Chapter 15: Health
15.1 Natural disasters can have an adverse impact on the health and wellbeing of individuals and communities. They can result in acute and chronic physical impacts, intensify mental health conditions and place pressure on the health system. The health and mental health response to natural disasters requires effective planning and those of national scale or consequence need to be supported by national coordination mechanisms.
15.2 In Australia, state and territory governments are primarily responsible for managing health emergencies, including those relating to natural disasters. Management of health emergencies is coordinated between state and territory health authorities, Local Hospital Networks and, to varying degrees, primary care providers. The Australian Government becomes involved when there is a national or international impact, or where an emergency has the potential to overwhelm or exhaust the capacity of state and territory governments. Under these arrangements, state and territory governments can request that national capabilities be activated by the Australian Government.
15.3 These principles appear to be well understood and clear. However, the experience of the 2019‑2020 bushfires, floods and pandemic highlight a need to clarify the delivery of the national health emergency response and capabilities – one example being the use of Australian Medical Assistance Teams domestically. Current and forthcoming reviews of national health plans and capabilities provide an opportunity to clarify arrangements and incorporate lessons from these extreme events.
15.4 Primary healthcare is generally the main point of contact that Australians have with the health system. Primary healthcare providers and Primary Health Networks can play an important role in supporting health responses during and following natural disasters. However, to date they have not been adequately incorporated in health responses and disaster planning processes at the local, state and territory and national levels. Similarly, there is scope for the Australian, state and territory governments to pre‑identify a set of measures which enable continuous access to healthcare and medications and to incorporate these into relevant disaster plans.
15.5 While a range of programs and funding are provided, there is scope to improve the coordination and delivery for mental health services. The long-lasting trauma of disaster events over the last decade underscores the need for greater planning for the delivery of long-term locally‑based and appropriate mental health services.
15.6 National health research and data linkages play an important role in identifying the health risks of a natural disaster and building resilience. Existing health data could be more effectively used and linked to other data sources, such as environmental data. Standards which guide the collection, storage and exchange of relevant data will support healthcare planning, resource allocation and health systems resilience.
Health and natural disasters
15.7 Natural disasters can have an adverse impact on the health and wellbeing of individuals and communities. Natural disasters, in both the short and long-term, can increase the incidence of many health conditions. 
15.8 Acute impacts can range from mild, short-term symptoms, such as irritated eyes, to more severe conditions. Burns to the body, as result of bushfires, can be life threatening or lead to lasting disabilities that require long-term medical treatment. Heat can be a serious stressor, leading to dizziness, confusion, dehydration and heat stroke.  It is also linked to preterm births, increased deaths in the elderly population and is associated with long-term neurological effects.  Smoke from bushfires can also have a significant impact through respiratory and cardiovascular complications  – see Chapter 14: Air Quality.
15.9 Adverse health impacts are not limited to fire hazards. It has been estimated that people affected by the 2011 Brisbane floods were 5.3 times more likely to experience worse overall health and 2.3 times more likely to experience worse respiratory health outcomes, compared to the general population. 
15.10 Natural disasters can also exacerbate chronic conditions, such as cardiovascular disease, diabetes and chronic obstructive pulmonary disease.  This can be caused by increased susceptibility to injury or infection, separation from medication or treatment, inhaled toxins, or crush injuries. 
15.11 Exposure to natural disasters also affects short and long-term mental health and wellbeing. Although the majority of those exposed to a disaster have only mild, transitory symptoms, some people will develop a mental health disorder post-disaster. 
15.12 Natural disasters also have indirect health impacts. These include damage to health infrastructure, requiring patients to be evacuated; loss of access to healthcare and medications; and dislocation between patients and their care providers resulting in deterioration of chronic conditions and a failure of early diagnosis of life-threatening diseases. 
15.13 Many vulnerable people live in areas at increased risk of natural disasters and more limited access to health services. Vulnerable population groups may also have a higher risk of, or higher potential exposure to, negative health outcomes when facing natural disasters,  in particular children and young people. Natural disasters can also lead to environmental health consequences, including through contaminated food and water. 
Australia’s health system during natural disasters
15.14 Responsibility for the health system is based on Australia’s federal system of government, and incorporates both public and private structures. The Australian Government‘s responsibilities include Medicare and the Pharmaceutical Benefits Scheme (PBS), elements of primary care, including Primary Health Networks (PHNs). State and territory responsibilities include delivering preventive health services, public community-based and primary health services, and funding and managing ambulance services.  The funding for public hospitals is complex and shared between Australian, state and territory governments. Local Hospital Networks (LHNs)  are responsible for a group of local hospitals, or an individual hospital, and linking to services within a local area.
15.15 In Australia, state and territory health authorities are primarily responsible for managing health emergencies. Responses to health emergencies are coordinated between state and territory health departments, LHNs and, to varying degrees, PHNs where they exist. Australian Government health authorities become involved when there is a national or international impact, or where an emergency has the potential to overwhelm or exhaust the capacity of state and territory governments. Under Australia’s arrangements, state and territory governments can request that national capabilities be activated by the Australian Government.
National health arrangements and capabilities
15.16 The National Health Security Agreement (NHS Agreement) was agreed between the Australian, state and territory governments in November 2011. The NHS Agreement supports the National Health Security Act 2007 (Cth) and establishes a framework for clear, quick and informed decision-making to support a coordinated national response to public health emergencies. A national response can be activated at the request of an affected, or potentially affected, state or territory. The Australian Government can act unilaterally only in the national interest. 
