our community learning partnership.

It was actually to a full meeting of all the neighbourhood houses in the southern region. It was through the funding that we were allocated as a region. So trying not to wear too much of a health promotion hat, I really tried to put it into very basic terms. So Ron did his photo presentation, which everyone really loved, and I talked for about five minutes just trying to explain how we assessed what the successes and what the challenges were.

I prepared five slides. They were based around the SWOT analysis. We looked at the strengths, the weaknesses, the opportunities and the threats. I really tried not to use too much HP language. I’ve only just added one extra slide at the end to try and put it into more of a health promotion setting. But really it was just explaining, in layman’s terms, some of the health promotion principles that were required through the project.

We had funding through the Australian Council for Further Education. Our partners were the Outlook Community Centre, which I said before is a new centre in Pakenham using the principles of community houses and trying to integrate people with disabilities into programs, so very commendable.

There was a representative from our community garden out at Cockatoo. I was involved with having established the community garden. We had had another community learning partnership through our garden and through exposing people to horticulture opportunities and all sorts of different land care and environmental issues. So they were involved into the partnership as well. So part of our project included some good environmental messages through gardening.

The other member was the University of the Third Age. I explained about Ron and their focus. They’re very much offering opportunities for older people, and challenging them to take on leadership roles and be teachers as well as students. The final one was the Upper Beaconsfield Community Centre, which for the last 10 years or so has been doing a wonderful job in integrating people with disabilities into [inaudible].

So here we were at the end of last year, at the end of our little project, where we had had some unexpected outcomes as well as expected outcomes. Our aim had been to try and engage people who were new to the area; so basically new to the Cardinia Shire, but particularly to Pakenham and the Beaconsfield corridor, which is part of the growth corridor area.

There are a lot of people moving in now, at least 5000 to 8000 per year. The population has gone from about 48,000 in the 2001 census to something like 49,050 in the 2006 census. The latest estimate is about 55,000. So in the last couple of years we’ve really zoomed ahead.

Saying that, we particularly decided that we would look at trying to help people from non-English speaking backgrounds. The dilemma there is that, as with everything, we get these bees in our bonnets about new people moving in and what the stats really mean; particularly with the CALD communities, and the refugee communities as a subset of that.

We had a real scare in Cardinia, being told that there would be about 5000 Sudanese moving in in the next two to four years. No-one really knew where that actual estimate had come from. Probably about eighteen months to two years ago, we had a bit of a panic. We developed a network of agencies to try and address that. This funding application reflects a part of that.

So as well as looking at people new moving into the area and trying to give them a bit of a sense of what sort of education opportunities there were through neighbourhood houses, what sort of social opportunities there were, and the linkages that we could provide through our various partners, we also really wanted to look at some of those CALD community people moving in.

In saying that as well, there was also a Brazilian community that was very much around the abattoirs, working at the abattoirs in Pakenham. They’re on a very limited visa which really reduces their ability to access mainstream services, including health services which our community health centre wanted to promote.

So after lots of activities – and we’ll quickly show you the slides as well. I’ll just go through the slides very quickly. We talked about the reach, how many people were actually touched by the project. That was 116 residents, of which 43 were from a CALD background. I would say 40 of those 43 would have been Brazilian, and 3 would have been Sudanese, and that was it.

But the network between the Brazilians is probably fairly high-need, given the size of the community and given their inability to access other services. We had 44 who said they were new to the area. They were mainly older people who were moving into retirement villages to be closer to family.

There were 50 odd who had attended at least one class or were attending a second class as well. A lot of those were multiple contacts. For instance, with the Brazilians, the need was identified to have English conversation, as distinct from the formal [AMES] English classes.

So they had English conversation that they had on a Friday night or Sunday afternoon, which are not mainstream times that you have courses available.

So it was very much based on what their needs were. They said this is the only time we can come: we work from 5:30am until 6:00pm during the week; we really don’t feel that we can put the energy into it. In saying that, they did put the energy into taking up soccer, which was a spin-off.

So I’m not going to read all of this. I have got the notes. They were some of the achievements. Then if you look at what the challenges were – there are always a lot of those. We did succeed in addressing some of the issues that the Brazilian community faced, and certainly in meeting some of those gaps. But a really big challenge was with some of the other ethnic groups.

As I said, there were a few Sudanese who were living in one particular estate that we could identify and engage with. The Good Samaritan Sisters were actually brilliant. They run some work through the Catholic Parish. They work in close liaison with the University of the Third Age.

