Year in Review 2024-25

Supporting Greater Brisbane to FindCareFast

In partnership with Brisbane South PHN, we launched service navigation website FindCareFast to support health service consumers across Greater Brisbane access their closest available provider in times of need. Over 40,000 users accessed “healthcare options at their fingertips”, taking more than 132,000 actions to find an appropriate care pathway across the site.

Visit FindCareFast.

Spanning the gap between distance and time to care

The Specialist Pain Assistance Network (SPAN) program supported 120 patients to access care an average of 489 days sooner (reducing time to care from 510 days to just 21), and up to 600 kilometres closer to home. SPAN provides community-based pain management services for lower acuity patients in partnership with the Tess Crammond Pain and Research Centre at Metro North Health.

See SPAN’s impact below.

Collecting health system savings

The Care Collective, a Health Alliance initiative, continues to deliver health system savings and improved health outcomes for patients who are chronically ill or who have complex health conditions. The program enables general practices in Caboolture and Redcliffe to employ Complex Care Coordinators to support people who are likely to be frequent presenters to Emergency Departments (EDs). This year, it secured a 24 per cent reduction in hospital admissions for 885 of these patients – saving the health system an average $302,301 per month and delivering up to 406 per cent return on investment.

Read the Care Collective Final Evaluation.

Care Coordination reduces ED presentations

Over 3,000 referrals were made to the Team Care Coordination’s (TCC) program holistically this year. For the 1,910 clients who worked with the program, ED presentations reduced by 44.2 per cent and unplanned hospital admissions reduced by 46.2 per cent, saving the health system up to $8.77 million.

TCC’s Steady Steppers Program Pilot supported 21 patients who have had a fall to build the confidence and strength to get back on their feet and take strides towards improving their quality of life. The program combines education and a basic exercise regime to build client capacity and help them to remain in their own home.

Enabling better aged and palliative care

Through the provision of dedicated business process support, our Healthy Ageing team enabled telehealth services in Residential Aged Care Homes (RACHs).

We launched a housing and homelessness guide to help our care finders to support vulnerable and vulnerably housed older people.

Our General Practice in Aged Care Initiative (GPACI) team, a collaboration between Health Ageing and Primary Care, led work with GPs, general practice managers, RACHs and Metro North Health to co-design an action plan to improve access to primary care for people living in RACHs.

Via the Palliative Care for Community Pharmacists Project, we upskilled community pharmacists in palliative care. As a result, we increased the number of palliative-friendly pharmacies across our region.

Accessing care closer to home for Norfolk Island residents

Norfolk Island Health and Residential Aged Care Services deliver programs and services on island, allowing residents to receive and access care closer to home. The Health and Wellbeing Team continue to deliver tailored health promotion initiatives across the lifespan including early childhood development programs, social prescribing, health literacy activities and coordination of the annual Norfolk Island Health and Wellbeing Expo.

This year 60 people, across 206 service contacts, accessed the child and youth psychology service both via telehealth and on island. In addition, the PHN successfully secured additional funding for next financial year.

Enhancing our approach to mental health, alcohol and other drugs and suicide prevention

Building on the strong foundations of the previous joint regional plan, Planning for Wellbeing, the development of Our Approach to Wellbeing (2025–2030) has been a deeply collaborative effort, led by Brisbane North PHN and Metro North Health. Informed by the voices of hundreds across the region, the process has evolved beyond a traditional plan into a more adaptive, action-oriented regional approach. With a shared vision of improving mental health and wellbeing outcomes for our community, Our Approach to Wellbeing has been shaped through co-design and is set to launch and begin implementation in the next financial year.

Building a more inclusive and fair healthcare system

To guide our work, we were proud to this year launch our Equity and Access Framework, a pivotal step towards building a more inclusive and fair healthcare system in our region. The embedding of this Framework into our core business reflects our PHN’s strong commitment to health equity.

Download our Equity and Access Framework.

Partnering to enhance early learning outcomes

In continued efforts to improve health outcomes and target developmental delay for the youngest members of our community, the PHN partnered with the Institute for Urban Indigenous Health (IUIH) and Youthrive to deliver a school readiness program in Caboolture and Redcliffe, boosting school readiness by 70 per cent for participating children.

Deadly mental health services for First Nations youth

An innovative First Nations focused mental health service was announced for Moreton Bay – Staying Deadly | headspace Deception Bay is the first to be specifically established to provide culturally safe support, care and connection for Aboriginal and Torres Strait Islander young people, and their families and kin.

Partnering to improve primary care access

Brisbane North PHN and Brisbane South PHN have jointly commissioned IUIH to extend primary care services in-clinics and virtually via Mob Link in the after-hours period to better meet the growing needs of our First Nations communities in the Greater Brisbane region.

