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Improving Access and Reducing Inequality

North Coast Primary Health Network
Project Added:
27 June 2016
Last updated:
11 July 2016

Improving Access and Reducing Inequality


North Coast Primary Health Network (NCPHN) created an outreach clinic that was co-located with a local soup kitchen in Lismore, to bring medical and nursing care to people in need.

This project was presented at the Rural Innovations Changing Healthcare Forum 2016.

View a presentation from the forum.


To increase access to primary healthcare services for people who are experiencing or at risk of homelessness in Northern NSW.


  • Provides quality primary healthcare services in a respectful, non-judgemental and flexible manner to vulnerable community members.
  • Increases access to a range of specialist, allied, primary and community healthcare services for marginalised and homeless people.
  • Provides an opportunity for clinicians to participate in an innovative program, with a unique training environment for student learning.
  • Increases the opportunity for collaboration among sectors and service providers.
  • Increases community engagement through collaborative partnerships.
  • Improves the facilities available at local soup kitchens.


In 2011, there were an estimated 1300 people who identified as homeless in the Northern Rivers and Tweed regions of NSW. Homelessness can have a serious impact on a person’s physical and mental wellbeing, often resulting in a diminished capacity to access healthcare services.

People in this group often have limited access to free medical care due to a significant lack of bulk-billing services in Northern NSW. They may also have difficulty accessing reliable transport and can experience judgement and negative attitudes from staff and the general public when sitting in waiting rooms at local healthcare facilities.

Outreach services have proven to be useful in reaching disadvantaged people in the community, particularly when they are located in an environment that is familiar. The Lismore Soup Kitchen Inc. (known as The Winsome) provides accommodation for approximately 18 disadvantaged men and daily hot lunches for up to 75 people who are experiencing or at risk of homelessness. It is a safe and welcoming place that was determined to be an ideal location for an outreach clinic.


  • The Winsome Outreach Clinic provides clients and residents of The Winsome with free access to general practitioners (GPs) and clinical nursing services for 2-3 hours per week.
  • The Clinic is based on strong collaborative partnerships between NCPHN, The Winsome/Lismore Soup Kitchen, Northern NSW Local Health District (NNSWLHD) and St. Vincent de Paul Society NSW.
  • A Clinic Working Group was established to support the operation of the clinic and provide a forum for communication, review, discussion, problem-solving and planning. It ensured that the operation and development of the Clinic was collaborative and aligned with the values, priorities and operation of The Winsome.
  • The Clinic is coordinated by an NCPHN program officer who works closely with a GP and community nurse, The Winsome volunteers and management.
  • A booking system allows people to make appointments during the week. However, the booking schedule is very flexible so that everyone who needs to see a GP or nurse can access these services.
  • The Medicare billing system is used for payment of GP services. If a client doesn’t have their Medicare card, Medicare is contacted by the program officer to get these details. Nursing services are provided by community nurses from NNSWLHD community and allied health services.
  • The Clinic supports clients who are referred to specialist services by the GP. This may involve a reminder phone call, advocacy around bulk billing, or arranging transport to the appointment through the St. Vincent de Paul Society outreach program.
  • In mid-2015, NCPHN and St. Vincent de Paul Society funded a purpose-built clinic in The Winsome to improve access and service delivery, and expand the range of services offered. These include:
    • annual flu vaccinations
    • podiatry services
    • women’s health services
    • mental health services (through the Healthy Minds program)
    • first aid and mental health first aid training for volunteers.
  • The Winsome Outreach Service Provider Network was established to strengthen the relationships among outreach services. These include:
    • Centrelink
    • Lifeline
    • Legal Aid
    • Women’s Health
    • Partners in Recovery
    • Life on Track
    • St. Vincent de Paul Society
    • Connecting Home.
  • Following the success of The Winsome Outreach Clinic, an additional three clinics were established in Tweed Heads (December 2013), Port Macquarie (March 2014) and Coffs Harbour (February 2015).

Project status

  • Sustained - the initiative has been implemented and is sustained in standard business.

Key dates

  • October 2012 – June 2016

Implementation sites

  • Fred’s Place, Tweed Heads
  • St Thomas Anglican Church, Port Macquarie
  • The Winsome / Lismore Soup Kitchen, Lismore
  • Uniting Church, Coffs Harbour


  • Northern NSW Local Health District
  • North Coast Primary Health Network
  • The Winsome / Lismore Soup Kitchen, Lismore
  • St. Vincent de Paul Society NSW
  • University Centre for Rural Health


  • The Winsome Outreach Clinic provided 146 GP and 85 community nurse occasions of service to patients between August 2015 and January 2016.
  • Women made up 22% of all occasions of service between April 2013 and January 2016.
  • Between April 2013 and January 2016, Aboriginal and Torres Strait Islander people accounted for 20% of all occasions of service.
  • Anecdotal feedback suggests there has been a noticeable reduction in anger and frustration among clients at The Winsome, after the Clinic was established.
  • A comprehensive evaluation of the program will take place in June 2016.

Lessons learnt

  • High levels of stakeholder engagement and coordination are necessary to bring all the elements of the Clinic together.
  • Establishing the Clinic Working Group allows us to work within the existing culture of The Winsome as the host organisation and foster collaborative relationships among key stakeholders.
  • A team approach, with multi-service and multi-disciplinary coordination, is essential to the success of the project.
  • Staff and clinicians need to be interested in the project and care about the Clinic and its patients to achieve positive outcomes.

Related resources

Further reading

  • Weiland T, Moore G. Health services for the homeless: A need for flexible, person-centred and multidisciplinary services that focus on engagement. InPsych: The Bulletin of the Australian Psychological Society Ltd 2009; 31(5): 14-15.
  • Hookey SJ. StreetHealth: Improving access to primary care. Australian Family Physician 2012; 41(1-2): 67-9.
  • Moore G, Manias E, Gerdtz MF. Complex health service needs for people who are homeless. Australian Health Review 2011; 35: 480-485.
  • Singer J, Conway J. Disadvantaged Communities Initiative: Improving healthcare access in the Northern Rivers – reporting the first 12 months. University Centre for Rural Health; 2013.
  • Rowe J. Access Health: Providing primary health care to vulnerable and marginalised populations – a practice paper. Journal of Primary Health 2005; 11(2): 32-37.
  • Homelessness Action Group. Survey of health services for people without secure housing in Northern NSW. North Coast NSW Medicare Local; August 2014.
  • O’Donnell P, McFarlane A. Health Inequity: Dealing with the silent killer. University of Limerick: Forum, March 2015.


Jane Conway
Program Officer, Disadvantaged Clinics
North Coast Primary Health Network
Phone: 02 6627 3300

Greg Bishop
Manager, Medical Services
North Coast Primary Health Network
Phone: 02 02 6659 1800

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