Evaluation of the Medical Specialist Outreach Assistance Program and the Visiting Optometrists Scheme

Appendix 2.g - Maningrida, Northern Territory

Page last updated: 28 February 2012

Overview

Maningrida is a remote community located in west Arnhem Land, located approximately 520 km east of Darwin, a six to seven hour drive. The road is sealed to Cahill’s crossing over the East Alligator River (approximately 300 kilometres), the balance being well-formed but largely unsealed. Access by road is typically limited to the dry season (June to November). Maningrida is accessible by air, with lights for night landings. There are morning and evening commercial flights from Darwin on weekdays with one flight on Saturdays and Sundays. A regular barge transports freight from Darwin. For health services, almost all movement of staff and patients is by air.

The Kunibidji people are the traditional owners of the Maningrida country. There are a range of other tribal groups who live in the area including the Kunbarlang, Nakkara, Burarra, Gunnartpa, Gurrgoni, Rembarrnga, Eastern Kunwinjku, Djinang, Wurlaki and Gupapuyngu people. Prior to the establishment of a settlement at Maningrida, local Aboriginal people travelled around the region with their clan members following the seasonal varieties of food, water supply and ceremonial commitments.

Maningrida was established by the Native Welfare Branch of the Commonwealth government as a trading post and rations depot in the late 1940s. A permanent settlement was established in 1958, and within a few years many people from the surrounding area moved to live in the settlement.

The estimated population of Maningrida and its outstations in the 2006 Census was 2,437 people, of whom 2,260 (92%) identified as Aboriginal or Torres Strait Islander (ABS 2011a). In Table 24, regional population statistics are presented along with the estimates for Maningrida. The accuracy of Census estimates is considered problematic for remote communities like Maningrida. People in the community believe that the population size is closer to 3,500.

One of the issues impacting estimates of the resident population is its high mobility. There are now more than 12 outstation centres in a radius of around 70 km around Maningrida, where clans have returned to live on their ancestral lands. There are frequent movements of people between Maningrida and the homelands and outstations. In addition, many Maningrida residents will often stay in Darwin.

Maningrida is located in the West Arnhem SLA, which had an estimated population of 3,333 in the 2006 census, of whom 3,078 identified as Aboriginal or Torres Strait Islander. The most recent population estimates for the West Arnhem Balance SLA (which has a slightly different set of boundaries to the West Arnhem SLA used for the 2006 Census), shows the population increasing from 5,074 on 30 June 2005 to 5,589 on 30 June 2010 (ABS 2011b).

Table 24 – Regional population statistics (2006)

Township/ location ARIA+
(GISCA 2010)
Remoteness Area SEIFA
(ABS 2008)
Resident Population
(ABS 2011a)
ATSI Population
(ABS 2011a)
% ATSI
Maningrida (Urban Centre/Locality) 11.34 RA5 Very remote Na 2,068 1,904 92%
Maningrida Outstation (Indigenous Area)   RA5 Very remote Na 369 356 96%
Balance of West Arnhem Statistical Local Area   RA5 Very remote Na 896 818 91%
Total of West Arnhem Statistical Local Area 12.84 RA5 Very remote 480 3,333 3,078 92%


Maningrida is one of the two largest Aboriginal communities in the Northern Territory (the other being Wadeye). While the economy is dominated by government services, Maningrida has a relatively developed commercial sector compared with other remote Aboriginal communities in the Northern Territory. Many of the local enterprises are associated with Bawinanga Aboriginal Corporation (BAC), the Maningrida Progress Association (MPA) and the Maningrida Aboriginal Enterprise Trust (MAET) (NT Government 2008). There are two community supermarkets operated by MPA and BAC. These are reported to stock a good range of goods at reasonably competitive prices, including fresh vegetables and fruit, milk, bread, delicatessen items and dry goods, basic chemist supplies, household goods, clothing and white goods (NT Government 2008; interviews). A weekly ‘tucker run’ is provided by BAC to supply outstations with basic foods, household goods and clothing. Other commercial activities in the community include an ANZ Banking Agency and Traditional Credit Union, the MPA motel (10 rooms), two BAC arts and crafts outlets (Indigenous arts; screen printing), the Arnhem Land Barra Fishing Lodge.

Employment in the community is also provided by a range of government agencies or government supported NGOs, including the Maningrida Health Clinic, Malabam Health Board, the School, the Shire Council, Centrelink, Batchelor Institute and JET (Jobs, Education and Training) Centre, community housing construction and repairs and maintenance.

