Evaluation of the Child Health Check Initiative and the Expanding Health Service Delivery Initiative - Final Report

7.2 The Expanding Health Service Delivery Initiative

Evaluation of the Child Health Check Initiative and the Expanding Health Service Delivery Initiative - Final Report

Page last updated: 17 April 2012

7.2.1 Service delivery
7.2.2 Leadership and governance
7.2.3 Health workforce
7.2.4 Financing
7.2.5 Information

The expansion and reform of health services in the NT is a significant and complex program of change and is not without challenges and risks. The overall message is that the program is heading in the right direction. The partnership between governments and the Aboriginal community controlled health sector is critical and well positioned to take the agenda forward. There has been significant progress to date which, given sufficient time and resourcing, is likely to bring improvements in health service delivery and outcomes.

7.2.1 Service delivery

This building block is concerned with how health services are planned, organised and managed to deliver effective population-level outcomes. The contribution of the EHSDI to service delivery has, to date, largely been through additional resources for expanded provision of PHC services, including staff positions and infrastructure. The impact of this on how services are planned, organised and delivered is only really measurable in terms of inputs into the system, as it is too early to measure tangible results. This section therefore considers the funding and staffing inputs into service delivery. Additional recommendations on workforce and financing are in Sections 7.2.2 and 7.2.3.

The main findings are:
  • the EHSDI provided a significant increase in remote PHC funding in the NT, adding 17 per cent to the overall budget in 2008–09 and 28.6 per cent in 2009–10
  • the EHSDI is contributing to more equitable distribution of resources across the NT, with regions furthest from their EHSDI benchmark making the greatest progress towards it
  • the EHSDI funded 251 FTE positions in the remote PHC workforce. This included an initial investment in non-clinical management positions, with greater focus on ‘front-line’ health practitioners in 2009–10.
  • there is some evidence that health clinics are providing additional services with a population health and preventative care focus, but also that extra resources are being diverted into acute care. Because of the increased workforce there is considerable potential for expanding the scope of PHC
  • recruitment and retention of health professionals remains a challenge and there is a lack of appropriate recruitment, training (including workplace training) and support opportunities for AHWs. This is a significant issue facing the NT remote health system
  • the roll-out of capital and infrastructure funding lacked a clear investment strategy and was poorly aligned with the release of funding for service expansion. Combined with the pressure to spend funds quickly under the initial two-year EHSDI time frame, this led to many cases of inefficient spending
  • the current level of funding, even if all HSDAs received 100 per cent of their EHSDI benchmark, falls short of the level required to provide access to the full range of core PHC services. The health needs of the NT remote Indigenous population are such that they require a higher level of funding than non-Indigenous Australians to achieve similar outcomes.

Recommendation 5-The NT AHF should develop an accurate costing model for delivering core PHC services to remote areas.

The costing model should incorporate regular reviews to ensure that it remains valid, accurate and appropriate. These reviews should be linked to reviews of national health funding systems, such as the MBS, to ensure that NT remote health funding increases in line with mainstream health funding. The model needs to include measures of funding equity, both between the NT and the rest of Australia and between NT regions. To be equitable, the model will need to correct for the costs associated with service delivery to geographically remote Aboriginal communities and the magnitude of improvement in health status that would be needed for people in remote Aboriginal communities to achieve the same health outcomes as other Australians.

Recommendation 6-The Australian Government and the NT Government should agree to a financing 
model that:

  • provides a funding pathway that enables the provision of core PHC services in all proposed HSDAs on the basis of the costing model (recommendation 5) within five years
  • commits to ongoing funding for three to five years to enable health providers to plan for the longer-term provision of core PHC services.
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7.2.2 Leadership and governance

Leadership and governance is concerned with system-wide policy, strategic oversight and collaboration. It is ‘arguably the most complex but critical building block of any health system’ (WHO 2007). The number and range of organisations and structures with an interest in the NT PHC system, coupled with the scale and complexity of the reform program, make matters of leadership and governance-including role clarification, relationships and communication-critical.