They just infiltrated and they [pulled out] people from different backgrounds in various small states, mainly [unclear]. So it was an informal partnership that comes with some of those challenges that we face.

The geographic area – it’s a bit catchment area in the shire of Cardinia. But the problem is that there’s only really transport along the railway corridor through Beaconsfield and Pakenham. So a lot of the activities that we tried to run were based around Pakenham and Beaconsfield. We also have partners in Upper Beaconsfield and the community of Cockatoo.

They’re about 20 to 30 kilometres away from the main drag. Trying to get people to mix across those geographic areas is a challenge. So we did a few bus trips. We actually went to the botanical gardens at Cranbourne to have a look at a low water usage garden.

We had about three buses. We had people from Pakenham. We had people from Cockatoo and Upper Beaconsfield. They had such a great time together. Then afterwards they went and visited each other and looked at the different garden approaches that we’re using.

So we don’t really think that [unclear] spinoffs. It’s a challenge though. Anything where you have got long distances – and Cardinia has something like 900 kilometres of [unclear]. The other thing that was a real challenge was the attitude towards people from a CALD background, or just from a non-English speaking background; not necessarily the culture, just the language differences.

One thing that was achieved as a spin-off, which is a physical activity initiative, was starting soccer. What happened was that two teams of Brazilians ended up going to Cockatoo to play soccer because there was no competition in Pakenham. There were refurbishments happening at the stadium, a big building program. They will be able to accommodate soccer, which they now can do as of the last couple of months. But at that stage basketball was dominant, soccer was not known.

There was a very small club up at Cockatoo. So these Brazilians, with help from some of our project team, went one night a week up to play soccer in Cockatoo. So the team of people who were playing soccer up there learnt how to be a little bit more tolerant about someone who can’t explain what they’re doing in English but plays brilliantly. You just watch them and you can get the hang of it.

Our Brazilians learnt a lot about – well they learnt some more English conversation. They had a chance to practise. They talked around the terminology of the sport. They certainly learnt a lot of English. The other thing they learnt was to express themselves very well and say they needed help in getting their learner’s permits and trying to learn how to drive Aussie style and get their Victorian Driver’s Licence. So we had two good spin-offs from that particular challenge.

You have to look at each challenge as an opportunity as well. I think that’s the way we dealt with it. We looked at sustainability very much [unclear] as well. All the partnerships that we’ve dealt with and approached, we’ve followed through in different ways.

We’ve developed a rapport with the AMES program, so we’re looking at really trying to get mainstream services happening for those from CALD backgrounds. Through our gardening networks, we’ve got a real push now for looking at food miles. Our community garden up at Cockatoo is taking on that passion for reducing food miles, so we’re running different activities [inaudible].

Some of the activities have been expanded through both the Outlook Community Centre infrastructure at their site, and the Upper Beaconsfield Community Centre. So people are more aware of what’s going on. That’s all then very positive. They’re all very positive relationships. But I think one of the big things is the knowledge of where you can go to learn, and learn in a non-intrusive environment.

So although our message is very much focused around the social determinants and giving people the opportunity to meet together, breaking down some of those barriers of isolation; giving them an opportunity to learn at the same time is a really good bridge between what ACFE is trying to do and what we’re trying to do in a more formal health setting. I think that’s probably the biggest message that I had.

Threats – being creative about how we address the opportunities that we face, which is difficult with the fact that we usually have no money. We were very lucky at the end of this program. We spoke to ACFE and they picked up a few things. But they’re not able to offer Friday nights and they’re not able to offer Sunday afternoons. So if you’ve got groups with particular needs and certain times, you can only negotiate so much.

We were very successful in getting some more ACFE money to actually pay for regular tutoring for conversational English. That’s a three-year funding stream, so it gives us a little bit more time. It’s still not long enough to be sustainable. Hopefully the needs of that community will change during that time, and perhaps some of the visa restrictions will be gone.

The other thing that I’m hoping will work out is that we don’t have to rely so much on one or two people to do everything. By sharing skills through these sorts of programs, it brings up skill levels and also confidence levels, so that you’ve got more volunteers who are prepared to keep up and fill the gaps.

We have found that without having any further funding for a project worker, we have certain volunteers involved with our program who have said we will organise a few tutors to help with the conversational English, or we will run scrapbooking, or we will run the computer class. I’ve probably been concentrating too much on the CALD sort of stuff, but the computer classes for older people were just absolutely fantastic and really well-received.

