Reports
Actions for Ensuring contract management capability in government - HealthShare NSW
Ensuring contract management capability in government - HealthShare NSW
This report examined whether HealthShare NSW, a part of NSW Health, has the required contract management capability to effectively manage goods and services contracts valued over $250,000.
The report found that HealthShare has a procurement framework that should support effective contract management, but it is not applying it consistently. In particular, the audit found that HealthShare was not applying key contract management elements to over 80 per cent of the high-value contracts it manages. The audit also found that HealthShare’s contract management practices were limited by inadequate performance monitoring.
'Effective contract management is essential to ensure the contracts HealthShare enters into are delivering as expected and ensuring value for money,' said the Auditor-General. 'Without this, the value for money or savings HealthShare achieves when it negotiates these contracts is at risk of being eroded over the life of the contract.'
The report recommends that NSW Health develop a performance improvement plan to ensure HealthShare is fully compliant with procurement policies and that NSW Health meets its obligations under the Government's Accreditation Program for Goods and Services Procurement.
HealthShare is a NSW Health entity responsible for providing shared services, including procurement, to support the delivery of patient care within the NSW health system. In 2018, HealthShare procured high value goods and services contracts with an annual estimated total spend of around $1.8 billion, with most of the contracts of long duration.
NSW Government agencies are increasingly delivering services and projects through contracts with third parties. These contracts can be complex and governments face challenges in negotiating and implementing them effectively. A robust contract management framework helps ensure all parties meet their obligations, contractual relationships are well managed, agencies achieve value for money, and deliverables meet the required standards and agreed timeframes.
Contract management capability is a broad term, which can include aspects of individual staff capability (such as staff knowledge, skills and experience) as well as organisational capability (such as policies, frameworks and processes).
The NSW Procurement Board is responsible for overseeing the Government's procurement system, setting policy and ensuring compliance. It has accredited the Health Administration Corporation (HAC) to procure goods and services with no upper financial limit. Under the terms of this accreditation, the Secretary, NSW Health (as head of HAC) has delegated the procurement of high-value (over $250,000) goods and services contracts within NSW Health to only the Ministry of Health and HealthShare NSW (HealthShare).
HealthShare NSW (HealthShare) is a NSW Health entity responsible for providing shared services, including procurement, to support the delivery of patient care within the NSW health system. In 2018, HealthShare procured high-value goods and services contracts with an annual estimated total spend of around $1.8 billion, with most of the contracts of long duration.
HealthShare’s Contract Management Guide states that, without rigorous contract management, 75 per cent of projected sourcing savings can disappear within 18 months of the contract starting.
This audit examined whether HealthShare has the required capability to effectively manage high-value goods and services contracts. Contracts we examined included critical items such as food services in hospitals, patient transport services, intravenous equipment and kidney dialysis services, where risks include patient safety as well as value for money. We did not examine infrastructure, construction or information communication and technology contracts. We also did not examine HealthShare’s sourcing processes, including identifying business needs, tendering and contract award.
We assessed HealthShare against the following criteria:
- HealthShare's systems, policies and procedures support effective contract management and are consistent with relevant frameworks, policies and guidelines.
- HealthShare has capable personnel to effectively conduct the monitoring activities throughout the life of the contract.
We included the NSW Public Service Commission and NSW Treasury, through NSW Procurement, as auditees because they administer policies which directly affect contract management capability. These include:
- NSW Procurement Board Directions and policies
- NSW Government Procurement Policy Framework
- Accreditation Program for Goods and Services Procurement
- the NSW Public Sector Capability Framework.
NSW Procurement was transferred to NSW Treasury from the former Department of Finance, Services and Innovation on 1 July 2019 as part of changes to government administrative arrangements.
Appendix one – Response from agencies
Appendix two – Contract performance management summary
Appendix three – About the audit
Appendix four – Performance auditing
© Copyright reserved by the Audit Office of New South Wales. All rights reserved. No part of this publication may be reproduced without prior consent of the Audit Office of New South Wales. The Audit Office does not accept responsibility for loss or damage suffered by any person acting on or refraining from action as a result of any of this material.
Parliamentary Reference: Report number #328 - released 31 October 2019
Actions for Mental health service planning for Aboriginal people in New South Wales
Mental health service planning for Aboriginal people in New South Wales
A report released by the Auditor-General for New South Wales, Margaret Crawford, has found that NSW Health is not forming effective partnerships with Aboriginal communities to plan, design and deliver appropriate mental health services. There is limited evidence that NSW Health is using the knowledge and expertise of Aboriginal communities to guide how mental health care is structured and delivered.