Since 1 July 2008, Maningrida has been included within the West Arnhem Shire, which is one of eight new shire areas located in the Northern Territory. (It was previously under the Maningrida Council Incorporated.) The West Arnhem Shire covers an area of around 50,000 km² and has a population of 6,591. It includes the communities of Maningrida, Jabiru, Minjilang, Warruwi and Gunbalanya. Expenditure by the shire in relation to the Maningrida community was reported as $8.2 million in 2009-10 (West Arnhem Shire Council 2010, p.68).

Health service organisation

There are two health service organisations that operate in Maningrida. The Northern Territory government run Maningrida Health Clinic and the independent Malabam Health Board Aboriginal Corporation. There is currently a close working relationship between these services, which is described in more detail below.

The Malabam Health Board Aboriginal Corporation is a community controlled local health service affiliated with AMSANT (Australian Medical Services Alliances of the Northern Territory). The Board’s members are local residents of Maningrida and its surrounds. Malabam operates an aged care facility (including residential and home based care) and a range of other services, some of which are closely integrated with services provided by the Maningrida Health Clinic. Malabam indirectly employs (through AMSANT) the resident and visiting GPs who provide primary medical care in the clinic.

Malabam has been around for about 10 years. The organisation is funded to employ health staff. However, it is not sufficiently established to directly recruit and manage staff. Therefore it purchases services from DHS, which are provided in the Maningrida clinic. The clinic then provides reports to Malabam on the services provided under this arrangement.

The Maningrida Health Clinic is a Northern Territory Government managed service. Within the Department of Health, it is managed by Remote Health within the Darwin Rural Region (see Figure 14).

Maningrida is located within the catchment boundaries of the Top End Hospital Network, which includes the Royal Darwin, Katherine and Gove hospitals. Most specialist outreach services are provided by specialists based at Royal Darwin Hospital. Organisationally, Darwin Rural Region is a separate entity to the Top End Hospital Network.

Maningrida is also located within the boundaries of the General Practice Network NT (which covered almost all the area of the Northern Territory and some parts of South Australia). The proposed Northern Territory Medicare Local will include the whole of the Northern Territory.
Health facilities in selected areas of the Northern Territory

Figure 14 - Health facilities in selected areas of the Northern Territory

Source: Northern Territory Department of Health and Families 2010



General practice and primary care

Primary health care services for Maningrida are delivered mostly in Maningrida Health Clinic by 2.6 FTE GPs, 12 FTE remote area nurses (with one currently away from clinical duties, acting as the centre manager) and 3 FTE Aboriginal health workers (one female and two male). The clinic also employs additional staff as Aboriginal community workers (there are two of these working as drivers) and support staff (two admin currently, with another about to start). The clinic has a full time manager.

One FTE GP is currently residing in Maningrida. Another is employed on a 0.6 FTE basis and flies into the community for around two days per week. Currently the other available GP position is covered by locums.

The remote area nurses based at the clinical are either employed to provide a generalist clinical service or a specialised role (full or part time). Specialised roles include chronic disease management, women’s health, midwifery, and children’s health.

The chronic disease nurse positions play a role in identifying patients with chronic conditions, developing chronic disease management plans, identifying patients requiring follow-up or specialist consultations and ensuring relevant protocols are followed. There are large numbers of people within the community with chronic conditions, including rheumatic heart disease, other heart disease, diabetes, and chronic respiratory conditions. However, there is sometimes a challenge in identifying them, as the major focus (due to the busyness of the staff at the clinic and competing work priorities) is on acute issues. Once identified with a chronic condition, patients are flagged as such on the electronic patient information system. This system can then be used to identify them for follow-up. However, setting priorities in terms of patients requiring specialist referral is a challenge. This is partly due to nurses having adequate time to undertake prioritisation, and partly due to not having clear and consistent clinical guidelines for this. The chronic disease nurse role needs to work closely with a range of visiting specialists, including general physicians, cardiologists, endocrinologists and nephrologists. However, there is little to no time for upskilling, which is much needed.