I think the U3A basically wanted more people to know that they offer really cheap opportunities and that it’s non-threatening: you don’t feel let down because your grandson doesn’t realise that you know how to use the internet now or how to send an email. So some of those personal challenges that some of our participants faced have really been addressed.

Our conclusions are that it is worth doing partnerships with the education sector. It’s a good opportunity to look at both primary and secondary prevention in that environment. It’s very much a non-threatening environment. So many of the social determinants can be addressed through just being here together, making them feel more confident, asking questions and then being given opportunities to go and do the tuition.

So I probably haven’t done this from a true health promotion model at all, because I have spoken ad lib. I don’t particularly like formal stuff. But let’s just finish with Ron’s – this was part of our evaluation. Ron did the presentation. There is a formal report as well, which has some really good matrixes which are required through ACFE.

We all know about the role that physical activity can have in terms of preventing chronic disease and improving health generally.

So I’m really keen to hear about this piece of work that was – the lead agency for which was [unclear] PCP. Certainly we’re going to hear today from the West Vic Division of General Practice; Joanne Martin and Rob Grenfell from the Division, but more recently from the Department of Human Services. They’re going to talk to us about this piece of work.

Joanne Martin: Thanks Sylvia. Can I just ask a quick question about everybody, about flossing our teeth? Put your hand up if you know that flossing your teeth is a good idea. How many of you do it every day? This is the challenge we face. We all know it’s a good idea. This is the challenge with physical activity. But yet participation and knowledge do not mean the same thing.

So that was one of our problems in the West Vic region. I’ll show you a slide of where we’re from. Obviously I’m from a Division of General Practice, federally funded. So I’m not familiar with a lot of your department work, so excuse my ignorance. This is where we are. Rural/remote is the top end of Victoria. They’re quite sparsely populated communities. There are 75 GPs in our whole area. Now there’s one less because I’ve moved down here.

Rob Grenfell: [Must have been] two days a fortnight.

Joanne Martin: And we have 33 practices, so we’re very much rural/remote. There are 80,000 people. There are a lot of older people in our community as well. Like most communities, physical inactivity is a big issue for us in terms of cardiovascular disease, diabetes and so forth.

In 2001, the West Vic Division was one of the first divisions in Australia to employ a health promotion person. Really, my role wasn’t really defined. We were going to work out how health promotion and general practice could work together. So that was a challenge. And I have seen a few other faces in the crowd today that I’ve worked with over the years as well.

Our challenge was how did physical activity complement general practice work? How could GPs get their patients who are sitting in front of them every day, in 10 minutes, when they know they need to be more active, and link them with the plethora of exercise options around?

There are exercise groups being planned by lots of community health centres and people from all over the community. Not all of them necessary have qualifications, but there are lots of little groups. GPs didn’t know when they were being run, who was running them, the quality. You know, you would think that was there one day and gone the next.

So linking people from the practice into options out here was just too hard. In 10 minutes, you just said it’s too hard, don’t worry about it. So our job through Active Script, and through working very closely with one of our GPs, was to make a system that suited general practice: so a patient is sitting in front of me and I want to join the dots to the lots of options out here.

So sometimes I think of Active Script as a bit of a bridge with people on one side, options on the other side, and Active Script is the big bridge in between. We obviously had a very forward-thinking Board, who were keen to just have a go at health promotion.

When they were looking at the SNAP framework, which you obviously would be familiar with, physical inactivity was one of the choices. We chose to go with that mainly because it had a very positive approach. Smoking, nutrition and alcohol in particular are our stop, don’t do, cut out – that was the kind of approach we had to take to those options.

Whereas physical activity was have a go at it, participate, increase; so it was like a positive approach. Also, with our rural community, everyone can access something somewhere. It didn’t have to be a group, but it was an exercise option somewhere. So that’s why we chose to go with physical activity.

The GP that I worked very closely with – and there are a few of us who worked very closely with this one particular GP. She said all I want to be able to do is refer my patient to somebody within this community who knows exercise; they can navigate the best option for my patient.

I don’t know about duration. I don’t know about intensity. I don’t know about the best option for this patient. So I want somebody to navigate the best option for that patient, and I want feedback. I want feedback my practice can manage. Not just pages and pages of written work; I want feedback my practice can manage.

So they were basically the principle things that we used to build Active Script up. There have been various models around the country

and internationally that we looked at: in particular, the Green Script, the Green Prescription in New Zealand, which has been well-funded and has had some excellent results.

We’ve also worked with VICFIT locally here in Melbourne, who also have a program called the Active Script. Their work was involving GPs writing scripts. That was sort of the end of their process. We added an extra referral network. So basically what happens – that’s the aim. Basically this is where we’re at six years later.