15.17 The National Health Emergency Response Arrangements (NatHealth Arrangements) are established under Part 3 of the NHS Agreement. They broadly outline coordination and governance principles applicable during national health emergencies.  National health sector plans are subordinate to the NatHealth Arrangements  and describe more detailed strategies for the management of specific hazards – such as the Domestic Response Plan for Mass Casualty Incidents of National Consequence (AUSTRAUMAPLAN).
15.18 Under the NHS Agreement and NatHealth Arrangements, strategic coordination of a public health emergency occurs through the Australian Health Protection Principal Committee (AHPPC). The role of the AHPPC is to develop strategic advice on how to meet national coordination needs associated with health emergencies. This could include coordinating operational health responses, developing national health protection policies, priorities, guidelines and standards, and assessing the need for coordinated national public health messaging. 
15.19 When a significant health event or emerging threat is identified, an emergency teleconference may be called at the discretion of the Chair of the AHPPC, the Chief Medical Officer of Australia (CMO). Professor Brendan Murphy, CMO during the early stages of the COVID-19 pandemic, told us the National Incident Room (NIR) is activated by the CMO ‘when there is an emerging issue’, be it a ‘threat to public health or require coordination or close monitoring’. 
15.20 The NIR is the Australian Government Department of Health’s emergency operation centre. The NIR has ongoing responsibility for monitoring health incidents and other incidents with actual or potential significant health impacts. The NIR supports the AHPPC to coordinate national health sector responses, including through routine intelligence gathering and reporting.  State and territory agencies provide information and data to the NIR. 
Figure 57: NIR activated for the COVID‑19 pandemic 
15.21 The NIR has been constantly active since late 2019, and has had a ‘significant expansion of capacity’.  This is due to a number of overlapping and consecutive health emergency responses, including: Ebola in the Democratic Republic of the Congo; poliovirus in Papua New Guinea and Indonesia; elevated measles importations into Australia (caused by a global resurgence of measles); a major measles outbreak in Samoa; the 2019‑2020 bushfires and heatwave; the Whakaari/White Island volcano disaster in New Zealand; and the COVID-19 pandemic. 
15.22 The NIR was activated for the 2019‑2020 bushfires on 12 November 2019, triggering coordination and information sharing under the NatHealth Arrangements.  Formal coordination of a national health sector response commenced on 5 January 2020 with the first meeting of the AHPPC  dedicated to the 2019‑2020 bushfires.
15.23 The NIR is the key Australian Government coordination facility in the event of a public health emergency, such as a pandemic. Professor Murphy told us it is directly linked to the World Health Organization, and during the acute phases of COVID-19 and in the peak of the bushfire response in December 2019/January 2020, it was run ‘24 hours a day’ so that there was a ‘single point of contact for information’.  Professor Murphy told us there was a ‘very close partnership’ between the NIR and the Australian Government’s Crisis Coordination Centre (CCC).  The CCC is a whole‑of‑government coordination facility that provides a single source of knowledge for all hazards monitoring and situational awareness of current and emerging sources of risk and threat to Australia.  There should be appropriate interaction and close coordination between the CCC and the NIR.
15.24 Under the NatHealth Arrangements, the AHPPC may task, activate or deploy a number of established coordination arrangements and capabilities, including the National Health Emergency Management Subcommittee, Australian Medical Assistance Teams (AUSMATs), and the National Medical Stockpile. 
Box 15.1 Australian Health Protection Principal Committee
The AHPPC is the peak national health sector committee responsible for preparing and responding to public health emergencies and is a key decision making body. The AHPPC is chaired by the Australian Government Chief Medical Officer and includes the Chief Health Officers of each state and territory. AHPPC also includes representation from the Australian Defence Force, Emergency Management Australia and the National Critical Care and Trauma Response Centre. 
In a public health emergency, the AHPPC will develop a consensus‑based approach to decision making and develop public health advice and appropriate responses, which are enacted in each jurisdiction.  During public health emergencies, Chief Health Officers are able to issue public health orders or directions which assist in managing the emergency (such as movement restrictions) - although the extent of these powers and broader functions varies between state and territory governments. These powers are similar to those available to combat agencies during a natural disaster.
The AHPPC is supported by five standing subcommittees – see Figure 58. The AHPPC typically advises health ministers on national health protection priorities and policy issues through the Council of Australian Governments’ (COAG) Health Council and the Australian Health Ministers’ Advisory Council.  During the COVID‑19 pandemic, the AHPPC provided advice directly to heads of government, through the National Cabinet,  collapsing several layers of bureaucracy.
During the 2019‑2020 bushfires, the AHPPC considered a range of issues related to national health responses, including health advice on the use of masks, national messaging on managing the effects of prolonged exposure to smoke, the supply of medications, and workforce pressures. The AHPPC also provided advice which led to the release of P2 masks from the National Medical Stockpile (a strategic reserve of medical equipment and medications). 
15.25 As noted, state and territory governments may call on the Australian Government for assistance in circumstances set out in the NatHealth Arrangements. While these arrangements worked reasonably well during the bushfires, there are opportunities for improvement. In particular, Queensland has suggested clarifying when and how national health capabilities can be used, and also in improving communication and coordination between national, jurisdictional and local structures involved in public health emergencies.  The Victorian Government has also suggested that further support and funding be provided for the standing committees of the AHPPC. 
15.26 We also heard that there may be benefit in reviewing existing national health sector plans and sub‑plans, under the NatHealth Arrangements, including the AUSTRAUMAPLAN and its Severe Burn Injury annex (AUSBURNPLAN).  This would ensure current capability and capacity issues are considered at jurisdictional and national levels.  The Australian Government has advised that it intends to review relevant national plans, such as the AUSTRAUMAPLAN as part of its 2021 review of the Australian Government Crisis Management Framework. 
