Reports
Governance of Local Health Districts
The main roles, responsibilities and relationships between Local Health Districts (LHDs), their Boards and the Ministry of Health are clear and understood, according to a report released today by the Auditor-General for New South Wales, Margaret Crawford. However, there are opportunities to achieve further maturity in the system of governance and the audit report recommended a series of actions to further strengthen governance arrangements.
Fifteen Local Health Districts (LHDs) are responsible for providing public hospital and related health services in NSW. LHDs are:
- established as statutory corporations under the Health Services Act 1997 to manage public hospitals and provide health services within defined geographical areas
- governed by boards of between six and 13 people appointed by the Minister for Health
- managed by a chief executive who is appointed by the board with the concurrence of the Secretary of NSW Health
- accountable for meeting commitments made in annual service agreements with the NSW Ministry of Health.
The NSW Ministry of Health (the Ministry) is the policy agency for the NSW public health system, providing regulatory functions, public health policy, as well as managing the health system, including monitoring the performance of hospitals and health services.
The current roles and responsibilities of LHDs and the Ministry, along with other agencies in NSW Health, were established in 2011 following a series of reforms to the structure and governance of the system. These reforms began with the report of the 'Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals' ('the Garling Inquiry'), which was released in 2008, and were followed by reforms announced by the incoming coalition government in 2011.
These reforms were intended to deliver greater local decision making, including better engagement with clinicians, consumers, local communities, and other stakeholders in the primary care (such as general practitioners) and non-government sectors.
The reforms empowered LHDs by devolving some management and accountability from the Ministry for the delivery of health services in their area. LHDs were made accountable for meeting annual obligations under service agreements.
This audit assessed the efficiency and effectiveness of the governance arrangements for LHDs. We answered two questions:
- Are there clear roles, responsibilities and relationships between the Ministry of Health and LHDs and within LHDs?
- Does the NSW Health Performance Framework establish and maintain accountability, oversight and strategic guidance for LHDs?
- continued progress in moving toward patient experience, outcome, and quality and safety measures
- improving the Health Performance Framework document to ensure it is comprehensive, clear and specifies decision makers
- greater clarity in the nexus between underperformance and escalation decisions
- including governance-related performance measures
- more rigour in accountability for non-service activity functions, including consumer and community engagement
- ensuring that performance monitoring and intervention is consistent with the intent of devolution.
NSW Health is large and complex system, operating in a dynamic environment. The governance reforms introduced in 2011 were significant and it is reasonable that they take time to mature.
The main roles of LHDs and the Ministry are clear and well-understood, and there is good collaboration between different parts of the system. This provides a sound foundation on which to further mature the governance arrangements of LHDs.
While the broad roles of LHDs, their boards, and the Ministry are well understood by stakeholders in the system, there are matters of detail and complexity that create ambiguity and uncertainty, including:
- the roles and relationships between the LHDs and the Pillars
- to what extent LHDs have discretion to pursue innovation
- individual responsibility and obligations between chairs, boards, executive staff, and the Ministry.
These should be addressed collaboratively between boards, their executives, and the Ministry, and should be informed by a statement of principles that guides how devolved decision making should be implemented.
Better clinician engagement in health service decision making was a key policy driver for devolution. Priority should be given by LHDs and the Ministry to ensuring that clinicians are adequately engaged in LHD decision making. It appears that in many cases they are not, and this needs to be addressed.
The quality of board decision making depends on the information they are provided and their capacity to absorb and analyse that information. More can be done to promote good decision making by improving the papers that go to boards, and by ensuring that board members are well positioned to absorb the information provided. This includes ensuring that the right type and volume of information are provided to boards, and that members and executive managers have adequate data literacy skills to understand the information.
Recommendations
- By December 2019, the Ministry of Health should:
- work with LHDs to identify and overcome barriers that are limiting the appropriate engagement of clinicians in decision making in LHDs
- develop a statement of principles to guide decision making in a devolved system
- provide clarity on the relationship of the Agency for Clinical Innovation and the Clinical Excellence Commission to the roles and responsibilities of LHDs.
- By June 2020, LHDs boards, supported where appropriate by the Ministry of Health, should address the findings of this performance audit to ensure that local practices and processes support good governance, including:
- providing timely and consistent induction; training; and reviews of boards, members and charters
- ensuring that each board's governance and oversight of service agreements is consistent with their legislative functions
- improving the use of performance information to support decision making by boards and executive managers.
