BNPHN Header 22 23

Year in review 2022-23

Our values in action: Brisbane North PHN's Year in Review brings together highlights from this past 12 months’ work.

CEO background 2

A message from our CEO and Chair

On delivering the best possible health and community care system for the people of North Brisbane and Moreton Bay through strong partnerships with our stakeholders and community.


Libby Dunstan

After two years coloured by the COVID-19 pandemic, in 2022-23 Brisbane North PHN turned our attention to getting back to business.

Our work, as always is underpinned by the strong partnerships we share with our valued stakeholders and our community. From state and federal health departments, Metro North Health and IUIH as well as our commissioned service providers – through our shared vision of co-creating the best possible health care system for the people in our region, we have another year of improved outcomes and milestones to celebrate.

The Health Alliance represents our key strategic partnership with Metro North Health, and our joint commitment to tackling systemic barriers to provide an integrated system of care that delivers quality health outcomes closer to home. This year's success of the Care Collective – Caboolture and ongoing work to develop a healthcare neighbourhood framework continue to demonstrate the impact that this shared model of care can have for our region.

Through our Mental Health, Alcohol and Other Drugs (MHAOD) portfolio, the PHN continues to improve mental health outcomes for our communities through best practice regional planning and the commissioning of support services. A key highlight occurred last September, when the Brisbane North Safe Space Network was officially launched by Assistant Minister for Mental Health and Suicide Prevention and Assistant Minister for Rural and Regional Health, the Honourable Emma McBride MP.

We have continued to fund crucial access to enhanced primary care and coordination services for priority communities. Residents of Bribie Island received much needed bulk-billed after-hours primary healthcare with the launch of an after-hours pilot at Bribie Doctors Banksia Beach. Women’s health was boosted with funding for two targeted Endometriosis and Pelvic Pain (EPP) GP Clinics – including a dedicated Aboriginal and Torres Strait Islander clinic. The care finder program launched with six local organisations commissioned to manage a workforce to provide intensive, face-to-face support to help older Australians with complex needs to navigate and access aged care services.

I commend Dr Jennifer Schafer for the work she has done in her first six months as Board Chair. Jennifer’s 35 years’ experience as a general practitioner, medical educator, leader and advocate has already proven invaluable to the PHN. I echo her sentiments in thanking and farewelling Dr Anita Green, and congratulating her on a tenure that we hope has been as rewarding for her as it has been profound for the PHN and our community.

To be celebrated also are the successes of our Brisbane North PHN staff and program teams – it is their hard work and dedication which underpin the work we do in, with and for our communities.

In our 2022-23 Year in Review we are proud to reflect on the numerous ways that our values – collaboration, courage, impact, integrity and diversity – have been put into action to deliver the best possible health and community care system for the people of our region.


Dr Jennifer Schafer

As one of 31 Primary Health Networks across Australia, Brisbane North PHN has an important role to play in supporting the people within our region to live healthy lives, as long as possible, with care available close to home.

Earlier this year the Strengthening Medicare Taskforce report was delivered to provide a roadmap for primary care reform. As its recommendations begin to be enacted nationally, as an organisation we continue to put patient-centred care at the heart of what we do. We supported general practice to enhance patient management at the point of care with the implementation of Primary Sense, to access grants to foster innovative practice and enhanced service delivery, and to manage the transition to voluntary patient enrolment through the new MyMedicare model of care.

With health system reform squarely on the agenda, internally we begin to turn our attention to revisiting and refreshing our Strategic Plan, laying the groundwork to bring a new iteration to fruition in 2024.

We continued to reaffirm our commitment to reconciliation and building an inclusive and culturally safe healthcare system by adopting a fifth domain into our local PHN Performance Framework: health equity. In our vision of a community where good health is available to everyone, our active role in continuing to implement the joint regional Health Equity Strategy is important work in empowering First Nations people to attain their full health potential.