15.27 The NHS Agreement and NatHealth Arrangements are scheduled to be reviewed in the latter half of 2020‑2021; having been delayed due to the priority placed on the COVID‑19 response.  The Australian Government has also advised that a comprehensive review of the operation of the NIR was in the early planning and consultation phase before being paused due to recent health emergencies. Referred to as the NIR Concept of Operations project, the review will focus on identifying opportunities for the NIR to better support state and territory governments in responding to public health emergencies. 
15.28 The principles established under the national arrangements for managing public health emergencies are reasonably clear and appear to be well understood across governments. The upcoming review of the NHS Agreement, NatHealth Arrangements and NIR provides an opportunity to clarify and improve the implementation of these arrangements.
15.29 Natural disasters have the potential to impact the health system’s capacity and ability to support communities during and following a natural disaster.  The health system will need, like other emergency responders, to adapt to the likely increase in the frequency and intensity of natural disasters and to the demographic changes that are altering disaster risk.
15.30 The Australian, state and territory governments and health authorities should develop comprehensive strategies to prepare and adapt the health system to the increase in natural disaster risk.
Australian Medical Assistance Teams
15.31 AUSMATs are World Health Organization accredited, multidisciplinary emergency medical teams that can rapidly mobilise and respond to disasters.  The AUSMAT capability can be used to rapidly boost regional health capabilities when logistical or access issues may preclude standard state-based arrangements.  AUSMAT have deployed numerous times internationally and were deployed domestically for the first time, under the NatHealth Arrangements, as part of the health response to the 2019‑2020 bushfires.
15.32 The Australian Government Department of Health is responsible for maintaining the AUSMAT capability and funds the National Critical Care and Trauma Response Centre (NCCTRC), based at the Royal Darwin Hospital, through the Project Agreement for the National Critical Care and Trauma Response Centre with the NT Government.  The NCCTRC was established in 2004, in response to the 2002 Bali Bombings. 
15.33 Each AUSMAT is tailored, based on the medical needs of the deployment. It can include a mix of doctors, nurses, paramedics, logistical experts, and allied health staff such as environmental health staff, radiographers and pharmacists.  AUSMAT members are drawn from personnel based in each of state and territory governments. 
15.34 To support the AUSMAT capability, the NCCTRC operates a certification process for potential AUSMAT personnel  and provides specialised education and training.  There are currently 800 trained AUSMAT personnel who may be deployed in response to a public health emergency. 
15.35 Domestic deployments of AUSMATs are made at the direction of the AHPPC, following a request from a state or territory.  All state and territory governments have agreed to a rotational AUSMAT ‘on call’ roster in which each jurisdiction is expected to provide AUSMAT personnel when it is rostered during the year. The NT is always ‘on call’, as a requirement under the Project Agreement, to ensure that AUSMATs are capable of being deployed at short notice. If a jurisdiction cannot provide the required technical skills when requested, state and territory governments that are not ‘on call’ are then requested to contribute personnel. 
Figure 59: Ambulance on standby in Queensland, during the 2019‑2020 bushfires 
Box 15.2 AUSMAT deployments for the 2019‑2020 bushfires 
During the 2019‑2020 bushfires, AUSMATs were deployed for the first time in a domestic setting to Victoria and NSW. The AUSMATs were co-deployed with Australian Defence Force (ADF) personnel and reported to ADF Joint Health Command as well as Victorian and NSW health authorities.
Figure 60: AUSMAT outside a field hospital in Batemans Bay, NSW 
On 5 January 2020, joint ADF‑AUSMAT operations commenced. Three AUSMATs were deployed to Sale, Mallacoota, Bairnsdale Regional Hospital and Wangaratta Hospital in Victoria. These teams consisted of three doctors, one intensive care paramedic, five nurses and two logisticians. The deployment to NSW consisted of two teams, which were deployed to Batemans Bay and various towns along the south coast. The teams consisted of two doctors, two paramedics, two nurses, and two logisticians.
The Victorian deployment highlighted a number of challenges with the initial deployment and consultation process. The team was initially prepositioned by the Australian Government, prior to a request being submitted by the Victorian Government. At the time, Victoria had activated its Field Emergency Medical Officer program and it did not identify gaps in health or medical support. However, at the local level, health facilities had directly requested AUSMAT assistance. These local facilities were concerned that they would be overwhelmed by the threat posed by the bushfires. The AUSMAT provided assistance to those local facilities.
Figure 61: AUSMAT supporting the health response at a local hospital in Wangaratta, Victoria (left) and co‑deployed AUSMAT and ADF personnel in NSW (right) 
15.36 Given that the 2019‑2020 bushfire response was the first time that AUSMATs were deployed domestically, a number of key processes had not been practised in a domestic crisis situation. For example, while international AUSMAT deployments are well-rehearsed, the NCCTRC has suggested that further work is required to develop insurance and cost recovery arrangements for domestic deployments.  Domestic deployments have also proven to be more operationally complex; for example, NSW and Victoria have different operational reporting and command structures. 
15.37 As highlighted in Box 15.2, the experience during the 2019‑2020 bushfires stressed the importance of clarifying the trigger points for the domestic deployment of AUSMAT and the associated consultation processes. In the case of Victoria, it appears that the pre‑deployment of the AUSMATs, prior to a request being made, impacted on the Victorian Government’s deployment of Field Emergency Management Officers.  However, once deployed, it appears the AUSMATs were able to provide support to the local health response. 