The women’s health role is a part time role. The nurse providing this role also works in a generalist clinical role. A women’s health clinic is run once a week, although women can come into the clinic at any time to seek advice or treatment. The women’s health nurse plays an important role in ensuring women receive regular screening (both for Pap smears and vulva cancer, which is common among Aboriginal women in the Arnhem regions), have access to birth control, undergo breast checks, and address continence and a range of other issues. The nurse works closely with the visiting gynaecologist, who has provided consistent outreach to the community over the years. The gynaecologist brings her own equipment, and also provides a nurse who assists with co-ordination between visits. The clinic provides a dedicated vehicle and driver to assist local women in attending the clinic on the days of the gynaecologist’s visit, although they are currently looking into recruiting a female driver to further increase attendances. Nevertheless, attendances for gynaecological appointments is higher than for other services provided by the clinic.

The midwife is a full time position. She is involved in working with pregnant women from the time that they suspect a pregnancy (i.e. she provides pregnancy testing and/or refers women with positive results to physician to confirm the pregnancy) through to the first post-natal visit. Her role includes education Anglicare currently plays the major role in providing education to pregnant women regarding nutrition and smoking, but the program is due to close, and when it does, the Maningrida midwife will provide this., arranging for women to have ultrasounds (from a visiting service), monitoring the progress of a woman’s pregnancy, identifying when women will need to travel to Darwin prior to a pregnancy and ensuring this occurs, managing emergency childbirths in the community, and following up women after birth. She works closely with a visiting obstetrician.

The child health nurse takes over the role of caring for children in the clinic from the midwife from when babies are about eight weeks old. She undertakes vaccinations on Tuesday and Wednesday each week for children up to four years of age. By that time, each child will get 20 or more vaccinations. During other times, she monitor’s progress of children (e.g. growth and nutrition), ensures that children who need regular medication are taking it (e.g. erythromycin post pneumonia), and identifies children at risk. She works closely with the visiting paediatrician, who comes once a month for two days at a time. She often needs to organise for children to go to Darwin for treatment, for example, if they develop a high temperature and the paediatrician is not there to attend to it.

In addition to the specialised roles, remote area nurses provide a consultation service for patients who visit the clinic for specific or acute conditions. More complex patients are referred to the GP. The remote area nurses are also the first point of contact for after-hours services. Most nurses share a roster.

The nurses and GP are able to consult (at any time) with a District Medical Officer for more complex cases, for example, where an evacuation to Darwin is required. In less urgent situations, the GP or nurse may also consult with a specialist who has previously visited Maningrida, who may also know the patient’s history.

Visiting services

All referrals of patients to visiting specialists are made through the GP. However, this may be based on advice from a remote area nurse who has seen the patient.

Referrals are made through both the electronic medical record system (the Primary Care Information System - PCIS) and through a paper based system (including a book in which appointments are recorded). Several nurses indicated that they needed to spend time reconciling the referrals made through the electronic system (which seemed to ‘misplace’ some referrals) and the paper based system.

Around a week prior to a specialist’s visit the relevant nurse will review the referrals, and reconcile the two systems. The patient list may be discussed with the visiting specialist to ensure all priority patients are identified. The patient list will also be discussed with a senior Aboriginal Health Worker who is often aware of which people will be away from Maningrida at the time of the visit.

Once this list is finalised, reminders/invitations will be prepared. These will be distributed to patients by one of the drivers employed by the clinic, typically on the day before the visit.

On the day of the visit, some patients will come to the clinic on their own accord. For others, a driver will try to find the patient and bring them to the clinic. It was reported by several informants that around 50% of patients on a list will attend on the day. This varies depending on the specialist and the nature of service being provided.

A range of MSOAP supported and other visiting services are provided into Maningrida. The visiting services that were identified through this visit are summarised in Table 25.

Table 25 – Visiting health services – ManingridaTop of page

Program Specialty Number of visits per year Number of days per visit Approx. patients per visit
Malabam Senior medical officer 23 4  
Malabam GP Locum 23 3  
MSOAP Obstetrics and gynaecology – General 4 1  
MSOAP Women’s health   2  
MSOAP Ophthalmology - General *    
MSOAP Physician – Cardiology  (includes capacity to do echo-cardiology, Registrar also attends) 8 1  
MSOAP Physician   1  
MSOAP Psychiatry – Adult 6 4  
MSOAP Surgery – General 2 1  
MSOAP ENT specialist   1  
MSOAP Paediatrician 12 2  
MSOAP-ICD Diabetic/Cardiac Education 4 1  
VOS Optometry (Fred Hollows) 1? 2  
NT Govt Dental 12 5  
NT Govt Oral health therapist   5  
NT Govt Spinal outreach team (rehabilitation physician, South Australia based, NT spinal cord nurse, 2 physiotherapists) 1 1  
Malambam Psychologists 23 2  
Malambam Physiotherapist   10  
NT Govt Mental health nurse   5  
Undetermined Chronic disease   5  
Undetermined Child      
Undetermined Podiatrist   5  
Undetermined Pharmacist   5  
Undetermined Adult health checks team   5  
Undetermined Ultrasound service 6 1  
Undetermined X-ray services 6 1  
Undetermined Dietitian   5  
Undetermined Age and disability team (including paediatric OT and SP)   5  
Undetermined Home medicine review   2  
Aust Govt Australian hearing service (audiologist)   2  
NT Govt Trachoma screening      