On behalf of the Board and the PHN, I extend my thanks and bestow our collective best wishes upon long-standing Board Member, Dr Anita Green, who departs after 11 years of service to Brisbane North PHN as a Director, inclusive of six as our Board Chair. The conviction with which Anita has offered her clinical expertise and guidance for more than a decade has left an indelible mark on the PHN, our community and Australian primary care.

Our heartfelt thanks also goes to Libby Dunstan and the Brisbane North PHN team who continue to strive for excellence in the work that they do ensuring better health outcomes for the people of North Brisbane and Moreton Bay.

As always, this work has been collaborative and we extend our thanks and gratitude to our clinicians and primary care teams, service providers, allied organisations and other stakeholders for their dedication and continued partnership in building the best possible health and community care system for our region.

2023 stats bg 4

Year in numbers

Working with others to create and deliver the best possible health and community care system.


practices transitioned to Primary Sense – a clinical decision support tool provided for free to practices in our region.


North Brisbane and Moreton Bay general practices supported.


Comprehensive Activity Plans delivered to improve health outcomes in our community.


events attended by over 4000 stakeholders and participants.


clients supported across 17, 872 interactions through our Team Care Coordination program.


new localised HealthPathways published.


per cent reduction in ED presentations to Caboolture Hospital attributed to the Care Collective – Caboolture.


highly vulnerable older people provided with care finder and service navigation support.


Commonwealth Home Support Programme outputs delivered to 9,059 clients. One output equates to one hour of service or one transport trip.

Milestone bg

Towards better health outcomes – key milestones



My Mental Health Service Navigators join the national Head to Health network.


Mental health hubs deliver improved outcomes.


Safe Space Network launches in North Brisbane and Moreton Bay.


GP Workforce Prioritisation and Planning program begins work.


After-hours GP services launched for Bribie Island community.


South East Queensland First Nations Equity conference, attended by Brisbane North PHN CEO Libby Dunstan, is convened.


Board welcomes new chair and board director to AGM.


Language guide to address ageism in aged care is published.


Palliative Care in Community Pharmacy Action Plan, co-designed to build capacity and capability of community pharmacists in supporting palliative care, is launched.



Planning for Wellbeing forum brings mental health, suicide prevention and alcohol and other drugs stakeholders together.


Funding granted to deliver specialised care for women at two endometriosis and pelvic pain (EPP) clinics.


Brisbane North PHN launches PHN Talk blog.


First Metro North Health Forum and GP breakfast briefing is held post-pandemic.


Success of the Care Collective – Caboolture sees its regional expansion.


Palliative Care Evening for Primary Care is held, with 68 per cent of health professionals intending to make changes to their clinical practice in response to attending. 95 per cent of respondent attendees would recommend the event to colleagues.


Publications review to improve communication with our key GP stakeholders is completed.


Primary Sense transition for 232 practices is successfully completed.


Norfolk Island Health Needs Assessment is completed.

Story bg

Courage and impact – delivering outcomes and leading new approaches in our community

Courageous and impactful stories from the programs we commission across the North Brisbane and Moreton Bay region.

Integrity and collaboration – working together, to the highest standards 

Highlighting the success of our program teams and the work they do in and for our community. 

TCC Standard with transparency 2019 02

Team Care Coordination

  • 2,601 referrals received, representing a 20 per cent increase (compared to previous year) in referrals received. Leading reasons for referral included falls or frailty, COPD, cardiovascular disease, dementia, osteoarthritis and diabetes.
  • 1,604 clients supported.
  • 17,872 client interactions – 3,652 more than last financial year.
  • 81 per cent of clients had their goals fully met.
  • 98 per cent clients rated the quality of the service as very good or good.