15.38 There is merit in reviewing the existing AUSMAT processes, to ensure that there are clear procedures for the domestic deployment of AUSMAT, including in relation to requests and operational arrangements and reporting.
15.39 We recognise the value of rapid deployment and a ‘no regrets policy’  to the use of AUSMATs in domestic context – that is, have capabilities ready rather than waiting for local capacity to be overwhelmed or exhausted. Providing emergency managers with a better understanding of AUSMAT capabilities, such as through exercising and training, would support more effective use of those capabilities and integration in planning processes. 
15.40 The desirability of greater clarity around the circumstances in which the Australian Government can provide support is one reason we have recommended that the Australian Government consider legislation to support the making of a declaration of a state of national emergency – see Chapter 5: Declaration of national emergency.
15.41 Greater awareness of AUSMAT capabilities and activation pathways in a domestic context is required. This could be accomplished through greater training, incorporation in national emergency response exercising and inclusion in relevant emergency planning processes.
15.42 We heard from the NCCTRC that, in the event of an increasing reliance on domestic deployments, AUSMATs would benefit from growth in personnel and equipment. We also heard that there is scope for the development of standards for emergency field hospitals. Relevant standards would ensure the availability of appropriate and quality care and services when communities are displaced by a natural disaster. 
15.43 We heard that many nurses and medical staff occupy roles in state level emergency services and that any increase in the ‘call-out’ of AUSMAT may have ‘unintended perverse consequences related to diminished state level emergency service staff/volunteer capacity’.  We agree that the use of AUSMATs should not unduly diminish the capacity of the deploying jurisdiction’s health systems. This should be able to be managed in a manner similar to the interjurisdictional deployment of emergency responders and Australian Defence Force Reservists.
15.44 The increasing use of domestic deployments of AUSMATs, to augment responses to public health emergencies, will require Australian, state and territory governments to bolster the AUSMAT capability. This should include strategies to increase the number of trained personnel willing to be listed as AUSMAT certified, to ensure that the operational structures have the capacity to support increased deployments and to develop relevant standards. State and territory governments are supportive of reviewing AUSMAT processes and capabilities. 
Recommendation 15.1 Australian Medical Assistance Teams
Australian, state and territory governments should review Australian Medical Assistance Team capabilities and procedures and develop necessary training, exercising and other arrangements to build capacity for domestic deployments.
15.45 State and territory health authorities are primarily responsible for responding to health emergencies. These emergencies are managed in accordance with jurisdictional plans which are typically subordinate to, or aligned with, broader emergency management arrangements  – see Appendix 22: Health and mental health.
15.46 In general, under these plans, state and territory health authorities are ‘combat agencies’ in human health emergencies (such as infectious disease emergencies) and ‘functional agencies’ in providing health support in other major incidents, such as a natural disaster. The operational command structure, in response to an emergency, will reflect these roles and the context of the incident. 
15.47 Consistent with the broader approach to disaster management, responsibility for preparation, risk management and response is delegated to the local level – generally Local Hospital Networks (LHNs).  State and territory governments require the development of local level plans, which outline control and coordination arrangements and specific capabilities. Plans also usually include processes for escalating requests to jurisdictional health authorities and control centres, depending on the severity of the event. 
Primary healthcare and access to healthcare during disasters
Primary healthcare providers and Primary Health Networks
15.48 Primary healthcare providers are generally the main point of contact that Australians have with the health system. They are the entry level to the health system and are a broad group, including general practitioners, pharmacists, Aboriginal health workers, nurses and allied health professionals.  Primary care providers have valuable local knowledge and strong connections with the communities they support. 
15.49 Primary Health Networks (PHNs) also have an important role in Australia’s health system. PHNs are independent organisations, primarily funded by the Australian Government, which support the coordination of health services and care for patients by primary healthcare providers. They work directly with primary healthcare providers, LHNs, and the broader community. PHNs also commission specific services to meet the primary healthcare needs of their region. 
15.50 It is well recognised that the health response to natural disasters needs a ‘whole‑of‑community’ approach to ensure that good health outcomes are achieved.  Joint planning and funding at a local level, including strengthening coordination between PHNs and LHNs, is a key reform priority of the National Health Reform Agreement – Addendum 2020-25  – an agreement between Australian, state and territory governments to improve health outcomes for all Australians and to ensure that our health system is sustainable.
We’ve gotten many stories of…people flooding in to a trusted health care professional that they know. The waiting rooms were packed with people who were in distress… 
15.51 During and after a natural disaster, primary care providers, such as general practitioners and pharmacists, play a vital role in supporting a health response. These providers are often on-the-ground as a disaster occurs, providing medical support as a trusted part of the community.  During the 2019‑2020 bushfires, local general practitioners and pharmacists supported patients and provided continuity of care when local health infrastructure had been disrupted.  Primary care providers also have a role in ongoing clinical care, as they remain within the community for years after a disaster, managing its ongoing health effects. 
15.52 There is often a significant surge in pressure on acute health services, such as hospitals, during a natural disaster.  Primary care providers play a role in alleviating this pressure by triaging and diagnosing patients and providing treatment, such as medical interventions and medications.  This helps prevent unnecessary presentations to hospital emergency departments and frees up resources for critical needs.
15.53 During the 2019‑2020 bushfires, some PHNs provided direct support to local primary care providers - facilitating information sharing, coordinating primary care volunteers and assessing local healthcare needs, providing governments with situational reports on the state of primary healthcare needs in bushfire-affected areas, and assisting with distribution of medical supplies, such as P2 masks. 
