B1.1 NSP servicesNew South Wales, the largest State, is also the jurisdiction with the largest Indigenous population – some 135,000 people. It also accounts for around 40% of national Hepatitis C notifications.
Within New South Wales' 'highly devolved' health service structure, NSP services are managed on a regional basis, in both metropolitan and non-metropolitan locations, by the eight Area Health Services (AHSs). The Central Office of the Health Department, however, sets 'the broad parameters in matters of policy, planning and finance'1.
In New South Wales the NSP is delivered primarily within the public sector, through the AHSs, complemented in the private sector through a government-subsidised community pharmacy scheme. Some non-government organisations are authorised to operate as secondary NSP outlets. A number of community-based organisations such as the NSW Users and AIDS Association (NUAA), the AIDS Council of NSW (ACON) and the Hepatitis C Council of NSW are funded to carry out a range of peer education and community development functions.
Overall NSW has the country's largest network of NSP services, .At the end of 2007 there were in total nearly 400 public sector NSP outlets across the State.
Primary outletsThere are primary NSP outlets in various locations within all Area Health Services. These are outlets where provision of needles and syringes to prevent blood borne viruses is the prime purpose of the service. A primary outlet employs staff in positions where their primary role relates to the provision of NSP services. Primary outlets are required to:
- provide a range of needle gauges, 1, 3 and 5 ml syringes, and condoms and lubricant
- provide fixed site disposal services
- provide education, health promotion and brief interventions
- provide referral to a wide range of health and community services
- collect relevant data
- provide support to secondary outlets as required – eg in staff training and education, provision of injecting equipment and resources, and data collection.
Secondary outletsSecondary NSP services are provided through a range of government and non-government agencies where the provision of needles and syringes is not a prime purpose of the service but occurs as one of a range of other health or community functions. Staff at secondary outlets are primarily employed to perform duties other than to provide NSP services. Secondary outlets are required, at a minimum, to:
- provide 1ml needles and syringes
- provide fixed site disposal services
- be able to refer people to the Alcohol and Drug Information Service and/or to a primary NSP
- record data on needle and syringe distribution in an appropriate way.
Some secondary outlets are involved in both treatment services and the distribution of sterile needles and syringes.
Service modality'Service modality' is the method by which an NSP service is provided. NSP services can be delivered from fixed sites (buildings), via outreach (pedestrian or vehicle) or via automatic dispensing machines. Often a primary or secondary NSP outlet will operate more than one service modality. The following strategies may be employed.
- Mobile outreach
Mobile NSP services operate through use of a vehicle, and are typically delivered from a specified location at a specified time. Mobile outreach services can be classified as primary or secondary depending on their prime purpose. Primary mobile outreach services provide a full range of injecting equipment and aim to provide education, briefing intervention and referral services at levels similar to those offered at a fixed outlet. All mobile outreach services are required to provide disposal services.
- Pedestrian outreach
Pedestrian outreach services are provided by staff who move around from place to place or group to group in an effort to promote and extend the reach of the service. Distribution of needles and syringes takes place as part of this broader promotional and education activity. Pedestrian outreach aims to increase access to IDUs who may not come into contact with NSP services in other ways. An important goal of outreach work is to develop rapport and credibility with clients, and refer them to other mobile or fixed site NSPs. The outreach worker's task includes developing an understanding of the social structures and characteristics of an area so that professional relationships are established leading to better access and use of sterile needles and syringes. Generally, pedestrian outreach provides basic injecting equipment and a limited range of education resources. Outreach workers use brief interventions with clients and seek to make referrals as required.
Where appropriate, outreach may also be provided at selected community events.
Automatic dispensing machinesThere are over 100 automating dispensing machines in operation across NSW. These are devices used for the purpose of dispensing needles and syringes without the personal attention of staff. Automatic dispensing machines may or may not charge a fee.
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Pharmacy outletsPharmacists across NSW may participate in the Pharmacy NSP Scheme, managed by the NSW Branch of The Pharmacy Guild of Australia. Under this scheme, in which 375 city and country pharmacies were participating at the end of 2007, pharmacies sell needles and syringes, or exchange used needles and syringes for new ones at no charge. (A small number of pharmacies sell needles and syringes independently of the Pharmacy NSP Scheme.)
Some retail pharmacies are involved both in methadone dispensing and in the distribution of sterile needles and syringes.
Over the four years to June 2008 NSW Health received some $2.5 million in COAG funding for diversification of NSP outlets and services and for increased counselling, education and referral.
B1.2 Serving Indigenous clientsProvision of NSP services in NSW comes within the broad terms of the NSW Health Aboriginal Partnership, signed off some years ago by the Health Department and the Aboriginal Health and Medical Research Council (AH&MRC – the NACCHO affiliate in NSW). The partnership agreement sets out guiding principles of consultation, support and shared understanding.
New South Wales also has an HIV/AIDS, STI and Hepatitis C Strategies: Implementation Plan for Aboriginal People 2006-2009. Among other things this sets out principles such as community ownership and participation, a holistic approach, workforce development and active outreach.
Within some Area Health Services there has been a long history of co-operation with Aboriginal Medical Services around the provision of NSP services, and across the state around eight AMSs are currently actively involved as secondary NSP outlets 2. In some locations, however, the provision of NSP services remains a controversial issue from the perspective of the Indigenous health sector.
During 2003, with financial support from OATSIH, the AH&MRC conducted a substantial research project on Increasing Access to Services in NSW for Aboriginal People at Risk of Contracting or who have Blood Borne Infections. Among other things the report on that study led to the establishment of two new positions within the AH&MRC – a Harm Minimisation Officer and a Workforce Development Officer. The AH&MRC continues to be actively involved in work designed to improve service quality and access to services for people at risk of hepatitis C. It has pursued a range of strategies, including training and awareness-raising for 'the Aboriginal hepatitis C workforce', which is largely identified with the sexual health workforce. NSW has a network of 40 Aboriginal Sexual Health Workers across the State, working in approximately equal numbers in the public and in the community controlled sector; they have specific responsibilities relating to blood borne infections and harm minimisation – including supporting access to NSPs – as well as sexual health.
The AH&MRC seeks to enhance capacity in the mainstream health workforce as well – including community pharmacies. There has also been work in innovative resource development – for example an interactive BBV resource designed for young people.
The aim is to increase awareness among Aboriginal service providers of Harm Reduction approaches and strategies (including NSP services), while also assisting mainstream services to become more Indigenous-aware and to offer more culturally appropriate services.
Relevant advocacy work by the AH&MRC includes work with appropriate Ministerial Advisory Committees and IASHC, the NSP Workers' Forum, the Hepatitis C Council and NSW Health.
Another interesting initiative, evidently at an early stage, is a joint project in the Hunter/New England Area involving Aboriginal medical services, NUAA and ACON in efforts to enhance NSP access for Indigenous IDUs in the Newcastle region.
The Health Department has committed itself to increased collection of data on Indigenous use of NSPs.