Equal Access for the Culturally and Linguistically Diverse

Published 19 October 2018. Last updated 20 November 2018.

The appointment booking process for clients accessing the Fairfield Orthopaedic Hip and Knee Service (FOHKS) was modified to enable the culturally and linguistically diverse (CALD) population greater access to the service.


To achieve an equitable time to access an initial FOHKS appointment for patients from the CALD community compared with the English speaking population.


  • The CALD community can access an initial appointment within the same time frame as English speaking clients.
  • A decrease in the number of clients failing to attend an appointment.
  • More efficient use of staff time as they are not waiting for patients to show up for an appointment that they may not attend.


Almost a third of the Australian population is estimated to have a chronic musculoskeletal disease, which represents the main cause of long term pain and physical disability.1 Chronic disease contributes to more than 70% of the disease burden in Australia and chronic non-communicable diseases account for 70% of health expenditure.2

Fairfield serves a multicultural community, with 53% of people born in another country and 17.4% being proficient in English.3 This project looked at access equality for the CALD community, which is a unique feature to the demographic cohort of South West Sydney Local Health District (SWSLHD). Access delays can have a negative impact on SWSLHD clients and increase the cost of healthcare.

Previously there has been a significant disparity in access to FOHKS for the CALD community with just 5% accessing an initial appointment within one month, compared to 35% of English speaking clients. The FOHKS program at Fairfield Hospital aligns with the Agency for Clinical Innovation’s Osteoarthritis Chronic Care Program (OACCP) Model of Care.4


The project team, comprised of clinicians and administrative staff, started with mapping out the booking process and identifying reasons for delays in access to an initial appointment for the CALD community. The team then identified where to target possible solutions and improvements within the booking process.

Over a two-month period, CALD clients who failed to attend their appointment were contacted to ask, with an interpreter or family member to assist them, why they failed to attend their appointment. The project team then met to explore possible solutions and changes to the booking process were made to improve the heterogeneity in the process for the CALD community. These changes included:

  • the patient or their next-of-kin is initially contacted to ascertain suitable appointment times
  • the interpreter service is then contacted with a list of suitable appointment times to confirm an appropriate appointment time
  • the patient, or their next-of-kin, is then re-contacted with the appointment time and a confirmation letter is sent
  • the appointment letters have been adjusted for CALD patients, asking them to call and confirm their appointment one week prior
  • patients are contacted the day prior to their appointment if they have not confirmed their appointment.


Sustained – The project has been implemented and is sustained in standard business.

We continue to review the access rates and will investigate other methods to continue to sustain improved access.


The project commenced in early 2013 as part of a clinical practice improvement project. The booking process changes occurred July 2013 and these changes were then monitored throughout 2014 and 2015. Following evaluation, the project was submitted to the SWSLHD Quality awards and NSW Health Awards in 2016. Further opportunities to sustain and/or improve the booking process are being investigated.

Implementation sites

Presently the process has been implemented within FOHKS at Fairfield Hospital.  Consultation is currently occurring with outpatient physiotherapy services throughout the district regarding the next phase of the clinical practice improvement.


Agency for Clinical Innovation


  • A new booking process has been established to provide improved access to the CALD community for an initial appointment (See Figure 1).
  • Following implementation of the new booking process, clients have improved access to the service, with 45% of English speaking patients accessing an initial appointment within one month of referral compared to 35% prior to implementation, and 40% of the CALD community, compared to 5% prior to implementation (See Figure 2).  This outcome demonstrates improved access for the CALD community to health information and quality health services as well as interpreters, which is a key performance indicator for SWSLHD.6,3  
  • The flow-on effect of changes made to the booking process meant that only two patients failed to attend their initial appointment in the year following implementation (See Figure 3).
  • This project is a good example of the NSW health policy directive to provide the CALD community equal access to public health services, and the responsibility we have as a health system to respond appropriately to the local population.6
  • We have monitored the improved access over the past few years and have been able to maintain the initial gains.
  • The trend of patients failing to attend appointments was actively monitored from 2016 to 2017 and it was observed that the majority of failure to attend occurred in January. The administrative officer usually has at least four weeks leave over the holiday period in January and the position is not filled during this time. This means that patients’ appointments are not confirmed during this period and shows the impact of the reminder service and the ability to re-allocate an appointment following cancellation. In 2018 some administrative support was given to the clinics during the administrative officer’s absence to enable appointments to be confirmed. We are currently examining processes to assist in further access improvements such as a text message reminder system. There are also plans to further investigate what contributed to the spike in failure to attend during the second half of 2017.

Lessons learnt

  • Following the clinical practice improvement methodology (courses are run by the Clinical Excellence Commission) allows you to establish a good structure and process for your clinical practice improvement project.
  • Try not to do everything at once. For example, we have left further refinements such as the potential for SMS reminders to be a second project on its own.  You need to have different implementation and evaluation phases otherwise you are at risk of feeling like you have not achieved anything.
  • It takes time - being a clinician, your primary role is a clinician. Working though planning, implementation and evaluation to complete a project takes time so be patient.


  1. Royal Australian College of General Practitioners. Guideline for the non-surgical management of hip and knee Osteoarthritis. South Melbourne (AU): The Royal Australian College of General Practitioners; July 2009 70p ISBN 978-0-86906-299-9
  2. George Institute. Statewide Evaluation NSW Health Chronic Disease Management Program. 2014
  3. NSW Health. NSW Health Policy and Implementation plan for culturally diverse communities 2012-2016. North Sydney (AU). NSW Health. April 2012  45p PD 2012_020
  4. South Western Sydney Local Health District. Healthy and Culturally Diverse Communities and Refugee Health Implementation Plan 2016. Liverpool (AU):South Western Sydney Local Health District. January 2016 48p ISBN 9 7817 4079 200 4
  5. NSW Agency for Clinical Innovation. Osteoarthritis Chronic Care Program Model of Care. Chatswood: ACI; 2012. 39p.
  6. NSW Health. Integrated Care Non English speaking background – standard procedures- Improving Access Area/Public Health Services. North Sydney (AU): NSW Health; Feb 2005 20p PD2005_483


Danella Hackett
Senior Physiotherapist Musculoskeletal Coordinator
Fairfield Hospital
South West Sydney Local Health District
Phone: 02 9616 8587


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