We have GPs. The criteria is very simple. If GPs have a patient they feel would benefit from physical activity and are medically stable, they refer them on. We started with one GP and one enabler. We call them enablers. It’s a name that has stuck.

Basically it’s a person who has physical activity qualifications. So we have exercise physiologists, physiotherapists, as well as Certificate IV in Fitness people. They also have health coaching skills as well, which is essential to the work that we do. Basically they receive the referral.

Initially we had one person based in the division and one GP. We were writing all this work down and faxing sheets through. That’s how we started off. That enabler contacts the patient, so rings the patient at home. The enabler asks them about their physical activity and where they would like to start with their physical activity: is it a priority for them?

Basically that’s where the conversation starts. They set goals after the conversation and they’re followed up three weeks, eight weeks, sixteen weeks and twenty-six weeks later. So that’s basically the principle of what goes on. After each phone call, the GP gets written feedback as to how the patient is going. So if they fall out of the system, basically you know that’s going on. So no-one should fall out of the cycle.

As I said, we started with one GP and one enabler. That’s not over an actual 12-month period, but in 2002 we had around 98 referrals. We used to have our phone calls spaced out every three months. So we’ve actually now made the service over a six-month period, as I just said.

I know that says 91 GPs, and you’re probably thinking I just said we only had 75. That’s obviously because we’ve had GPs come and go. We’ve partnered up – one of the key successes with this program is being able to partner up with health services. As a division, we don’t get Active Script money or physical activity money. It has been our core funding that has funded my position.

We’ve been able to partner up with health services in our region who also had – obviously they’ve got a similar population to us. They have similar issues to us. They also had physical activity on their agenda. So they actually employ the enablers that service GPs in their catchment. For example, the hospital took in four towns, or a health service took in four towns.

Then the GPs in those catchments refer to somebody within the health service who uses that. It’s the same model as the next person in the next health service. The enablers are not full-time. Across our seven current active enablers, we would only have around two-and-a-half to three FTE. They all have competing demands.

So it’s not a specifically funded position within these health services. It’s health services who can see the benefit in receiving their local GP referrals and matching these people up with exercises that suit the patient. It has been an investment at the local level. Obviously some of them are using public promotions, some are using [acute] dollars to fund these very part-time positions.

It also used to be just GP referral. We obviously have encouraged practice nurses now to use the Active Script referral. So currently we have about 1100, probably close to 1200, referrals. Of those 1200 referrals, we’re averaging around 70 per cent behaviour change. So from people who have entered the program, to finishing and receiving the phone calls, especially using the health promotion techniques, we’ve seen around a 70 per cent behaviour change amongst those people.

These are not your average people. These are not the people who – if Rob sees Nicole and says you need to get more active, and they walk out the door and they do. These are the people who think I know I should but I don’t. A community health nurse who happens to be one of our referral points has been a community health nurse in her area for 25 years.

She has seen people through this referral pathway with the general practice, and she has never seen in her life – and these are communities that are not hundreds of thousands. They’re three or four thousand, like we have with the catchment area. She lives in that community. She is a community health nurse.

She said she used to run exercise classes for the most active people in the community. She would go and run a night good eating class. The same women would come along. They were the best eaters in the town. This was a group of people she had not seen at her groups. She has seen people that she hasn’t otherwise seen. So for her, it has been absolutely fabulous in terms of connecting to people that were traditionally hard to reach.

As a program, they’re the statistics down on the left-hand side. This is what I’ve found quite interesting from the statistics of our enablers. This is just for the year 2008. Weight issues has been one of our greatest increases. People can be referred for more than one issue by the way.

People can be referred for more than one issue by the way.

Seventy-one per cent of our referrals now are for weight issues. Thirty-five per cent of our referrals now are for diabetes. So this is a program for prevention, early intervention, chronic disease management, and tertiary. And arthritis; I mean that’s quite amazing as well.

So I think one of the successes with these figures is that not only are we getting the numbers, but we’re also getting general practice to think that exercise is a good option for health conditions, or for good health. There’s no MBS item number, so that’s not the driver for these referrals. There is no payment to the GP. It’s a quick, simple process that they know gets results.

So that’s the criteria. As I said, they need to be stable, who the GP thinks would benefit from an increase in physical activity. As I said, knowledge alone is not the problem. These people know they should be more active. It’s not the knowledge that’s the problem. Ninety per cent of adult Australians know that they should be active. It’s that participation rate that’s the problem.