This cultural shift has achieved greater recognition of the importance of transparency in how well LHDs perform. However, as NSW Health is a large, complex and dynamic system, it is important that these accountability and oversight mechanisms continue to evolve to ensure that they are sufficiently robust to support good governance.
There are areas where accountability and oversight can be improved including:
- continued progress in moving toward patient experience, outcome and value-based measures
- improving the Health Performance Framework document to ensure it is comprehensive, clear and specifies decision makers
- greater clarity in the nexus between underperformance and escalation decisions
- by adding governance-related performance measures to service agreements
- more rigour in accountability for non-service activity functions, such as consumer and community engagement
- ensuring that performance monitoring and intervention is consistent with the intent of devolution.
Recommendations
3. By June 2020, the Ministry of Health should improve accountability and oversight mechanisms by:
a) revising the Health Performance Framework so that it is a cohesive and comprehensive document
b) clarifying processes and decision making for managing performance concerns
c) developing a mechanism to adequately hold LHDs accountable for non-service activity functions
d) reconciling performance monitoring and intervention with the policy intent of devolution.
Appendix one - Response from agency
Appendix two - Functions of a Local Health District
Appendix three - Functions of a Local Health District Board
Appendix four - Routine performance monitoring and reporting
Appendix five - Escalation model for the NSW Health Performance Framework
Appendix six - About the audit
Appendix seven - Performance auditing
Parliamentary Reference: Report number #316 - released 18 April 2019
Government Advertising 2007
Since our performance audit in 1995 the government has improved guidance for agencies and introduced a more robust framework for approving advertising campaigns. Greater rigour has been introduced into the process by requiring campaigns to be peer reviewed and approved by Cabinet. This new approach aims to improve the effectiveness and value for money of government advertising. We found however that the current guidelines are not adequate to prevent the use of public funds for party political purposes. We also found it difficult to obtain information on the total amount spent on advertising campaigns. This is because there is no central record of the total expenditure, only the cost of placing advertisements in the media. Greater transparency around what is spent would support more accurate and informed debate.
Parliamentary reference - Report number #171 - released 29 August 2007
Signal failures on the metropolitan rail network
Between 2004 and 2006, the number of signalling failures, signalling downtime and the number of trains delayed as a result of signal failures all fell. RailCorp’s on-time running performance improved over the same period. The fall in failures is a clear indication of improved performance. Changes in the definition of on-time and to the timetable during 2005 and 2006 however make it difficult to determine whether improvements in response downtime and signalling delays are due to a true performance improvement. To build upon this strong base, RailCorp needs to determine with more confidence the number and duration of signalling failures the network can tolerate without impacting on service levels.
Parliamentary reference - Report number #170 - released 15 August 2007
Connecting with public transport
We see considerable potential for the Ministry of Transport to plan and manage interchanges more effectively, so as to make better use of our public transport network. We believe that the Ministry now needs to focus more on multi-modal transport planning and interchange performance. It needs to assign responsibility for the coordination and oversight of inter-modal operations to an entity resourced for the purpose. Without this it will continue to be very difficult to identify and address unmet needs, seek and secure stakeholder funding, and monitor and evaluate system performance.
Parliamentary reference - Report number #168 - released 6 June 2007
Readiness to respond: Follow-up audit
The Ambulance Service of New South Wales has substantially implemented the 28 recommendations of the 2001 audit report that it accepted. It has also introduced significant new initiatives to improve performance that were not part of the 2001 recommendations. It has made substantial changes to its organisation and operations to implement these changes. Many of the changes are still proceeding. The Service has addressed a key finding of the 2001 audit report - that it did not have adequate, relevant or credible management data for decision making. The Service now has five years of operational data from the Computer Aided Dispatch (CAD) system.
Parliamentary reference - Report number #167 - released 6 June 2007
Responding to homelessness
Many projects, both Partnership Against Homelessness and by individual agencies, have shown good results or led to improvements. One example is helping mental health patients maintain stable housing. Another is providing street outreach services to homeless people in inner Sydney. Despite these efforts, we were unable to determine how well the government is responding to homelessness statewide. This is because there are no statewide performance measures or targets on homelessness. Also there is limited benchmarking, and no formal means of spreading information on homelessness initiatives and projects.
Parliamentary reference - Report number #165 - released 2 May 2007