Note: This table represents information collected through MSOAP national data and data collected during the site visit to Maningrida. It may not capture all visiting services
* There is funding for an ophthalmologist from Darwin, but this position is currently vacant.



Visiting optometry services to Maningrida are provided by the Fred Hollows Foundation. Top of page

Visiting physicians also provide upskilling locally. Thursday afternoons at the clinic are dedicated for this. In addition to this, it was reported that visiting physicians are generous with their time in terms of providing one-to-one advice to GPs during their visits and being accessible outside of visits.

Organisational and resource issues

One of the key issues with visiting services is the organisation that is involved, both for the specialist and at the local level. A complicating factor is when specialists just ‘turn up’, without prior notification (or an adequate lead time). This sometimes happens due to errors on either end.
The drivers and Aboriginal Health Workers are important resources that all visiting services compete for. Vehicles and clinic space are also issues. There are currently 16 consulting health professionals living in Maningrida, as well as the GP, but there are only 13 consulting rooms. This is managed by rotating health professionals to outstations, and using other parts of the clinic (e.g. lawns) to provide services.

The Maningrida clinic is currently expanding. A ‘renal ready’ room is being built for home-based haemodialysis adjacent to the clinic, and a dialysis centre is to be built across the road from the clinic. Once the dialysis centre is operational, the ‘renal ready’ room will be used for consulting. A family care centre is also being built across the road from the clinic, where baby checks may be moved to.

The clinic has a lot of equipment. However, an issue is having people with the training to use it.

One of the issues raised with visiting services from Darwin is that someone needs to organise them, and needs to champion them at a senior level. If there is no one taking on this role, physicians would not volunteer on their own, because they are often too busy within the hospital. This is one of the benefits put forward for MSOAP, that is, that it is a dedicated program for specialists to visit. Otherwise, with other positions from Darwin, there needs to be good championing and/or dedicated positions for outreach.

Another issue is the linkage of specialists with primary care locally. That is, primary care staff need to know when particular specialities are visiting so that they can prepare referrals.

Gaps in specialist services/assessment of need

Eye services in the Top End are generally problematic. For example, there has not been a regular ophthalmology service for three to four years and cataracts are currently done in Darwin. The Central Australian model was put forward is a good model. The key features of its success were quoted as a (skilled) team-based approach bringing their own equipment and integrating with the primary sector locally.
Another big gap is dental. Currently a dentist visits one week per month, but the need is for at least one full time dentist.

Other gaps are:
    • chronic disease management
    • cardiology (main issue is irregularity of the service)
    • ENT (e.g. myringotomies done in Katherine).
The visiting GP is an advocate for the health clinic back in Darwin (0.3 of his 0.6 FTE appointment is spent in Darwin), and he assists in communicating what the needs of the clinic are. The new LMO may be able to take on this role in the future.

The clinic is currently trying to recruit for the other LMO position. However, even when this is filled, they will still be shortage of staff. For example, there are 670 people with chronic disease in the region, with almost all of them needing a six-month review, and some needing a three-month review.

One of the issues for the clinic is that like others, it is focussed on the acute burden, and there are not a lot of resources left for the chronic component.

Malabam and the Maningrida clinic have a shared strategic plan. There is a community reference group to discuss the needs of the community. However, there are many clans in Maningrida, and it is difficult to get a consensus for action on many issues.

Therefore, some of the improvements that can be made to services within Maningrida need to occur locally. These include better planning and assessment of need, for example, looking more closely at demography, morbidity and mortality, and an analysis what people go to Darwin for (or use patient transport assistant scheme). Currently about $7 million is spent on evacuation, for the plane trips alone, and therefore, the service model may need to change. For example, Maningrida may need a hospital given its population size and health care issues.

Succession planning is also needed for visiting specialists, as continuity suffers when someone retires or does not visit any longer.Top of page