Mental illness (including substance use disorders) is the main contributor to lower life expectancy and increased mortality in the Aboriginal population of New South Wales. It contributes to a higher burden of disease and premature death at rates that are 40 per cent higher than the next highest chronic disease group, cardiovascular disease.1
Aboriginal people have significantly higher rates of mental illness than non Aboriginal people in New South Wales. They are more likely to present at emergency departments in crisis or acute phases of mental illness than the rest of the population and are more likely to be admitted to hospital for mental health treatments.2
In acknowledgement of the significant health disparities between Aboriginal and non Aboriginal people, NSW Health implemented the NSW Aboriginal Health Plan 2013 2023 (the Aboriginal Health Plan). The overarching message of the Aboriginal Health Plan is ‘to build respectful, trusting and effective partnerships with Aboriginal communities’ and to implement ‘integrated planning and service delivery’ with sector partners. Through the Plan, NSW Health commits to providing culturally appropriate and ‘holistic approaches to the health of Aboriginal people'.
The mental health sector is complex, involving Commonwealth, state and non government service providers. In broad terms, NSW Health has responsibility to support patients requiring higher levels of clinical support for mental illnesses, while the Commonwealth and non government organisations offer non acute care such as assessments, referrals and early intervention treatments.
The NSW Health network includes 15 Local Health Districts and the Justice Health and Forensic Mental Health Network that provide care to patients during acute and severe phases of mental illness in hospitals, prisons and community service environments. This includes care to Aboriginal patients in the community at rates that are more than four times higher than the non Aboriginal population. Community services are usually provided as follow up after acute admissions or interactions with hospital services. The environments where NSW Health delivers mental health care include:
- hospital emergency departments, for short term assessment and referral
- inpatient hospital care for patients in acute and sub acute phases of mental illness
- mental health outpatient services in the community, such as support with medications
- custodial mental health services in adult prisons and juvenile justice centres.
The NSW Government is reforming its mental health funding model to incrementally shift the balance from hospital care to enhanced community care. In 2018–19, the NSW Government committed $400 million over four years into early intervention and specialist community mental health teams.
This audit assessed the effectiveness of NSW Health’s planning and coordination of mental health services and service pathways for Aboriginal people in New South Wales. We addressed the audit objective by answering three questions:
- Is NSW Health using evidence to plan and inform the availability of mental health services for Aboriginal people in New South Wales?
- Is NSW Health collaborating with partners to create accessible mental health service pathways for Aboriginal people?
- Is NSW Health collaborating with partners to ensure the appropriateness and quality of mental health services for Aboriginal people?
NSW Health is not meeting the objectives of the NSW Aboriginal Health Plan, to form effective partnerships with Aboriginal Community Controlled Health Services and Aboriginal communities to plan, design and deliver mental health services.
There is limited evidence that existing partnerships between NSW Health and Aboriginal communities meet its own commitment to use the ‘knowledge and expertise of the Aboriginal community (to) guide the health system at every level, including (for) the identification of key issues, the development of policy solutions, the structuring and delivery of services' 3 and the development of culturally appropriate models of mental health care.
NSW Health is planning and coordinating its resources to support Aboriginal people in acute phases of mental illness in hospital environments. However, it is not effectively planning for the supply and delivery of sufficient mental health services to assist Aboriginal patients to manage mental illness in community environments. Existing planning approaches, data and systems are insufficient to guide the $400 million investment into community mental health services announced in the 2018–19 Budget.
NSW Health is not consistently forming partnerships to ensure coordinated care for patients as they move between mental health services. There is no policy to guide this process and practices are not systematised or widespread.
In this report, the term ‘Aboriginal people’ is used to describe both Aboriginal and Torres Strait Islander peoples. The Audit Office of NSW acknowledges the diversity of traditional countries and Aboriginal language groups across the state of New South Wales.