Not only were we NOT been engaged to respond to the primary care needs of evacuees, but our involvement was questioned, despite the fact that we were attending to problems well within our scope of practice and were all well recognised local health professionals appropriately credentialed and indemnified. 
15.54 However, primary care providers and PHNs are not systematically included in health emergency response and disaster management planning. The extent of their involvement is ad hoc and varies between local areas and jurisdictions,  including in related plans and training and exercising processes. This results in roles and responsibilities of primary healthcare providers and PHNs not being clearly defined and can impede the delivery of services during and in the aftermath of disasters.  We heard that some local general practitioners were unable to assist in evacuation centres, or were even actively excluded, in part, because they were not included in formal planning processes. 
15.55 In addition, we heard that there are limited jurisdiction-wide and national forums and other structures in place to facilitate the inclusion of primary healthcare providers and PHNs in disaster management processes.  This limits the provision of advice and primary healthcare perspectives to decision makers. 
15.56 We heard that primary care providers are progressively being integrated within disaster management systems at the local level, primarily through stronger linkages between PHNs and LHNs.  For example, in response to the challenges experienced in the 2019‑2020 bushfires, the Murrumbidgee Local Health District is updating its local emergency response plan to integrate the Murrumbidgee PHN and create a single recovery committee. 
15.57 We heard considerable support for a greater level of involvement of primary healthcare providers in disaster planning and response.  Some evidence suggests that PHNs should play a formal coordinating role in the disaster management context, on the basis that PHNs are said to be ideally placed to provide training, advice, and support to primary care providers, including by helping to identify and prioritise emerging issues during the recovery phase. 
15.58 Primary healthcare providers and PHNs can play an important role in supporting health responses during and following natural disasters. Primary healthcare providers and PHNs should be included in disaster planning processes at the local, state and territory and national levels, as appropriate.
15.59 We heard that one of the principal challenges of including primary care providers and PHNs is funding and resourcing.  Primary care providers are private businesses and may not have the financial capacity to be actively engaged in planning and preparedness activities.  However, we also heard that there is variability in the capacity of PHNs between jurisdictions and local areasy. 
15.60 PHNs are not funded by the Australian Government to undertake an emergency management role, although they have the flexibility to perform these functions.  Only a small proportion of PHNs have established disaster management plans. Victoria has specifically funded each of the six Victorian PHNs to maintain capacity to respond to emergency primary care requests, including participation in emergency planning.  The inclusion of primary healthcare providers in disaster responses is limited by the need for familiarity with emergency management arrangements  and varying capacities to ‘surge’ during a natural disaster.  We heard that this could be addressed through dedicated training and capacity building activities.  In addition, we heard of the importance of primary healthcare providers being specifically trained in emergency management structures and systems.  A strong understanding of emergency management command and control structures is vital for efficient tasking and use of resources, and for the safety of primary care volunteers and patients. 
15.61 The management of volunteer primary care practitioners is also a key element of incorporating primary healthcare in disaster responses. This includes identifying, and registering, a pool of primary care volunteers before a disaster. For example, we heard that having a register of suitably trained personnel in the Blue Mountains and Nepean areas, before the 2019‑2020 bushfires, ensured that general practitioners were appropriately and effectively deployed into evacuation centres. This register was developed and maintained by the Nepean Blue Mountains PHN and provided confidence that attending practitioners had the necessary familiarity with emergency arrangements and ensured greater safety and protection for staff. 
15.62 The use of PHNs in disaster management processes is limited by the variability in the existing capacity of PHNs across Australia.  The diversity of the primary health sector and a lack of a unified voice for primary care that can appropriately represent all local areas and contexts means that there is not a single solution to integrating primary care in disaster management systems. 
15.63 Australian, state and territory governments should encourage primary healthcare providers to undertake a formal role in disaster planning and response to natural disasters. This should include facilitating relevant training and education activities and arrangements to support primary healthcare providers who volunteer during natural disasters.
Recommendation 15.2 Inclusion of primary care in disaster management
Australian, state and territory governments should develop arrangements that facilitate greater inclusion of primary healthcare providers in disaster management, including: representation on relevant disaster committees and plans and providing training, education and other supports.
Access to healthcare and medications
15.64 Natural disasters can hamper the ability of communities to access healthcare and medications. The barriers which affect the provision of healthcare vary according to the specific disaster, but can include being unable to access prescriptions, physical isolation caused by road closures and damaged health facilities (such as pharmacies), loss of power, telecommunications and potable water, and evacuations of health and care facilities. 
15.65 Natural disasters can also exacerbate existing health disparities in local communities, particularly in regional, remote and isolated areas.  It is common for these areas to have shortages in specialised equipment and supplies, vulnerable supply chains, limited patient transport and evacuation capacity, and workforce shortages. 
15.66 The Australian, state and territory governments introduced a number of temporary measures to address the difficulties in accessing medications during the 2019‑2020 bushfires. To assist people who had lost their prescription or were unable to see a doctor,  the Australian Government temporarily expanded ‘continuing dispensing’ arrangements. Under the National Health (Continued Dispensing – Emergency Measures) Determination 2020,  pharmacists were able to give patients a one-off, standard quantity of an eligible PBS medicine, without a prescription.  Normally, under continued dispensing arrangements, only eligible oral contraceptives and lipid lowering medicines can be so supplied. 
15.67 The changes to continued dispensing arrangements were in addition to emergency supply provisions under state and territory legislation (Appendix 22: Health and mental health) and specific emergency public health orders made by some state and territory governments. Collectively, these provisions and public health orders allowed the supply of PBS and non‑PBS medications without a prescription under specific circumstances.
