Our priority areas

System Integration


NQPHN's System Integration priority area forms a pivotal element in our commitment to advancing primary health care.  

Our objective aims to connect and align healthcare systems, services, and stakeholders to improve the coordination, quality and efficiency of care delivery leading to patient-centred care.    

We work with partners to jointly plan, co-commission and deliver innovative models of service delivery to address key health priority areas.  

It involves integrating and streamlining information, resources and processes to ensure efficient and effective healthcare delivery.    

Our key focus areas include data integration, care coordination, resource optimisation, quality and safety, patient engagement, and population health management.

A selection of our System Integration projects are highlighted below.

Our Region, Our People
PHNs and DVA working together for veterans

Two doctors have facilitated separate workshops involving veterans and general practitioners (GPs) as new pathways are created to help former and transitioning Australian Defence Force (ADF) members receive care in the mainstream civilian healthcare system.

Dr Wai-Keung Lee of Townsville and Dr Kerry Summerscales of Mackay were involved in the Townsville workshops as part of a partnership-first between Primary Health Networks’ (PHNs) and the Department of Veterans’ Affairs (DVA) contributing to a national suite of tailored HealthPathways to help former and transitioning Australian Defence Force (ADF) members access mainstream primary healthcare.

The activity is one of many actions resulting from a national PHN submission to the Royal Commission into Defence and Veteran Suicide. The partnership led by the Hunter New England Central Coast Primary Health Network (HNECCPHN), Northern Queensland Primary Health Network (NQPHN), and DVA is the first of its kind, underpins this key action, and is a direct result of the recommendations made in the report submission.

The HealthPathways will help GPs support former and transitioning ADF members to navigate the mainstream civilian health care system. The clinical pathways will be provided to all PHNs nationally to ensure a consistent approach, localised for each region, based on the available resources.

To help ensure the Veterans’ HealthPathways (VHPs) are effective and to identify areas to improve GP and veteran engagement more broadly, HNECCPHN, NQPHN, and DVA consulted former and transitioning ADF members, and GPs in two focused, yet robust, workshops, held in the Oasis Centre in Townsville.

In the first workshop, former and transitioning ADF members discussed the transition from Defence into mainstream healthcare and were asked what worked well, what didn’t, and what could be improved.

In the second workshop a group of local GPs reviewed the prioritised activities from the former and transitioning ADF members and provided ways to improve or add to the VHPs pages.

Using the outcomes from the consumer workshop, a survey was undertaken in August to encourage further feedback from former and transitioning ADF members and families. Feedback from the survey will also be used in the pathway development and revision process.

Workshop facilitator HealthPathways GP Clinical Editor Dr Wai-Keung Lee, of Eastbrooke Family Clinic in Townsville, said the former and transitioning ADF members were pleased a national rollout was being prepared and having clear pathways would improve ease of access for them and better management by GPs.

As the clinical editor for the lead region supporting national HealthPathways development, Dr Lee said the next steps included updating Veteran HealthPathways for health assessment, referral, and support.

“The use of HealthPathways needs to be tested in a real setting involving patients and GPs,” he said.

Assisting GPs with up-to-date pathways will better enable former and transitioning ADF members to access all the programs available to them. The VHPs are being developed in close collaboration with DVA.

Dr Kerry Summerscales, of Health on Central in Mackay, said generally civilian GPs were less aware of the challenges facing veterans in mainstream health care and were less aware of how DVA operated.

She said practical issues such as filling out forms correctly and receiving the proper renumeration were other concerns discussed.

Dr Summerscales, an Army veteran of 30 years, said having DVA representatives at the workshops was vital as they listened to the concerns of both former and transitioning ADF members and GPs.

Dr Summerscales specialises in and is a strong advocate of veteran healthcare with most of her patients either former or current ADF personnel, some travelling from as far away as Townsville to seek treatment.

“The latest Census figures show there are close to 600,000 former and current ADF members in Australia. It’s a significant number that can’t be ignored,” Dr Summerscales said.

