Reports
Actions for Governance of Local Health Districts
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
Actions for Supply of secondary teachers in STEM-related disciplines
Supply of secondary teachers in STEM-related disciplines
The NSW Department of Education’s plans and strategies to respond to the demand for secondary teachers in STEM-related disciplines are limited by incomplete data and underperforming scholarship and sponsorship program. The Department does not collect sufficient information to monitor what disciplines teachers actually teach nor does it predict supply and demand for teachers by discipline and location. This restricts the Department’s ability to track and forecast the supply and demand for secondary teachers in STEM-related disciplines.
In recent years, Australian and international education policy has focused on improving outcomes in Science, Technology, Engineering and Mathematics (STEM) subjects. However, research has identified a shortage of qualified secondary teachers in STEM-related disciplines 1. This is projected to worsen due to a combination of student population increases, an ageing workforce, and fewer people going into teaching. Shortfalls are likely to be more acute in rural and remote areas, and areas of low socio-economic status.
The Department of Education (the Department) has a variety of strategies to encourage teachers to practise in locations or disciplines of need. These include scholarships for tertiary students going into teaching, sponsorships for teachers seeking approval to teach additional disciplines, and incentives to attract teachers to rural and remote locations.
This audit assessed the effectiveness of the Department's workforce plans and strategies in responding to the demand for secondary teachers in STEM-related disciplines. We assessed:
- how well the Department tracks the supply and demand for secondary teachers in STEM-related disciplines across NSW
- whether the Department has effective strategies to attract and retain secondary teachers in STEM-related disciplines.
There are two key shortcomings that fundamentally limit the effectiveness of the Department's plans and strategies to respond to the demand for secondary teachers in STEM-related disciplines. First, the Department is not accurately tracking the supply and demand for secondary teachers by discipline due to incomplete data. Second, not all scholarship and sponsorship places are allocated and many scholars withdraw from the programs before completion. The Department has recognised and started to address these problems with a new workforce model, revised incentives and scholarship programs.
The Department’s current workforce planning model does not provide the information needed to target workforce plans and strategies to areas of need. This is because it does not predict supply and demand for teachers by discipline and location. An internal review in 2017 acknowledged the limitations of this model. In response the Department developed a new model, which it is currently enhancing, to predict supply and demand for teachers by discipline and location. For this to be successful, the Department needs to monitor the level of out-of-field teaching and improve data on the willingness of teachers to work in particular locations.
The Department does not allocate all available scholarship and sponsorship places and around 30 per cent of recipients do not complete the term of their agreement. An internal review in 2017 highlighted that some programs were not targeting workforce need and that there were no key performance indicators to determine the overall effectiveness of these programs. However, scholarship programs and incentives are promoted well through social media and face-to-face events at Universities. Further, the Department has used findings from internal reviews of incentives and scholarships in 2016 and 2017 to inform recent changes to programs.
The Department has little oversight of access to practicum placements for pre-service teachers in areas of need. Professional experience agreements were established with each University in 2015 to improve the placement process for disciplines of need. Initial teacher education students must complete several ‘practicum placements’ before they can be qualified to teach in a school. Several universities we consulted reported difficulties finding practicum placements for pre-service teachers specialising in STEM-related disciplines. The Department is now revising the agreements to improve the quality of data it collects on the number, location and subject area of practicum placements.
The Department is not accurately tracking the supply and demand for secondary teachers by discipline due to incomplete data.
The Department’s current workforce planning model does not accurately predict supply and demand for teachers by discipline and location. An internal review in 2017 acknowledged the limitations of this model. In response the Department developed a new model which it is currently enhancing to address the findings of the review. For this model to be successful, the Department needs to monitor the level of out-of-field teaching and improve data on the willingness of teachers to work in particular locations. Further work also needs to be undertaken to refine the assumptions that underpin the Department’s workforce planning models as it starts to predict the need for teachers by discipline.
The Department has not publicly reported on the supply and demand for teachers by discipline since 2015. While it does report annually on its current workforce profile, this information is not detailed enough to inform future strategies or programs. More detailed public reporting may help the Department to influence the future supply of teachers by communicating its projected areas of need. Planned improvements to the Department's workforce planning model, as relayed to us, will add to the data available on areas of need. Once available, this should be reported publicly.
Recommendations
By December 2019, the Department of Education should:
- Improve its workforce planning model to better understand and communicate supply and demand for teachers by:
- determining the extent, and analysing the impact, of out-of-field teaching by permanent and temporary teachers in each school
- sourcing additional data to more accurately reflect teacher location preferences
- projecting supply and demand by subject level and geographic area
- regularly reporting on the supply and demand for secondary teachers in each discipline to communicate future areas of need to future teacher education students.
The Department's current scholarship and sponsorship programs are not allocating all available places and many scholars withdraw from the programs before completion. An internal review in 2017 raised several issues with the effectiveness of programs and the Department has started to revise its scholarship, sponsorship and incentive programs.
An internal review in 2017 highlighted that scholarship and sponsorship programs were not targeting workforce need, and that there were no key performance indicators to determine the overall effectiveness of these strategies. In addition, the review found that only 79 per cent of available scholarship placements are allocated each year, and 31 per cent of scholarship recipients withdraw prior to completing their required service period. The Department recently announced changes to its scholarship programs from 2019 onwards.
The Department has incentives to encourage teachers to work in rural and remote areas, including teachers in STEM-related disciplines. Incentives include access to priority transfers, rental subsidies and other allowances. Research conducted in 2016 examined the influence of incentives in encouraging teachers to work in rural and remote areas. The Department used findings of this research when updating its set of rural and remote incentives in 2017.
The Department promotes its scholarship and sponsorship programs through the teach.NSW website. It uses social media to direct applicants to this website. It also promotes its programs through careers fairs, University open days, and professional events. Past applicants have reported that the website clearly communicates eligibility criteria and the terms of agreement for all scholarship programs.
The Department could strengthen its relationship with universities to attract teachers to areas of need by collecting and analysing data on practicum placements, facilitating placements for scholarship recipients, and communicating predicted teacher needs by discipline.
Recommendations
By December 2019, the Department of Education should:
2. Implement changes to address the findings of the 'Teacher Scholarship Realignment' report, including by:
- testing a range of program designs with target candidates to determine the best options to attract more suitable applicants
- establishing key performance indicators, and setting targets, to better monitor the effectiveness of the programs
- reducing the number of scholars appointed to over-establishment positions
- increasing the proportion of scholars appointed to priority locations
- further analysing scholarship recipients career paths to inform future improvements to the scholarship programs.
3. Review its role in the practicum placement process of pre-service teachers by:
- analysing how many students each school accommodates per year, to ensure there are appropriate placements available for students in high needs disciplines
- working with universities to facilitate practicum placements for scholarship recipients
- establishing mechanisms for ongoing monitoring of its partnerships with universities to ensure they are meeting their aims.
Appendix one - Response from agency
Appendix two - About the audit
Appendix three - Performance auditing
Parliamentary Reference - Report number #313 - released 29 January 2019.