15.68 Further, to support access to medications during the 2019‑2020 bushfires, the Therapeutic Goods Administration (TGA) gave temporary permission (Therapeutic Goods (Restricted Representations - Salbutamol) Permission 2020) to advertise the availability of salbutamol inhalers (asthma medication).  This allowed for public health campaigns to remind people to bring their inhalers with them in the event of evacuation and to advertise the continued dispensing provisions for these medicines. The temporary permission also extended to activities conducted or facilitated by evacuation centres. 
15.69 In addition, given the TGA’s role in monitoring medicine shortages, it was able to reassure the public of the general availability of salbutamol inhalers, despite isolated and localised shortages, which helped to discourage stockpiling and over‑ordering. 
15.70 We heard that funding through the Medicare Benefits Schedule is one of the Australian Government’s ‘key levers’ to support access to healthcare and enable continuity of care.  On 10 January 2020, the Australian Government introduced a number of temporary Medicare items to enable mental health and wellbeing services to be delivered via telehealth to patients whose mental health was affected by the bushfires. In addition, from 17 January 2020, specific Medicare telehealth items were made available for psychological services, enabling bushfire-affected patients to access 10 Medicare‑eligible psychological therapy sessions without a referral from a medical practitioner.  These were extended to people subjected to further restrictions in areas impacted by the second wave of the COVID-19 pandemic in August 2020.  The number of Medicare-funded psychological services was doubled from 10 to 20 through the Better Access Initiative in the October 2020 Federal Budget, in recognising that the 2019–2020 bushfires and the COVID-19 pandemic have significantly affected the mental health and wellbeing of individuals, families and communities. 
15.71 In response to workforce shortages, the Australian Government also developed emergency protocols for Medicare Provider Numbers. A provider number is a unique identifier issued to eligible health professionals who participate in the Medicare Program. The Medicare Provider Number enables a health professional to bill, prescribe, refer or request services that are eligible for a Medicare benefit and is tied to a specific location. 
15.72 The emergency protocol allowed doctors and allied health workers to practise for up to two weeks in different bushfire-affected areas using their existing Medicare Provider Number. The protocol also included an online service to provide an immediate Medicare Provider Number for work beyond two weeks, and provided exemptions for restricted doctors (including locums) to allow relocated medical practices to offer Medicare-eligible services to communities. 
15.73 We heard support for these measures, which enabled access to healthcare and medications during the 2019‑2020 bushfires.  However, medical groups suggest that these systems should be established before a natural disaster, to allow for rapid activation and to be clearly communicated to health providers and the community. 
15.74 The Australian, state and territory governments should identify a set of measures which enable access to healthcare and continuous access to medications during and following any natural disaster and incorporate these into relevant plans.
Mental health and natural disasters
Mental health effects of natural disasters
15.75 There is compelling evidence of the impacts of natural disasters on mental health. Natural disasters give rise to increased rates of stress, depression, anxiety, post‑traumatic stress disorder (PTSD), alcohol and substance abuse, aggression and violence, suicide, and exacerbation of other underlying mental health problems.  Individuals may also experience somatic symptoms, disorders where a person has excessive or abnormal feelings or thoughts about physical conditions.  People can also suffer from insomnia and broken sleep. 
15.76 One study examining the impacts of the 2011 Brisbane floods found that those impacted by the floods were 1.9 times more likely to report psychological distress, 2.3 times more likely to report poor sleep quality, and 2.3 times more likely to have probable PTSD than the general population.  The 2011 Brisbane floods were also reported to be linked to increased alcohol and tobacco use. 
15.77 The mental health effects of natural disasters can also endure over an extended period and it may take time for symptoms to present. Following the 2009 Victorian bushfires, 21.9% of people in ‘high-impact communities’ were still reporting symptoms of mental health disorders five years later.  Over time, others reported delayed onset of mental health disorders. 
15.78 Geographical barriers, unsafe conditions and loss of essential services all arise after a disaster and can lead to significant delays in support, prolonging trauma and exacerbating emotional distress.  Long-term mental health is also linked to the practical challenges of rebuilding after a natural disaster, including experiences relating to housing, insurance and obtaining financial assistance. 
And I really worry about the kids: the kids who may have experienced the fire at its worst, the kids who, in some cases, their families have lost multiple homes and multiple properties. 
15.79 A number of vulnerable groups are particularly susceptible to mental health issues following natural disasters.  Children and young people are particularly susceptible to ongoing mental health effects – which can result in poorer educational outcomes and a loss of a sense of stability and safety.  The elderly are also vulnerable, particularly if they are dependent upon others for care and support.  We heard that there are mental health effects resulting from the exposure to bushfire smoke, particularly for those with underlying conditions, such as asthma. 
15.80 Natural disasters can also impact on the mental health of first responders. A range of psychological issues can arise from traumatic events, including anxiety, depression and PTSD.  Traumatic stress may also affect the ability to process information, perceive threats and may disrupt rational decision-making. 
15.81 Some studies have found that up to 39% of emergency responders have been diagnosed with a mental health condition in their life, compared to 20% of all adults in Australia.  These effects can also persist over an extended period – one follow‑up study of the 1983 Ash Wednesday bushfires found that a core group of firefighters reported psychiatric disturbance and PTSD symptoms seven years after the event.  These effects could potentially extend to the loved ones of those responding to natural disasters. 
