Catchment snapshot · executive summary

Sydney North Health Network — one-page brief

15 May 2026 Generated · 931,439 residents
Top 6 procurable gaps · service-commissioning summary
Quantified service-need gaps where commissioned SNHN services would have highest expected impact.
  1. 01
    100,782-person mental-health service gap · modelled MH cases minus BetterAccess uptake. 61% concentrated in Hub LGAs (NB, Hornsby, Ryde).
    Tool 07 ↗
  2. 02
    3,174 unmet AOD treatment episodes / yr · +2,142 short of NSW provision rate. NA-cited "non-residential rehab access" priority.
    Tool 11 ↗
  3. 03
    12,108 after-hours GP attendances / yr below NSW rate · 7 of 9 LGAs have zero local Urgent Care Clinic. NA-cited "after-hours including RACFs".
    Tool 14 ↗
  4. 04
    4,161 missed 75+ health checks / yr · 25% modelled uptake vs national 30%. NA-cited "low proportion of 75+ receiving annual health check".
    Tool 10 ↗
  5. 05
    349 Aboriginal & TSI 715 health checks short / yr · Modelled 15% uptake vs NSW 22%. NA-cited "significant under-reporting of Aboriginal status" qualifies this as a floor.
    Tool 08 ↗
  6. 06
    ~9,200 missed CALD cancer screenings / round · Breast 4,093 + bowel 5,117 per screening cycle. Ryde 50% CALD share drives the geographic concentration.
    Tool 09 ↗

§ 01 Population & Demographics

931,439 residents across nine LGAs (ABS ERP 2024). Catchment skews older than NSW — 17.6% aged 65+ vs 17.1% NSW. Population growth 0.89% p.a., slower than the NSW 1.2% average.

Population
931,439
ABS ERP latest
Aged 65+
163,588
17.6% of catchment
Aged 85+
25,787
Complex-care cohort
+65 by 2034
+44,169
+27.0% over decade
Open Tool 01 · Population & Ageing

§ 02 CALD & First Nations

32.1% CALD (336,628 people) — well above NSW 23%. Concentrated in Ryde (50.5%), Willoughby and Hornsby. Top languages: Mandarin 96k, Cantonese 28k, Korean 21k. Aboriginal & TSI population 4,982 (0.475% of catchment).

CALD population
336,628
32.1% of catchment
Limited English
31,642
3.02% · modelled
Aboriginal & TSI
4,982
0.475% · Census 2021
MBS 715 gap
349
Indigenous health-checks / yr to NSW rate
Open Tool 09 · CALD planning

§ 03 Mental Health & Suicide

Modelled 176,415 people with mental illness (18.94%) — within 0.7pp of the SNHN NA's 18.3%. A 100,782-person service-need gap between modelled prevalence and BetterAccess uptake, 61% concentrated in the three Hub LGAs (Northern Beaches, Hornsby, Ryde).

MH cases (modelled)
176,415
18.94% · NMHSPF
Service-need gap
100,782
vs BetterAccess uptake
Suicide rate (5y)
7.6/ 100k
vs NSW 10.8 · National 12.4
High-composite SA2s
15
of 69 · candidate sites
Open Tool 07 · Mental Health

§ 04 Maternal & Child Health

161,011 children aged 0–14 (17.3% of catchment). Modelled 10,499 births/yr at SNHN fertility rate 48.0/1,000 women 15–49 (vs national 56.0). AEDC vulnerability 16.8% (NSW 22.4%, national 22.0%) — among the lowest of any PHN. Perinatal depression cohort ~1,575 mothers/yr.

Kids 0–14
161,011
17.3% of catchment
Births / yr (modelled)
10,499
48.0/1k women 15–49
AEDC vulnerable / yr
1,420
16.8% Year-1
Perinatal-MH / yr
1,575
PANDA · 15% of mothers
Open Tool 13 · Maternal & Child Health

§ 05 AOD & Hospitalisation

164,914 modelled risky-AOD users (21.4% of adults). Catchment-wide treatment gap of 3,174 episodes between modelled seeking and AODTS-received, with a separate 2,142-episode deficit to even the NSW provision rate.

Risky AOD users
164,914
21.4% of adults
AOD treatment gap
3,174
unmet episodes / yr
Gap to NSW rate
2,142
extra episodes / yr
AOD hosp seps
4,452
per year · modelled
Open Tool 11 · AOD treatment gap

§ 06 After-Hours Care + Telehealth

Modelled 60,544 after-hours GP attendances/yr at 65.0/1,000 (vs NSW 78.0, national 85.0). Catchment runs 12,108 attendances/yr below NSW provision. Telehealth uptake above NSW + national: 144,373/yr (+18,629 vs NSW). Only 2 Urgent Care Clinics in catchment, both in Northern Beaches — 7 of 9 LGAs zero UCC coverage.

AH GP visits / yr
60,544
65.0/1k modelled
Gap to NSW rate
12,108
extra attendances / yr
Telehealth / yr
144,373
above NSW · digital uptake
UCCs · RACFs
2 · 85
PIP-AH 25.0% (Nat 36.0%)
Open Tool 14 · After-Hours + Telehealth

§ 07 Aged Care · Demand & Supply

49,784 CALD-elderly people 65+ (30.4% of 65+ cohort) — the single biggest service-design lever for CHSP and HCP commissioning. Commonwealth provision-ratio targets at current 70+ pop: 9,392 RACF beds + 5,419 Home Care Packages. 75+ MBS health-check uptake modelled at 25% (NA-cited low) vs NSW 28% / national 30% — gap of 4,161 assessments/yr.