DVA’s Chief Health Officer Professor Jenny Firman is leading DVA’s engagement with GPs including their involvement in the VHPs, while DVA’s Deputy Chief Health Officer Dr Trish Batchelor and Senior Medical Officer Dr Dan Corkery have provided clinical review and input into the VHPs.

The three are practicing GPs; Professor Firman and Dr Corkery are veterans of the ADF.

Professor Firman said GPs played a vital role in supporting the health and wellbeing of veterans and their families.

“DVA has had a particular focus on making it easier for GPs to support veterans and connect them to the right care; and we’re thrilled to be working with the PHNs to help achieve our shared goal, through national Veterans’ HealthPathways,” she said.

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Key projects

GP data dashboard

In 2022-23, the Data and Intelligence Team undertook the complete overhaul of the existing method of delivering benchmark reports to general practices participating in the Data Program, resulting in the team developing a new, modern, secure, and interactive dashboard to replace the PDF reports, which can be time consuming for practices.  

The Primary Care Engagement Team onboarded the participating practices to the new dashboard, with 64 per cent of those practices now accessing and using the new dashboard.  

The dashboard will increase general practices’ ability to use their data to provide better care to patients, resulting in overall better patient outcomes.  

It will also support general practices to run more sustainable businesses through identifying opportunities for appropriate optimisation of Medicare Benefits Scheme (MBS) billing.  

It will assist practices with accreditation preparation, increasing the quality of the data NQPHN can then use to inform service planning, and population health activities.  

Key statistics
of onboarded practices accessing the new dashboard
respondents to the NQPHN Annual Surveys

Consumer Dementia HealthPathways

During the 2021-22 financial year, NQPHN, on behalf of Better Health North Queensland (NQ), led the Joint Health and Local Area Needs Assessment Working Group, with the purpose of collaborating to support the development of needs assessment documentation in relation to the population of North Queensland in order to inform future service planning. The needs assessment documents support a system and service aligned northern region by informing priority areas of focus for service development and where required, funding allocation proposals, contributing to the Better Health NQ vision and purpose. This project draws on both NQPHN’s Health Needs Assessment and Hospital and Health Services (HHSs) Local Area Needs Assessments.

This is a long term and complex project, and it is continuing to achieve its deliverables for each reporting period. A recent highlight has been engagement with the Queensland Aboriginal and Islander Health Council (QAIHC) around potential data sharing.

Another significant project for NQPHN in the last 12 months was Consumer Dementia HealthPathways, where we engaged My Community Directory to establish a dementia support web page that would connect those living with dementia and their carers to reliable, local dementia care information, events, and specialist care.  

The Dementia Supports and Service Finder helps the community members find appropriate information for their loved ones when the early signs of dementia present and helps them better plan for keeping well while living at home through their dementia journey.  

NQPHN will promote this resource to practices and their staff, offering reassurance to patients about available care and support options that prioritises quality of life. This will aid people in planning for the future and aims to reduce the emotional impact of dementia stigmas.  

The initiative, made possible through PHN Aged Care Program funding, was informed by Dementia Australia’s Consumer Consultation Report, prepared for the Australian Government, and through consultation with local dementia advocates.  

Consumers living within the NQPHN region will also be able to download the My Community Info app, which has its own dementia tile to help navigate to the online resources. Hardcopy fridge magnets will be distributed with QR codes to also assist with navigation to these resources.

Commissioned Services Directory

In early 2023, NQPHN launched a new tool to support improved access to commissioned primary care health services.  

The Commissioned Services Directory, featuring an interactive map that displays NQPHN-commissioned services by category and location, now makes it easier for healthcare providers and consumers to locate and access these services.  

The new NQPHN directory does not duplicate the My Community Directory tool, instead it leverages the existing platform and pulls organisational information already listed on My Community Directory linking funded services through to their full directory listing.  

The Commissioned Services Directory is a valuable resource for those seeking locally funded healthcare services in North Queensland. The information provided in the directory will also assist local councils, Hospital and Health Services, and other key stakeholders to plan complementary services in the region.

Key statistics
NQPHN-funded service providers listed on the directory

Our priority areas

First Nations Health