Delivery of mental health services
Arrangements for the delivery of mental health services
15.82 The 2019‑2020 bushfires highlighted both challenges and good practice in the delivery of effective and coordinated mental health services. Mental health issues following a disaster can go unidentified and consequently untreated  – mental health conditions can take time to emerge  and affected individuals, especially during the early stages of a disaster, may initially present with physical symptoms that mask psychological symptoms.  Those who do receive treatment may face chronic and relapsing conditions. 
15.83 The psychological effect of natural disasters on communities and those responding to a disaster can be widespread and enduring. In recognition of these effects, state and territory governments facilitate the delivery of mental health services to the community and those responding to natural disasters – in-line with broader arrangements for managing the health response for a major incident.  Most state and territory governments have specific sub‑plans (see Appendix 22: Health and mental health) with a mental health focus  while others rely on existing protocols. 
15.84 The effective integration of mental health response is an essential part of disaster planning and ensures a proactive response to the short, medium and long‑term mental health effects following natural disasters.  We heard that there is ‘often a tendency to want to respond acutely to deal with the mental health trauma of the event itself’, but that ‘the more pervasive problem is the long-term impacts’, and particularly when there are ‘cumulative natural disasters’ it is important to focus on ‘more than just the acute response’. 
15.85 At a national level, as part of the response to the 2019‑2020 bushfires, the Australian Government funded the National Mental Health Commission to develop a National Natural Disaster Mental Health Framework.  This framework, being developed cooperatively with state and territory governments, is intended to improve mental health and wellbeing coordination arrangements and allow governments to foster and enable participative, localised responses following natural disasters. 
15.86 Specific frameworks and sub‑plans, if implemented, can reduce the likelihood of ad‑hoc and uncoordinated mental health responses to a natural disaster (when supported by organisational processes that enable the use of institutional knowledge and incorporation of lessons from prior disasters). 
15.87 All state and territory governments should develop and implement plans or policies to guide the delivery of mental health services during and after an emergency incident, such as a natural disaster. This could build on the National Natural Disaster Mental Health Framework, once completed.
15.88 We were informed that states are considering the lessons identified during the 2019‑2020 bushfire response as part of reviews of their public health emergency plans.  Consideration should be given to establishing mechanisms for sharing identified lessons nationally. 
Locally based services
15.89 It is important that a diversity of services, programs and delivery models be available to the community. We heard of the importance of early, appropriate and culturally informed mental health support for disaster-affected individuals.  Early intervention can help to prevent relatively minor mental health issues, such as sleep disturbances, from becoming chronic or severe. 
15.90 Local and community support can alleviate some of the stressors common in the aftermath of natural disasters. One of the strongest predictors of positive mental health outcomes is social ties. Family members are generally seen to be the main source of mental health support, and involvement in local community groups and organisations tend to be associated with more positive mental health outcomes. 
15.91 Mental health services should be delivered and driven locally, with a key focus being the delivery of mental health through primary and community care.  Similar to broader health responses, primary care providers have strong connections with local communities and are trusted by their patients  – although primary care providers need to have appropriate training in trauma informed care, in order to provide meaningful mental health support.  We heard that the introduction of alternative services and centralised solutions can undermine continuity of care.  In addition, we heard that the introduction of new services into communities and later withdrawal of those services, once funding expires, can leave service gaps in the community at times when people may still be recovering and needing mental health support. 
15.92 Additional support should be provided to disaster-affected areas by augmenting existing and well established services. This maximises community trust in, and engagement with, services and maintains long-term continuity of care.  In order for this to be effective, it is important to understand the range of mental health services and programs available in a local area before a disaster – this includes identifying capacity and resourcing constraints  and pre‑planning at the local level, incorporating a broad cross-section of service providers.
15.93 Due to the scale and impacts of natural disasters, it is common for local communities to be inundated with offers of mental health support from a variety of agencies and organisations outside the local area. While an increase in these services can be positive it can also create a challenging and complex system of support for the community to navigate.  It can also result in a lack of clarity about the role and scope of the different organisations and understanding of how they work together and who to contact for the right level of support.  We heard that some state and territory governments adopted formal coordination mechanisms to ensure a clear system of mental health and wellbeing support, with clear referrals and localised partnerships.
15.94 For example, the SA Government used its Local Recovery Coordinators and established the Bushfire Recovery Mental Health Multi-agency Coordination Group to enable the coordination of resources and referral pathways.  Their clinical mental health support teams also conducted shared clinical team meetings with Primary Mental Health Providers (funded by Country SA PHN) to collaborate on triaging new referrals and support transition of care to higher or lower levels of support.  Similarly, during the 2019‑2020 bushfires, the Victorian Government created a Wellbeing Coordinator within their State Control Centre. The role aimed to better coordinate wellbeing services on-the-ground during an emergency response. 
15.95 Pre‑planning at the local level and establishing coordination mechanisms is important for the delivery of mental health support. These mechanisms should include local providers and build local partnerships and establish referral pathways before a disaster.
15.96 The provision of mental health services also needs to be evidence‑based. We heard concerns that some mental health interventions used following natural disasters, such as psychological debriefing services, have limited evidence of efficacy and in some cases may cause harm. 
15.97 We also heard of the value of specialist clinical mental health support teams in providing advice and support on trauma assessment and needs identification, and planning referral pathways and bridging the gaps across mental health services. 
15.98 However, we also heard that there were some challenges in the assessment and referral processes for clinical support. For example, we heard of instances where individuals providing support and assistance to members of the community in evacuation centres incorrectly perceived distress suffered by community members as requiring mental health service intervention. On occasions, these misunderstandings resulted in unnecessary allocation of clinical mental health support.  Additional training to primary care providers would support those providing services to have the resources and skills to meet the increased mental health demands following a disaster,  including a stronger understanding of assessment processes.