2 Australian Institute of Health and Welfare data 2016–17 (unaudited).
3 NSW Health, The Aboriginal Health Plan 2013-2023.
In May 2019, the Audit Office of New South Wales invited Aboriginal mental health clinicians and policy experts from government and non-government organisations to attend a one-day workshop. Workshop attendees advised on factors that improve the quality and appropriateness of mental health care for Aboriginal people in New South Wales. They described appropriate mental health care as:
- culturally safe, allowing Aboriginal people to draw strength in their identity, culture and community
- person centred and focussed on individual needs
- delivered by culturally competent staff with no bias
- holistic, trauma-informed and focussed on early intervention where possible
- delivered in places that are appropriate including outreach to homes and communities
- welcoming of the involvement of local Aboriginal community and connected to local knowledge and expertise including totems and kinship structures.
The definition of 'appropriate' mental health care for Aboriginal people throughout this report is based on this advice.
Aboriginal people access emergency services at much higher rates than non-Aboriginal people
The choices that people make in relation to health service options provide some insight into the suitability and appropriateness of the service to their needs.
Aboriginal people have different mental health service use patterns than non-Aboriginal people. Aboriginal people are much more likely to be in a crisis situation before receiving mental health services, usually in an emergency department of a hospital.
Aboriginal people make up three per cent of the total New South Wales population, but they constitute 11 per cent of emergency department presentations for mental health treatments. In regional areas, Aboriginal people make up 20.5 per cent of presentations at emergency departments for mental health reasons.
A number of factors help to explain Aboriginal mental health service usage patterns. According to government and non-government mental health organisations:
- emergency department services are better known to Aboriginal people than other mental health services
- community-based models of care are not appropriate for Aboriginal people
- Aboriginal people are reluctant to access community-based mental health services to prevent crisis situations
- community mental health services are not available for Aboriginal people after hours and during the weekend, so emergency services are the only option.
The statewide proportions of Aboriginal people presenting at emergency departments for mental health treatments has been increasing over time (Exhibit 6).
Appendix one – Response from agency
Appendix two – The NSW Aboriginal Health Plan
Appendix three – About the audit
Appendix four – Performance auditing
Parliamentary Reference: Report number #326 - released 29 August 2019
Copyright reserved by the Audit Office of New South Wales. All rights reserved. No part of this publication may be reproduced without prior consent of the Audit Office of New South Wales. The Audit Office does not accept responsibility for loss or damage suffered by any person acting on or refraining from action as a result of any of this material.
Actions for Development assessment: pre-lodgement and lodgement in Camden Council and Randwick City Council
Development assessment: pre-lodgement and lodgement in Camden Council and Randwick City Council
The report found that both councils could do more to monitor and assess the effectiveness of their pre-lodgement and lodgement stages. The audit highlighted that Randwick City Council closely follows guidance designed to encourage good practice in these initial stages of its development assessments. It also demonstrated it was timely when processing lodgements. Camden Council is partially following the guidance and could not demonstrate that its lodgement stage was timely.
A development application is a formal application for development that requires consent under the NSW Environmental Planning and Assessment Act 1979. It is usually lodged with the local council for processing and determination, and consists of standard application forms, supporting technical reports and plans.
In March 2017, the NSW Department of Planning and Environment (DPE)1 released the ‘Development Assessment Best Practice Guide' designed to help councils assess development applications in a timely manner and provide a better experience for applicants.
DPE's guide describes the development assessment process in five stages.
According to the Guidance, councils should systematically measure, monitor and review development assessment outcomes and timeframes against performance targets to ensure the process is transparent, accountable and outcome-focused.
Appendix one – Response from agencies
Appendix two – Council's alignment with the guidance
Appendix three – About the audit
Appendix four – Performance auditing
Parliamentary Reference: Report number #322 - released 20 June 2019
Copyright reserved by the Audit Office of New South Wales. All rights reserved. No part of this publication may be reproduced without prior consent of the Audit Office of New South Wales. The Audit Office does not accept responsibility for loss or damage suffered by any person acting on or refraining from action as a result of any of this material.
Actions for Domestic waste management in Campbelltown City Council and Fairfield City Council
Domestic waste management in Campbelltown City Council and Fairfield City Council
The Auditor-General for New South Wales, Margaret Crawford, today released a report on Domestic waste management in Campbelltown City Council and Fairfield City Council.The report found that both Councils collect and transport domestic kerbside waste effectively and process it at a low cost. The Councils also effectively process waste placed in green-lid and yellow-lid bins, but neither Council has been able to enforce their contracts for processing red-lid bin waste. As a result, almost all such waste goes straight to landfill.