People have such individual motivators. That’s what we tap into at an individual level. It’s not group exercise suiting everybody. It’s not that everyone wants to be a certain size. It’s that some people want to play with their kids, want to play with their grandkids. They want to be able to walk to their mailbox. Some of these people have never been past their mailbox. These are people that are really, really hard to motivate.

Some of the strengths – as I said, I think we’ve been able to tap into a group of people that are traditionally hard to access. By getting the referral sent to our enablers, and the enabler contacting the patient, that has been a huge step. We’re not waiting for these people who are insecure about themselves or not sure what they’re going to need to get or ringing a 1800 number. We’re contacting them. So that is a big strength of the program.

Obviously the support of GPs is important. If it doesn’t work for the GP, if it doesn’t work for the patient, if it doesn’t work for the health service, it doesn’t work. That’s why we keep engaging and keep talking to all those three people; to find out if this is a good system for them.

We also obviously do the follow up phone call. So it’s not just them showing up once or taking a phone call once. We follow up. So people often have great ideas and great intentions, but it’s maintaining those changes or those intentions for longer than three weeks.

Health coaching principles – I couldn’t speak highly enough of the skill of health coaching. We have very much a similar model across all our areas, but there’s very much local flexibility. I think that’s really important too. We have no authority over these enablers and other health services. We don’t fund anybody.

But the evidence is there, so good practice is our guiding role. And letting health services also have a lot of flexibility about how they provide the service has also been very encouraging of the partnership as well. Obviously, if it wasn’t for the division – we’re driving it locally, but it’s just the supportive rapport that has encouraged and maintained the work that we’re doing.

Opportunities – at the moment, a lot of the relationships are built around people. We need referrals to people. We need referrals to departments because we lose lots of people in rural areas. Our workforce is a constant challenge for us. So we need to have dedicated people in these enabling roles.

It can’t just be like it’s added on to what they do: then when they get too busy in physiotherapy or they get too busy in their EP role, the Active Script just slides away; and then the system falls over if they’re not doing their phone calls in a timely manner. So at the moment people have committed to it on paper – sorry, not on paper, but in principle. They’ve committed to maintain this as a priority of work.

Strength in our protocols – there are a lot of different ways to refer to programs. We don’t refer to our district as a program; we refer to it as a service. I think if you say project or program it always conjures up limited lifespan, so we call it a service. Our Active Script process might be different to the next referral process, which might be different from the next one.

As a GP, I’m sitting here with very limited time. I’ve got to remember right, how am I going to do that, refer to that program or that service? If it’s too difficult or I can’t remember it, chances are it won’t happen. So I would like to align a lot of our referral processes in general practice to health services so that it doesn’t become a difficult process to think about the referral process itself.

As I said, I would like perhaps a little bit more formal structure around Active Script involvement. But it has worked well for seven years. The million dollar dream – Katie said if you had endless money, what would you do? There are lots of things I would do. Obviously capacity – sometimes money can’t buy everything.

But in rural areas, providing exercise groups and quality exercise referral options will cost money. There is no money in it for a private business to run an exercise group in a town of 500. There is not a business model around that. So it has to cost dollars if it’s going to…

…prevention, early intervention, and to have the plethora of benefits, it will cost money to somebody. But it has to be locally driven. We also obviously need to reorientate the thinking of consumers. As we know, prevention is still a challenge. We all know the good things we should do.

We need to see general practice as a place you go for prevention and now just when you have an acute illness or a chronic illness. And also the general practice – obviously there are some new Medicare item numbers that encourage the change of thinking to prevention. However, it’s still not complementary to the way the general practice works.

I know with some of the new item numbers around diabetes, we’re encouraging patients to come in to the general practice for their prevention item numbers, and no-one is responding. They’re too busy. There are other things on. We need to keep encouraging general practice to do this work in prevention and be creative around how that works.

Obviously more workforce – I don’t know how we solve that problem, but it’s a challenge for us. It’s not just health. It’s attracting people and attracting quality resources.

Do you want to give us a brief about where you fit into this?

Rob Grenfell: I guess the town that I practise in, and still practise in, is a little town west of Horsham. It’s a town called Natimuk, which has a population of 700 people. When I look at chronic disease management – of course, general practice has gone through an enormous amount of reform from the federal strategy in how they manage chronic disease.

That has occurred at a micro level. So micro managing that within a practice – and your practice team may have three people in it if you’re in a small and isolated practice. And how do you actually get people to work in one area? There have been a lot of strategies that have look at that.

