Chronic conditions are the leading cause of illness, disability and death in Australia. The most recent study on the impact and cause of illness and death in Australia (AIHW 2016) indicates that chronic conditions now cause most of the burden of ill health.

The personal, social, and economic impacts of disease become increasingly complex and burdensome with each additional condition. And while chronic disease is found across all parts of our society, the most vulnerable tend to be impacted most frequently and profoundly. The north western Melbourne region has extremely high rates of diabetes compared to the Victorian and national average, particularly in Brimbank, Hume, Maribyrnong, Darebin and Moreland. Mortality rates from cardiovascular disease are very high in some areas, and, significantly, chronic disease accounts for a significant proportion of potentially preventable hospitalisations. To limit the impact of chronic conditions across the north western Melbourne region, we commission activities that:

  • increase the efficiency and effectiveness of medical services, particularly for patients at risk of poor outcomes; and at the same time
  • improve coordination of care to ensure patients receive the right care in the right place at the right time.

In 2016-2017 our PHN commissioned over $1.5 million to support the prevention and management of chronic conditions in the north western Melbourne region. We use a range of strategies, mechanisms and tools to support our work in this area:

Population based approaches

Our work in the prevention and management of chronic conditions is underpinned by our knowledge of the north western Melbourne region.  By understanding and identifying need, we can prioritise and plan our activity to target populations who need it most.  Read here about how we support priority populations in Hume, Brimbank and Moreland to better self-manage their chronic conditions.

Supporting primary care

To encourage consistent and best-practice care for chronic conditions in primary care, we offer chronic disease specific:

  • training and education;
  • information and resources;
  • business tools.

Read how our PHN supports primary care providers to manage hepatitis B and hepatitis C.

Workforce development

Our PHN supports primary care nurses to take a greater role in the management of chronic conditions. Read how General Practice and Primary Care Nurses  are supporting patients to better understand and manage their chronic conditions through the CareFirst program.

HealthPathways Melbourne

HealthPathways Melbourne is a web-based system that helps coordinate patient care across the acute and primary care system.  A range of pathways have been developed for use by health professionals in the assessment, management and referral of chronic conditions. Read how HealthPathways Melbourne supports our work in implementing Optimal Care Pathways for cancer.

Optimal care pathways for cancer

NWMPHN is implementing the Optimal Care Pathways (OCP’s) for cancer across our region. This is part of the Victorian Department of Health and Human Services statewide integrated approach to optimal care pathways. The aim is to improve patient outcomes by facilitating optimal care using evidence-based pathways of care.

Optimal care pathways prostate cancer education in five parts: (Total 105min) Presenters: Dr Anita Munoz | GP and Clinical Editor, HealthPathways Dr Homi Zargar | Urologist Mr Dave Gray | Nurse Practitioner

RACGP acknowledges the personal learning value of various activities. For unaccredited activities visit and submit a self-directed activity.

Malignant melanoma webinar: An Update for GPs

The risk of an individual dying from melanoma by their 85th birthday is now one in 118 people. Yet, melanoma is primarily preventable if found in the early stage. General practitioners are at the front line of skin cancer detection for most Australians.

Watch this webinar to learn the latest on the diagnosis of malignant melanoma and an update on advances in investigations and treatment from leading clinical specialists.

  Access the webinar

Community-led Cancer Screening Project

The Community-led Cancer Screening Project (CLCSP) is a three-year project, (to November 2020). The project is led by North Western Melbourne Primary Health Network (NWMPHN) and funded by Victorian Department Health and Human Services (DHHS). The Victorian Aboriginal Community Controlled Health Organisation and Cancer Council Victoria are partners in the project. The focus of the project is to increase community participation in bowel, cervical and breast cancer screening programs by building capacity within primary care settings and through facilitated community-led interventions. The goal of the project is equitable participation in cancer screening programs for low socio-economic and Culturally and Linguistically Diverse communities in Brimbank and the Aboriginal community in Wyndham. There are four key principles that will drive the project outcomes:

  • Equity -to ensure needs of under-screened groups are the priority
  • Locally driven initiatives -to ensure the unique needs of under-screened communities are addressed
  • Partnerships -to foster collaborative relationships
  • Sustainability -to ensure successful initiatives endure

We are currently engaging with local communities in Brimbank and Wyndham to understand their experiences of cancer screening and ideas on how we can increase uptake of free screening services. If you are a community member or organisation in either Brimbank or Wyndham and would like to be involved please contact us. We would welcome your input. We are also planning to work with General Practices in Brimbank and Wyndham on Quality Improvement around identifying under-screened patients and improving systems to increase cancer screening. If you are a GP who would like to be involved please contact us.

More information

For further information or to get involved with the NWMPHN Community-led Cancer Screening Project please contact Meg Boyle on or call (03) 9347 1188.

For further information about individual screening programs:

 Bowel screening
 Cervical screening
 Breast screening

For further information on the wider Community-led Cancer Screening Program in other Victorian PHNs please visit the VTPHNA website.


 CLCSP Project Logic (.pdf, 458 kB)
 CLCSP Local Cancer Screening Community Profile (.pdf, 2.4 MB)

Making time to talk about bowel cancer screening: A guide for community groups 

This guide was created as part of the Community-led Cancer Screening project. The guide aims to help local communities to talk about the importance of bowel cancer screening, and share the message
with their friends, families and networks.

Download the guide and read our news story to find out how you can help share the guide.

Regional Collaborations

To improve coordination of care across the health system we work collaboratively with all levels of government, general practice, primary health care service providers, local hospital networks, non-government organisations, private sector, consumers and carers. Read here how we are working with The Collaborative to implement Stepping Up, a new model of care to support the management of diabetes in general practice.