8,008 additional appointments were delivered to Aboriginal and Torres Strait Islander patients, with 5,797 new appointments accessed directly through Mob Link.

Specialised mental health services for our priority communities

Brisbane Youth Service’s (BYS) Specialised Mental Health Service offers dedicated support for young people aged 12 to 25, some with children, who are at risk or experiencing homelessness. This critical stop gap will work to address the significant barriers young people across our region are facing in accessing affordable mental healthcare, by enabling free and immediate access to diagnostics and support.

Read more about BYS’s impact.

Trans Femme programs commenced via Open Doors, an organisation that supports young people with diverse genders, bodies and sexualities and their families. The program assisted 296 young people in accessing safe, inclusive pathways to specialist mental health services and community support - often delivered by skilled team members with lived experience.

Prescribing connection to tackle social determinants of health

We continued tackling the social determinants of health for vulnerable adults via the expansion of Social Health Connect (SHC), our social prescribing partnership with Footprints Community, to include the Redcliffe catchment. SHC supported 139 clients with services to address social issues affecting their wellbeing, including isolation and loneliness, transport difficulties, or housing and financial insecurities. Each client received an average of 15.5 service contacts with their Link Worker, leading to a statistically significant improvement in their physical, psychological and social health, and overall quality of life. 100 per cent of clients reported a positive (excellent or very good) experience of care.

Enhancing access to specialist care models for women

Our Endometriosis and Pelvic Pain Clinics improved access for over 600 patients to diagnostic, treatment and referral services for endometriosis and pelvic pain, including culturally appropriate care for 77 First Nations women. 95 per cent of patients rated their experience of care from their provider as excellent or very good.

Assessing the needs of our shared communities

Our triennial Health Needs Assessment (HNA) was delivered for the first time in partnership with Metro North Health as a Joint Regional Needs Assessment to set priorities, address service gaps and highlight opportunities for improving overall population health for our shared region for 2025-2027 and beyond.

This financial year we completed targeted Health Needs Assessments (HNA) to discover opportunities to support the most vulnerable people across our region, including:

• a supplementary HNA for care finder services in the Kilcoy region
• a HNA for people experiencing homelessness, providing critical insights into the shifting demographics and unmet needs of people at risk of, or experiencing, homelessness across the region.

Access our Health Needs Assessments.

Embedding lived and living experience

In partnership with Lived Experience Australia and lived and living experience (LLE) representatives, we pioneered a Lived and Living Experience Lifecycle Kit for future use across PHNs nationally – work which began as a quality improvement (QI) initiative in response to feedback from LLE representatives during the latest mental health, alcohol and other drugs (MHAOD) regional planning cycle, but has and will now expand beyond this sector and across all areas of our PHN’s work.

Read Ben’s story.

MHLEEN – closing the chapter, continuing the impact

Since 2018, the Mental Health and Lived Experience Engagement Network (MHLEEN) has played a pivotal role in supporting PHNs to embed lived-living experience (LLE) expertise into mental health service planning and delivery. With the announcement of the new national consumer and carer peak bodies, MHLEEN concluded in June 2025. The legacy of MHLEEN will be a final suite of best practice tools and resources to support PHNs in continuing to embed LLE principles, coordinated by our colleagues at North West Victoria PHN.

Consumer insights improving care coordination

Team Care Coordination established a Consumer Advisory Body to drive ongoing quality improvements based on increased consumer participation and feedback – including introduction of the Consumer Newsletter, provision of oversight of Steady Steppers program, developing consumer information sheets and other QI initiatives.

Delivering care when it’s urgent, but not an emergency

We have continued to support Northside (Kedron) Medicare Urgent Care Clinic (UCC), Murrumba Downs Medicare UCC, and the transition of Morayfield Minor Accident and Illness Centre to become a third Medicare UCC for our region. All three Medicare UCCs continued to deliver timely urgent care in the community, with 62,264 episodes of care delivered across our region across the year. Between 20 per cent and 63 per cent of patients reported they would otherwise have gone to an emergency department.

Enhancing Practice Support

We continue to support practices and clinicians across our region via our Primary Care Engagement Officers and Practice Support website. More than 200,000 actions have been recorded across 50,000 visits to the Practice Support website this year, including the download of 10,000 general practice focused resources and documents, demonstrating that the site is fulfilling a crucial support function for our practices.

Visit Practice Support.

Delivering health equity, one vaccine clinic at a time

Together with QuIHN, we delivered 453 free influenza, COVID-19 and essential National Immunisation Program (NIP) vaccines to 280 patients across a series of five clinics in Kilcoy, Woodford and Wamuran – these communities, where rurality limits access to healthcare, are some of our most vulnerable, with the lowest levels of vaccine coverage.

Read more about the impact for these communities.