Regional Assessment Service

  • 6,455 referrals accepted and actioned. Assessors noted increasing complexity of clients’ needs.
  • Clients indicated over 98 per cent satisfied or very satisfied with quality of service.
  • Completed 281 Integrated Assessments (IAT) trailing the new IAT Tool for the proposed Single Assessment Service.
PHN Talk Logo 002
RAP artwork
  • Launch of PHN Talk blog with 12 good news stories, to increase the visibility of the work of our project teams across the organisation and to stakeholders.   
  • Conducted and finalised a six-month consultation and review of our publications resulting in more targeted, fit-for-purpose communication to GPs.  
  • Refreshed Brisbane North PHN's brand identity, incorporating visual elements from our RAP artwork, Flowing Knowledge, Healing Country. 
  • Relaunched the Metro North Health Forum, jointly hosted with Metro North Health.  
  • 24 Network Link publications sent fortnightly to over 2500 health professionals.  
  • 16 Practice Link publications sent to over 525 practice managers, nurses and staff each month.  
  • Partners in Health publications providing regular updates to over 1,300 PHN stakeholders, partners and allied organisations. 
  • Commenced review of our Strategic Plan.
  • New contract management system Folio implemented to streamline contracts processes and create greater efficiencies across our organisation and for providers.
  • Successful audit outcomes for Aged Care Standards, ISO9001 and 27001.
Aged Care Forum Oct 2022
Aged Care Forum Oct 2022 2
  • Commonwealth Home Support Program delivered 156,158 outputs (one output equates to one hour of service or one transport trip) to 9,059 clients, 18 per cent of whom identified as Aboriginal and/or Torres Strait Islander.
  • Care finder program launched with six local organisations. Care finder support to navigate the aged care system is provided to 220 highly vulnerable people.
  • Intergenerational program co-designed in four locations by three service providers, including one First Nations specific program.
  • CarFreeMe driving cessation program started across the North Brisbane and Moreton Bay region for culturally and linguistically diverse communities.
  • $777,400 (96 per cent) of telehealth grant funding provided to 85 per cent of residential aged care services.
  • An action plan to improve access to at-home palliative care for people with disability was created following consultation with 52 stakeholders including consumers, carers and professionals from health and disability sector.
  • 44 per cent of Residential Aged Care Homes in the North Brisbane and Moreton Bay region have had a support visit from the Out of Hours team to provide assistance and guidance in developing documented After-Hours Action Plans.
MNHF Forum crowd May 2023 2
  • Commissioning Collaborative convened.
  • First patients admitted by GPs to First Nations Integrated Hospital in the Home program.
  • The Care Collective – Caboolture reaches 12-month milestone with evaluation showing a 75 per cent reduction in ED presentations and a 48 per cent decrease in clients with greater than one ED presentation per month – an average saving to the health system of $311,488 per month. The program's success will see its expansion to Redcliffe next financial year.
Medicare Urgent Care Clinic Logo RGB
  • After Hours Health Needs Assessment undertaken and delivered.
  • Provided support to the Morayfield Minor Accident and Illness Centre.
  • Social Prescribing program co-designed and commenced in Caboolture and Kilcoy hospital catchments jointly undertaken with the Healthy Ageing program team.
  • 24 new localised HealthPathways published.
  • Funding secured to deliver two new Medicare Urgent Care Clinics (UCCs) – one in the vicinity of the Redcliffe Hospital, one in the vicinity of The Prince Charles Hospital.
  • 79 commissioned programs delivered.
  • Norfolk Island Health Needs Assessment submitted in conjunction with the Priority Communities program team.
  • Population health snapshot, including a dedicated women's health snapshot, launched.
  • Development of a roadmap for the Primary Health Insights conference.
  • Annual Practitioner Survey conducted.
BNPHN 230209 002
SS group photo

Mental Health Lived Experience Engagement Network (MHLEEN)

  • 100 per cent of PHNs represented on the National PHN MHLEEN network.
  • Average of 65 per cent attendance rate at monthly meetings, a 15 per cent increase from last financial year.
  • Representation from 72 per cent of PHNs at the annual MHLEEN forum, 50 per cent of attendees who were people with a lived experience.