CALD-elderly 65+
49,784
30.4% of 65+
RACF target
9,392
beds · 78 per 1k 70+
HCP target
5,419
packages · DoHAC 2024
75+ HC gap
4,161
assessments / yr
Open Tool 10 · Aged-Care capacity

§ 08 Chronic Disease & PIP-QI

212 of 240 GP practices reporting PIP-QI (88.3% vs NSW 91.0%, national 88.3%). 617,544 regular clients across the 10 PIP-QI Quality Improvement Measures. Largest register-coverage gap is CKD at 36,311 unregistered, then mental-health register at 75,013.

PIP-QI practices
212
of 240 · 88.3%
Regular clients
617,544
10 QIMs monitored
Diabetes register
40,278
88.0% coverage
CKD unregistered
36,311
biggest register gap
Open Tool 15 · Chronic Disease & PIP-QI

§ 09 Digital Health Adoption

446,848 modelled My Health Record active users in catchment (58.0% of adults · NSW 51.0% · national 49.0%). SNHN runs ahead of state and national across all 6 adoption tracks — GP Shared Health Summary uploads, secure messaging, telehealth, e-prescribing, HealthPathways. Only 26,965 modelled opt-outs (3.5% non-registered).

MHR · active
446,848
58.0% adults · ADHA modelled
GP SHS uploads
—%
NSW —% · Nat —%
Secure messaging
—%
practices · ADHA NCSP
HealthPathways
—%
GP practices using · localised
Open Tool 16 · Digital Health Adoption

§ 10 Immunisation Coverage

Childhood 1yr coverage at 94.3%1.7pp below NSW (92.6%) and 0.7pp under the 95% herd-immunity target. An estimated 70 children/yr left short of full protection — Northern Beaches + Mosman hesitancy patches drive the gap. Adult cohorts run above state + national: flu 65+ 69.0%, COVID booster 33.0%, pneumococcal 53.0%.

Children 1yr immunised
9,480
94.3% of modelled birth cohort
Under 95% target
70
children / yr — preventive gap
Flu 65+ uptake
112,876
69.0% · above NSW
COVID 65+ (6mo)
53,984
33.0% boosted
Open Tool 17 · Immunisation Coverage

§ 11 Cancer Screening

All three national programs run above NSW + national: BreastScreen 62.3%, NCSP cervical 68.7%, NBCSP bowel 48.1%. Bowel screening still carries the largest absolute gap — 35,991 adults 50-74 under the 60% target. Cervical self-collect at 11.5% (vs 8% national) is the highest near-term uplift lever.

BreastScreen screened
96,095
62.3% · target 70%
Cervical (NCSP) screened
217,320
68.7% · self-collect 11.5%
Bowel (NBCSP) screened
145,475
48.1% · target 60%
Bowel under target
35,991
adults 50-74 · biggest absolute gap
Open Tool 18 · Cancer Screening

§ 12 Preventable Hospitalisations · ABF ROI

17,568 PPH admissions/yr modelled. SNHN at 1886.1/100k — below NSW (—) and national (2650.0). At best-practice rate, 3,514 admissions are avoidable — A$19.0M in Activity-Based Funding cost on the table. Chronic-PPH dominates (6,698/yr) — tying directly back to Tool 15 register-coverage gaps.

Total PPH admissions
17,568
1886.1/100k · AIHW 2022-23
Avoidable @ best-practice
3,514
admissions / yr
ABF cost avoided
A$19.0M
NWAU 2024-25 weights
Chronic PPH
6,698
38% · biggest lever
Open Tool 19 · Preventable Hospitalisations

§ 13 Burden of Disease · ABDS 2024

156,668 DALYs lost per year — 168.2/1k vs NSW 182.4 vs national 188.7. 32.0% attributable to modifiable risk factors — 50,134 DALYs/yr preventable through commissioning levers. Overweight, tobacco, diet, BP, alcohol top the risk-factor stack.

Total DALYs
156,668
168.2/1k · AIHW ABDS 2024
YLL · YLD split
46% · 54%
YLL 72,067 · YLD 84,601
Preventable
50,134
32.0% · modifiable factors
Top burden group
Cancer
19.2% of DALY · Tool 18 lever
Open Tool 20 · Burden of Disease

§ 14 Disadvantage · NDIS · Income Support

All nine LGAs at IRSD decile 10 — but the catchment carries 87,490 income-support recipients and 14,880 NDIS participants. NDIS growth +41.7% over four years. Within decile 10, IRSD raw-score spread is 55 points — real sub-LGA variance.

Income support recipients
87,490
97.8/1k
Age pension
56,100
DSS latest qtr
NDIS participants
14,880
+41.7% over 4 years
IRSD score range
1055–1110
all decile 10 nationally
Open Tool 02 · Disadvantage
Snapshot composition. Headline figures pulled from each tool's underlying data.json. Modelled values clearly labelled per their respective tools' methodology sections. Every figure is reproducible from public sources cited in the source tool — ABS Census 2021, ABS ERP, AIHW (NMHSPF, Indigenous HPF, NDSHS, AODTS NMDS, Suicide & Self-Harm Monitoring, MyHospitals), MBS Item Statistics, NCIRS, DSS Payment Demographics, NDIS Quarterly Reports, DoHAC Aged Care Planning Provision Ratios.
Generated 15 May 2026 · phn.domato.ai/snhn/snapshot Built by Domato AI · ABN 94 695 794 346 · support@domato.ai
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