Collaborative continuous quality improvement (CQI) success

Concerted and collaborative strides have been made to successfully increase cervical and bowel cancer screening rates across our region. With support from the Primary Care team and Queensland Health’s Cancer Screening Unit, 54 general practices successfully enhanced their use of the National Cancer Screening Register (NCSR), improved awareness and uptake of bowel cancer screening for their patients, and promoted both clinician- and self-collected cervical screening.

Across 294 activities focusing on enhanced cultural awareness and competence, 65 general practices successfully completed a Multicultural Access Program funded CQI project designed to improve the health outcomes of multicultural patients in their communities.

In addition, 28 general practices completed CQI activities to support clients with diabetes and 60 practices participated in CQI activities to increase vaccinations for COVID-19, influenza and pneumovax.

Supporting general practices and GPs with health reform readiness

With the introduction of voluntary patient registration under MyMedicare, and accompanying new Medicare Benefits Schedule (MBS) items to support Chronic Condition Management and bulk billing incentives for practices and patients, we have supported general practices and GPs to be aware and ready for the changes. This has included providing information on our Practice Support website, delivering webinars, and launching a monthly MyMedicare Bulletin. 264 general practices across our region registered for MyMedicare, with 118 registering for the General Practice in Aged Care Incentive (GPACI) initiative.

We deepened our understanding of utilisation of the Workforce Incentive Program – Practice Stream funding and multidisciplinary team-based (MDT) care models across our region to support future opportunities for delivery of more integrated and patient-centred primary care.

Support when disaster strikes

During Tropical Cyclone Alfred, our PHN played a pivotal role in supporting continuity of primary healthcare through active involvement in local disaster management arrangements. By working with our partners at Metro North Health (MNH) we ensured a coordinated primary healthcare response whilst supporting 307 general practices, 85 Residential Aged Care Homes (RACHs) and three Medicare Urgent Care Clinics to continue to deliver essential services. This alliance allowed the PHN and the MNH Emergency Operations Centre to align with critical stakeholders, including the Queensland Ambulance Service, MNH Public Health Unit and the Institute for Urban Indigenous Health.

Insights secure primary care workforce for the future

222 consultations with GPs, Registrars and other general practice stakeholders were undertaken to deliver Training Pathways Report 1 and Relative Workforce Need and Capacity Report 4 as part of the GP Workforce Planning and Prioritisation (GP WPP) program’s work to secure a robust primary care workforce pipeline for the future.

Our local GP WPP team partnered with Health Consumers Queensland to elicit further consumer perspective about workforce need that helped us to better understand community challenges and expectations around accessing primary care.

Accredited to deliver first class care

Team Care Coordination (TCC) have continued to establish themselves as a trusted partner in the North Brisbane and Moreton Bay region by successfully meeting the National Safety and Quality Primary and Community Healthcare Standards to achieve accreditation. This milestone highlights TCC’s commitment to delivering first class care to adults living with complex and chronic health conditions.

Committed to building commissioning capacity

Fundamental to our role commissioning health and community care services for our communities, we established the Commissioning Steering Committee to enhance commissioning knowledge and capability, and ensure understanding and consistency through the commissioning process, across our PHN.

Paving The Ways for POWA trainees

Team Care Coordination, in partnership with the Institute for Urban Indigenous Health (IUIH) Pathways Our Way Academy (POWA), supports First Nations school-based trainees completing Certificate III in Allied Health Assistance. This program helps students gain practical skills and a recognised qualification to strengthen their future career opportunities.

A great place to work

This year we’ve taken big steps to make Brisbane North PHN an even better place to work. With strong support from our Board for the People and Culture Strategy, we’re investing in our people and shaping a workplace where everyone feels valued. A key milestone was completing a Cultural Audit – both a commitment to our Reconciliation Action Plan, and an important step in making our workplace more culturally safe and supportive for our First Nations team members.

We’ve also started running quarterly pulse surveys, and our eNet Promoter Score has held steady at 23, showing that our team think Brisbane North PHN is not just good, but a genuinely great place to work. We’re proud to have halved our staff turnover, and our people continue to enjoy the benefits that matter most – flexibility, professional development and a meaningful focus on wellbeing. We invested in our leaders and hold regular Leaders in the House touchpoints, providing opportunities for our leaders to connect and grow.

Strengthening foundations for the future

In 2024, the PHN Board endorsed a comprehensive review of its governing documents, led by the Governance Committee. Central to this review was the most significant of these documents, the Constitution. The objective was to resolve inconsistencies between existing clauses and current practices, modernise both format and content, embed contemporary governance principles, and introduce greater flexibility.

These reforms have enhanced the Board’s ability to remain agile and responsive to a dynamic operating environment, ensuring the Constitution remains relevant and effective over time. The updated Constitution was formally ratified by members at the Annual General Meeting in November 2024.