Under the National Mental Health Consumer and Carer Forum (NMHCCF) Queensland partnership:

Alcohol and other drugs

  • Alcohol and other drugs services delivered to 142 individuals including 20 who identify as Aboriginal and/or Torres Strait Islander, across 2838 occasions of service. 96 per cent reported satisfaction with services.
  • The data for this period shows an increase in the number of referrals received, which is reflective of the work being done within the MHAOD program team to increase our direct referrals.
Bribie After Hours Dr Innocent Terry Dr Vaid Dr M Libby cropped
Bribie After Hours
  • Support given to 342 general practices in our region.
  • 232 general practices transitioned to Primary Sense.
  • Funding granted from the Department of Health and Aged Care for two endometriosis and pelvic pain (EPP) clinics.
  • 295 grant payments delivered to practices under the Strengthening Medicare General Practice Grants program.
  • Provided general practice support to the Norfolk Island Health and Residential Aged Care Service.
  • 20 training sessions offered to general practice to support GP capacity building for after-hours education.
  • Commenced the Bribie Island After-Hours Pilot Project. From October 2022 to June 2023, 740 patients presented to the service between the hours of 6.00 pm and 10.00 pm Monday to Wednesday, including 32 Aboriginal and Torres Strait Islander patients.
PHN Staff Collaborating image
IMG 4244

Brisbane North PHN transitioned from having a Human Resources (HR) function to having a more holistic People and Culture function in February 2023. Since this transition:

  • 52 recruitments on ELMO (including those where we had to recruit more than once), thanks to the finalisation of ELMO Recruitment implementation.
  • recruitment undertaken for 65 roles – this includes where we had to recruit more than once and non-ELMO internal moves, direct recruitment from sector groups.
  • 111 new contracts issued in April as we changed from maximum term to permanent contracts for all relevant roles.
  • supported 45 new starters through the induction process.
  • a review of our internal Vaccination Policy led to removing mandatory vaccination as a requirement for most roles, resulting in better recruitment opportunities.
  • Family Domestic Violence Leave Policy updated to better support our people.
  • Psychosocial safety training for leaders and staff as part of the implementation of new Psychosocial Safety legislation.
  • team expansion to have a full-time People and Culture Coordinator (replacing a part-time HR advisor) and now includes Office Management and Workplace Health and Safety.
  • Reward and Recognition Policy went live via ELMO with first awards presented at all staff development day in May.
  • Leadership Lunchbox Series – a short, targeted, monthly development opportunity – implemented for all people in leadership roles.
  • Leadership Community of Practice development opportunity around all operational matters implemented monthly.
  • paid parental leave implemented – with one team member already enjoying paid leave and another two team members soon to realise this new initiative.
  • standardised, transparent salary benchmarking implemented to support staff in understanding their role and assist with quality candidate recruitment.
  • Engagement Survey conducted to enable our people to be heard.

Currently underway is the development of a People and Culture Strategy to support the refreshed Organisation Strategy.

WPP QLD WG Meeting 2 240123
  • Launch of the GP Workforce Planning and Prioritisation (GP WPP) program, with Brisbane North PHN as the Lead Agency for the Queensland PHN Consortium comprised of all seven Queensland PHNs.
  • Submission of the first Workforce Needs and Training Capacity Report for Queensland, providing independent planning and prioritisation advice to inform the distribution and placement of Registrars training on the AGPT program across the states 164 GP Catchments within seven PHN regions.
BN PHN RAP Artwork 1

Health equity and diversity – our commitment

Underpinning Brisbane North PHN’s commitment to improving health outcomes for our community is our Performance Framework – a set of organisational competencies and performance domains that allow us to remain an accountable and high performing organisation. 

In line with global healthcare industry thought leadership and best practice, the PHN has adopted a fifth domain into our local PHN Performance Framework to form the Quintuple Aim: health equity.

Cta bg

Download a printable copy of the 2022-23 Year in Review.