Reports
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
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Managing demand for ambulance services 2017
NSW Ambulance has introduced several initiatives over the past decade to better manage the number of unnecessary ambulance responses and transports to hospital emergency departments. However, there is no overall strategy to guide the development of these initiatives nor do NSW Ambulance's data systems properly monitor their impact. As a result, the Audit Office was unable to assess whether NSW Ambulance's approach to managing demand is improving the efficiency of ambulance services.
NSW Ambulance uses a telephone referral system to manage triple zero calls from people with medical issues that do not require an ambulance. This has the potential to achieve efficiency improvements but there are weaknesses in NSW Ambulance's use and monitoring of this system. Paramedics are now able to make decisions about whether patients need transport to a hospital emergency department. NSW Ambulance does not routinely measure or monitor the decisions paramedics make, so it does not know whether these decisions are improving efficiency. Extended Care Paramedics who have additional skills in diagnosing and treating patients with less urgent medical issues were introduced in 2007. NSW Ambulance analysis indicates that these paramedics have the potential to improve efficiency, but have not been used as effectively as possible.
Our 2013 audit of NSW Ambulance found that accurate monitoring of activity and performance was not being conducted. More than four years later, this remains the case.
NSW Ambulance has recognised the need to change the way it manages demand and has developed initiatives that have the potential to improve efficiency. However, there are significant weaknesses in the strategy for and implementation of its demand management initiatives.
NSW Ambulance has identified the goal of moving from an emergency transport provider to a mobile health service and developed several initiatives to support this. Its demand management initiatives have the potential to contribute to the broader policy directions for the health system in New South Wales. However, there is no clear overall strategy guiding these initiatives and their implementation has been poor.
NSW Ambulance's reasons for changing its approach to demand management have not been communicated proactively to the community. Demand management initiatives that have been operating for over a decade still do not have clear performance measures or targets. Project management of new initiatives has been inadequate, with insufficient organisational resources to oversee them and inadequate engagement with other healthcare providers.
NSW Ambulance uses an in-house Vocational Education and Training course to recruit some paramedics, as well as recruiting paramedics who have completed a university degree. No other Australian ambulance services continue to provide their own Vocational Education and Training qualifications. Paramedics will need more support in several key areas to be able to fulfil their expanded roles in providing a mobile health service. Performance and development systems for paramedics are not used effectively. Up to date technology would help paramedics make better decisions and improve NSW Ambulance's ability to monitor demand management activity.
There are gaps in NSW Ambulance's oversight of the risks of some of the initiatives it has introduced, particularly its lack of information on the outcomes for patients who are not transported to hospital. Weaknesses in the way NSW Ambulance uses its data limit its ability to properly assess the risks of the demand management initiatives it has introduced.
Parliamentary reference - Report number #295 - released 13 December 2017
Planning and evaluating palliative care services in NSW
NSW Health’s approach to planning and evaluating palliative care is not effectively coordinated. There is no overall policy framework for palliative and end-of-life care, nor is there comprehensive monitoring and reporting on services and outcomes.
Parliamentary reference - Report number #291 - released 17 August 2017
Purchasing Hospital Supplies: Follow-up of 2002 Performance Audit
Periodically we review the extent to which agencies have changed their practices as a result of our audits. This gives Parliament and the public an update on the extent of progress made.
In this follow-up audit, we examine changes following our September 2002 report, to assess whether NSW Health has improved its buying of hospital supplies using electronic systems.
NSW Health spends over $1.3 billion on hospital supplies. It is the largest expenditure area after employee costs. Reform of this area has the potential to make significant savings that could be redirected to frontline services.
As part of our series of audits in the area of e-government, our previous audit looked closely at the extent to which technology was being used to deliver potentially major savings in purchasing hospital supplies. This is a key area of so-called “process re-engineering” in the “e” field, and NSW Health provided an ideal case study.
Whilst implementing large-scale e-procurement has many technical aspects, it is not chiefly a technical issue. The key requirements for success reside in effective change management, in particular being clear as to who has the authority to make change decisions and be held accountable.
This audit looks at NSW Health’s successes to date, and its frustrations and challenges in making further progress in this field. Many of the issues raised in this report may provide lessons for any agency that is seeking to drive a significant change program.
Parliamentary reference - Report number #145 - released 23 November 2005
Implementing Asset Management Reforms
Hospitals, schools, public housing, roads, bridges, buses and trains are just some of the assets used by government in providing services to citizens.
The NSW Government’s asset base is impressive in size - with a value of around $167 billion and with government plans to spend around $8 billion acquiring or replacing assets in the current year. Another $2 billion is spent each year on maintenance.
Good asset management is very important to government; even a small efficiency gain in this area can provide significant returns. Good practice by those responsible for managing assets can improve reliability, extend asset life, save on maintenance costs and aid in identifying and disposing of unnecessary or non-performing assets.
Improving the NSW public sector’s approach to asset management has been on the reform agenda for at least a decade. Changes in practice have been accelerated more recently by integrating asset management policy with the budget process.
In this audit we examined NSW Treasury’s efforts to improve asset management practices in the public sector and the progress made by 3 agencies - the Department of Corrective Services, NSW Fire Brigades and the Powerhouse Museum - towards better managing their asset portfolios.
This report informs Parliament and the community on progress to date and what more needs to be done to ensure that agencies manage assets effectively and achieve best value.
Parliamentary reference - Report number #143 - released 12 October 2005
Emergency Mental Health Services
It is estimated that one in five people will be affected at some stage by a mental health problem or illness. The increasing prevalence of mental illness means that at some point in time most of us will either be affected or we will know of someone who is.
Although most people with mental illness can be treated in the community, at times some may require emergency treatment or admission to hospital for shortterm intensive therapy.
Not only are more mental health patients presenting to an emergency department for treatment than ever before, they are reportedly sicker and a greater number require admission to a hospital bed for further treatment. And, because of its very nature, those suffering from acute mental illness may not understand what is wrong or be able to communicate their problems clearly.
This makes access to emergency mental health services a significant issue for government that requires continuing attention.
The focus of this report is on the provision of 24-hour crisis services to adults. Emergency mental health services play a vital role in providing timely and appropriate care. Without proper treatment the severity of the illness may escalate, increasing the risk of self-harm or harm to others.
There have been many changes to mental health services over the last decade to deal with increasing demand. Much has been done to improve access to, and the quality of emergency services through significant increases in funding, the opening of new beds and the employment of more mental health staff.
Yet recent reviews have highlighted problems with accessing mental health beds and inadequate levels of psychiatric support in rural areas.
I believe that our report will provide valuable assistance to area health services on alternative models of emergency mental health care that better manage patient risk and further improve service quality.
Parliamentary reference - Report number #136 - released 26 May 2005
Follow-up of Performance Audit: Collecting Outstanding Fines and Penalties
Periodically we review the extent to which agencies have implemented the recommendations they accept from our earlier audits. This gives Parliament and the public an update on the extent of progress made.
In this follow-up audit, we examine changes following our April 2002 report on how well the State Debt Recovery Office (under the Office of State Revenue) was collecting outstanding fines and penalties.
Parliamentary reference - Report number #132 - released 17 March 2005