When it comes down to it, it’s time, but also focus. For instance, with a diabetic patient, how do we know who they are? Are they registered? What are we doing for them? What measures are we using for the service we’re giving? What can we actually do to assist in their management?

You can extend that to any of the chronic diseases, and mental health and the other things which are on the list. The problem in a town of 700 that doesn’t have public transport, and doesn’t have any formal exercise providers, is that we actually don’t have any avenue – particularly for a number of the population – for any exercise program whatsoever.

Basically most people need to have some sort of direction and assistance. So everyone here today, what sort of exercise do you do, what drives you to do your exercise? Most of us can be self-motivated. Most of us are pretty poor at that and we need to have continual drive into that.

As a GP, you really literally only have 10 minutes. How do you do chronic disease management in 10 minutes? That’s easy: somebody else does it for you. So if you micro manage these things, your practice nurse starts to take those on. For instance, in my practice, the practice nurse does all of these referrals, not me.

I just say right, you’ve got to do a care plan on this person, and exercise is important. I say to the patient you need to exercise, exercise is important for your management. Then it is referred on to do the motivational type of work in the practice nurse area. So the practice nurse is educated in motivational counselling strategies so that they can institute the change. The person is put on a regular review pattern, and they’re meant to do that.

Okay, I live in a town with no exercise facilities. How do the over 65s actually exercise? This is where the division came in, by developing the infrastructure behind. Who can fund and enable us? Who can actually assist in getting an exercise program going? Who can actually support this?

Through the PCP, the division, and the regional health service, we were able to actually get a small grant – we’re talking extremely small grants here – to get the YMCA to actually put in an exercise program. We’ve now got an over-subscribed over 65 years exercise program going on, with four sessions a week.

The main thing is that if we look at links that that has got – and so the previous presentation is the idea of access. So in Cardinia you’ve got lack of education, lack of language, a cultural isolation, and your program put people in to include them in the community. This exercise program – in a sense, there’s no access to those programs.

But suddenly we’ve actually got it, and now we’ve actually got community inclusion. Who am I sending into these programs? People with chronic, severe mental illness: so chronic schizophrenics; some of your bipolar to liven up the whole exercise programs.

Also, particularly [unclear]. I don’t care how old the mental health ones are. We slip them in under the radar into the programs for the over 65s. Why? Because they need to be there. The second is that they don’t leave the building. After they have their exercise and they get a cup of tea and a biscuit, they won’t go home. So they’re still hanging around having a cup of tea while the next group comes in to do their program.

There are those that come back to us and say look I’m hurting here and hurting there. I say well you’re supposed to hurt. That’s what exercise does to you. No pain, no gain. This is in fact actually what a strength program is. It will stop hurting after a while.

Some of our oldest attendants need help just to get out of the car to go into a program. Again, a skilled exercise trainer can actually deal with that sort of severe disablement. Again, we’re dealing with personalities that will go and will attend. I think, reflecting on where Jo is talking about why this happened and how it has been so successful, is that there’s a common goal.

There has been cooperation for that common goal, and a clear idea about what we wanted to do and what we wanted to actually add into there. We’re talking again about how extremely small sums of money have actually caused a great degree of change. These are perhaps the value of small [unclear] grants, but also a willingness of actually moving funds from other areas.

The biggest problem is the lack of health literacy in the health services. In the previous one, we might have talked about health literacy in consumers. But in the health services alone, particularly as you move more and more out of Melbourne – although now that I’m actually based here as the Advisor of Preventative Health I’m finding it’s just the whole health system.

The lack of health literacy as to what preventative health is, of what community health is, of what including others into health and health activities, is extremely poor. Jo’s problems with the CEOs of the health regions – they’re only interested in [waste]. They’re not interested in the health of the community. Now, they would say they are, but they’re not.

Health providers, the GPs, the committee nurses; the list is enormous as to people who just don’t understand what they could actually do. The previous presentation is so beautiful in that it’s actually getting people to deal with people. Unfortunately a lot of facilities in the funded structures have actually lost that connection. Because what we now have is very small rural towns in very isolated areas that are actually more connected.

As Jo used in the example, people who haven’t been engaged, isolated people who have been in homes – and I’m sure, again, that many, many more exist in suburban Melbourne that are completely isolated. So, in one sense, a common goal in leadership from multiple factors.

But it has taken an awful lot of work to actually drive this through from those blockers, as I call it, in the middle management level to stop this. So the challenge for the future is actually getting that level of management to actually understand what they can do and what they should do for the health of the communities