15.99 We heard of the importance of ensuring that mental health support services are culturally informed and tailored to particular groups. For example, school based disaster resilience programs can help young people manage the mental health impacts of a disaster, particularly for high-risk students.  These programs are focused on social, emotional, learning and vocational support for children and teenagers and may mitigate disaster-related mental health impacts, such as poorer academic outcomes. 
15.100 Any recovery framework should include mental health support for emergency responders, including volunteers, as well as workforce training on the impact of trauma and recovery processes for these professions.  Employed emergency responders are generally able to access the same mental health services that are available to the community, including during a natural disaster, and workplace specific supports (provided by their respective emergency services organisation).  However, appropriate systems need to be in place to monitor their mental health and wellbeing effectively and to ensure that they get help when needed.  Appropriate support for volunteers should also be considered.
15.101 Australian, state, and territory governments should work together to ensure that mental health responses are appropriate for addressing the impacts of natural disasters. This should include consideration of localised support that is augmented by additional external services as necessary, provision of appropriate training to providers, ensuring appropriate and timely mental health services which are supported by appropriate assessment and referral processes. The delivery of these services should extend over a number of years.
15.102 In response to the 2019‑2020 bushfires, Australian, state and territory governments funded specific initiatives to address impacts on mental health – see Appendix 22: Health and mental health. This investment in mental health initiatives was in addition to standing programs and was aimed at supporting affected communities and emergency services. However, there is scope for greater national coordination in these programs.
15.103 A number of state and territory governments use the Disaster Recovery Funding Arrangements to provide financial support for the deployment of clinical mental health support teams – see Chapter 22: Delivery of recovery services and financial assistance. For example, the Queensland Government has established Mental Health Disaster Recovery Teams under Category C of the Disaster Recovery Funding Arrangements. These teams comprise clinicians and peer workers who deliver a stepped care model of practice with impacted communities. This includes community engagement, training and capacity building with other frontline agencies, and provision of specialist mental health care for people impacted by the natural disaster.  Similarly, during the 2019‑2020 bushfires, NSW used the Disaster Recovery Funding Arrangements to deploy 34 mental health clinicians across all bushfire-impacted local government areas. 
15.104 State and territory governments have also funded various mental health support initiatives, focused on building local capacity and community resilience. We received particularly detailed insight from Victoria. The Victorian Government is providing $23.4 million for the Community Resilience, Psychosocial and Mental Health Response. This program is intended to build capacity of local services and enable multiple entry points and seamless referral pathways to specialist support where required. It will also fund specific training and outreach to enhance local screening and assessment capabilities and will allow local community groups to access funds and resources to support local events, projects and activities that will help to bring community members together after the 2019‑2020 bushfires. 
15.105 Australian, state and territory governments should establish pre‑agreed recovery programs under the Disaster Recovery Funding Arrangements that focus on the delivery of mental health services.
15.106 To support mental health needs of emergency responders, the Australian Government, as part of its Mental Health Bushfire Response Package, has allocated approximately $4.5 million to develop a national emergency services mental health literacy network and a national action plan. The mental health literacy network is intended to support emergency responders and their families, to promote early identification and intervention, and is expected to be finalised by 30 June 2021. The national action plan is intended to improve mental health outcomes for emergency service workers and is expected to be finalised by 30 June 2022. 
15.107 State and territory governments are also developing specific support services for the mental health and wellbeing of emergency responders. The Victorian Government has commenced the Provisional Payments Pilot, which allows eligible emergency responders to access payments for medical treatment and services for a mental injury while their compensation claim is being determined. 
Recommendation 15.3 Prioritising mental health during and after natural disasters
Australian, state and territory governments should refine arrangements to support localised planning and the delivery of appropriate mental health services following a natural disaster.
Health and environmental outcomes data
15.108 The effective use of data is important in improving health outcomes associated with natural disasters. Health research and data linkages play an important role in identifying the health risks of a natural disaster.  For example, enhancing the collection and use of environmental and health data linked with natural disasters would provide a better understanding of health impacts, enable the design of health interventions  and enable evaluation and comparison of events.  However, we heard of the limited use of primary healthcare data for research and that health data collected across the health system could be better linked.  Data collected by general practice are an important resource for research into the impacts of natural disasters.  Effective use of data is also essential for healthcare planning, resource allocation and health systems resilience. 
15.109 To enhance the collection and use of such information, there is a need for standards to guide the collection, storage and exchange of relevant data.  These datasets could be underpinned by standardised definitions, clinical coding protocols and collection methods to ensure that data are consistently and accurately recorded across acute (hospital admissions and emergency department) and primary (general practice and other primary care services) care. 
15.110 In addition to consistent datasets, it is important that a robust model be developed for sharing data. This model should be underpinned by national data sharing across all phases of a disaster and a strong data security framework.  Australian, state and territory governments broadly support the development of consistent metrics, and the sharing of health related data. 
15.111 We recognise that the development of consistent datasets and any data sharing framework, will be challenging and will take time. It is important for development to occur collaboratively between the Australian, state and territory governments.
Recommendation 15.4 Enhance health and mental health datasets
Australian, state and territory governments should agree to:
- develop consistent and compatible methods and metrics to measure health impacts related to natural disasters, including mental health, and
- take steps to ensure the appropriate sharing of health and mental health datasets.
Figure 62: Local doctor in Cobargo, NSW, provides primary healthcare services in a motorhome after his practice was destroyed by the 2019‑2020 bushfires 
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