Local councils provide waste management services to their residents. They collect domestic waste primarily through kerbside services, but also at council drop off facilities. Waste management is one of the major services local councils deliver. Each year, councils collectively manage an estimated 3.5 million tonnes of waste generated by New South Wales residents.
Waste disposed of in landfills attracts a NSW Government waste levy. Councils’ kerbside services help residents to separate recyclable and non recyclable waste. This reduces the cost of waste disposed to landfill. These services typically provide yellow-lid bins for dry recyclables, green-lid bins for garden organics and red-lid bins for residual waste. To increase the level of recycling, some councils deliver residual waste to alternative waste treatment facilities for processing. This can involve composting and the recovery of resources, including plastics and metals, which can be recycled.
Appendix one - Responses from local councils
Appendix two - About the audit
Appendix three - Performance auditing
Parliamentary Reference: Report number #320 - released 5 June 2019
Actions for Workforce reform in three amalgamated councils
Workforce reform in three amalgamated councils
The Inner West Council and the Snowy Monaro and Queanbeyan-Palerang Regional Councils have all made progress towards efficient organisational structures following the amalgamation of their former council areas in 2016, according to a report released today by the Auditor-General of New South Wales.
All three councils are now operating with a single workforce and have largely achieved the milestones they planned for the first stage of their amalgamations. None have finished reviewing and aligning services across their former council areas nor integrated their ICT systems. They need to do this to be in a position to implement an optimal structure.
On 12 May 2016, the NSW Government announced the amalgamation of 42 councils into 19 new councils. This followed a period of 18 months during which the NSW Independent Pricing and Regulatory Tribunal (IPART) had assessed councils' ‘fitness for the future’, and communities were consulted about proposed mergers. A further amalgamated council was created on 9 September 2016.
Upon amalgamation, existing elected councils were abolished, interim General Managers appointed, and Administrators engaged to undertake the role of the previously elected councils until Local Government elections were held 18 months later. During the period of administration, councils were asked to report on the progress of their amalgamations to the Department of Premier and Cabinet (DPC).
Council amalgamations not only require a re-drawing of boundaries, but re-establishment of local representation, decisions about alignment of services across the former council areas, and establishment of an amalgamated workforce.
The objective of this audit was to assess whether three councils, Inner West Council, Queanbeyan-Palerang Regional Council and Snowy Monaro Regional Council, are effectively reforming their organisation structures to realise efficiency benefits from amalgamation and managing the impact on staff.
Following amalgamation, all three councils developed detailed plans to bring their former workforces together, review positions and salaries, amalgamate salary structures and align human resources policies. All three councils have largely achieved the milestones included in these plans.
Benefits realisation plans show that councils did not expect to achieve material savings or efficiencies from workforce reform within the first three years of amalgamation.
Administrators at all three councils endorsed lower savings targets than the NSW Government’s early analysis suggested may be possible. All three councils have plans or strategies to progress and achieve benefits from the amalgamation. However, Inner West Council and Snowy Monaro Regional Council could more clearly link their reform initiatives with expected benefits and include this in public reporting.
Amalgamations represent a substantial period of change for affected communities and amalgamated councils should be routinely reporting to their communities about the costs and benefits of amalgamation.
Councils have not yet determined their future service offerings and service levels nor completed integration of ICT systems. These decisions need to be made before an optimal organisation structure can be implemented.
Before amalgamated councils can implement an optimal organisation structure, they need to review and confirm their customer service offerings and service levels in consultation with their communities. This work is underway but is not yet complete in any of the councils.
Progress towards an efficient structure has been slowed by staff protections in the Local Government Act 1993 (the Act) and a range of logistical and administrative issues associated with amalgamation. These include multiple IT systems and databases that need to be integrated and different working conditions, policies and practices in the former councils that are not yet fully
harmonised.
The councils implemented legislated staff protections and focused on the people side of change but cannot reliably measure the impact of their change management efforts.
The Act provides protections that reduce the impact of amalgamations on staff. Beyond implementing these protections, the councils have communicated with staff, sought to prepare them for change, and involved staff in key decisions. All councils have conducted staff surveys over time. However, at this stage these staff surveys have not provided an effective or reliable measure of the impact of change management efforts.
Appendix one - Response from councils and Office of Local Government
Appendix two - Compliance with staff protections in the Local Government Act 1993
Appendix three - About the audit
Appendix four - Performance auditing
Parliamentary Reference: Report number #317 - released 1 May 2019
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