Our main findings on leadership and governance are:
  • the existing governance framework provided by the NT AHF has enabled the sudden increase in resourcing under the EHSDI to be managed within existing systems. The strategic partnership between the Australian Government, the NT Government and the Aboriginal community controlled sector, embodied in the NT AHF, is well positioned to provide the leadership needed to continue to implement the program of PHC reform and expansion
  • the NT AHF partner organisations have a number of roles in the system: national health policy, funding and purchasing (DoHA); provision of remote PHC services (DHF, AMSANT); provision of secondary and referred services, other social services, NT policy and health system monitoring (DHF); and consumer voice (AMSANT). The NT AHF’s dominant strength is in the provision of governance, leadership and oversight rather than in developing implementation policy for the reforms
  • the PHRG is the ‘engine room’ of the reform program; however, it is under-resourced for the magnitude of the task. Policy capacity in the NT for the implementation of the reform program will need to be enhanced if the pace of change is to be sustained
  • regionalisation and Aboriginal control are not synonymous. One is primarily about increasing critical mass for service efficiency and effectiveness; the other is about control by Aboriginal communities, which may not currently be organised around regions. Movement towards Aboriginal control and regionalisation are necessary steps, though insufficient on their own, to ensuring high-quality PHC delivery for remote NT Aboriginal populations
  • to date, community involvement in the delivery, management and control of PHC services has not changed significantly as a result of EHSDI regionalisation activities. A major challenge is to engage with community members in such a way that they are confident that increased community control and the move to regionalised ACCHOs will deliver improved health services and health outcomes
  • RaDU has not yet been required to provide formal governance and other training, and capacity-building activities to empower Aboriginal leadership and governance. People who will be involved in new health boards in at least two proposed HSDAs will soon need this training to be able to meet the standards set out in the draft Regionalisation Competency and Capability Support Framework (DHF 2010). This is a central aspect of the reform program, and further work is required to clarify how capacity building will be carried out
  • there appears to be some ambivalence among the NT AHF partners about the establishment of regional ACCHOs. Communication within and across the NT AHF partners about increasing community control and regionalisation has not been consistent and there appear to be varying degrees of ‘buy-in’ to the concept. RaDU’s role in leading the process will remain problematic while mixed messages from the leading organisations persist
  • the regionalisation component of the EHSDI has been under-scoped and under-resourced, and the partners are not currently ‘speaking with one voice’. The NT AHF partners need to confirm agreement on the aims and expectations of regionalisation (for example with regard to efficiency, quality, equity of access and community control) and ensure that these remain as central principles or outcomes of the transition to regional Aboriginal community control of health services. The NT AHF then needs to be clearer about how to progress the different components of the regionalisation process (such as merging health services, decentralising DHF services and establishing new regional structures) in support of these principles or outcomes. If this does not occur the process may deliver other outcomes
  • the PHRG is considering the breadth of PHC delivered through community health services. If this approach is taken at a systems level there will be benefits in adopting a people-centred approach with PHC as the platform that guides people through the health system (for example into secondary and other specialist care) rather than as a layer of care; engaging more explicitly with the social determinants of health in tackling poverty, housing and other wider determinants more directly; and reviewing the role and expanding the current concept of hub services
  • further reform of the remote NT PHC system needs to consider the impact of the evolving Australian Government PHC reforms
  • a perception that the NT Government lacks capacity and capability needs to be addressed by both the Australian Government and the NT Government. A whole-of-government approach is required with the two governments working together to improve remote Aboriginal health, supported by adequate resourcing.

Recommendation 7-The NT AHF partners should review current governance and leadership arrangements focusing on the need to bring coherence to functional areas including policy and funding. As part of this review, we recommend:

  • that the governance function, which should continue to be provided by the NT AHF, focus on providing strategic leadership across the health sector including primary and secondary care and monitoring the reform process
  • considering mechanisms for strengthening consumers’ voices (such as the Health Complaints Commission) to act as vehicles for communicating consumers’ experience of health services. The NT AHF should formally consider the Health Complaints Commission’s reports as a means of consumer input into its decisions, outside the interests of provider organisations
  • increasing policy capacity in the NT to sustain the pace and effectiveness of the reform agenda and to effect the intended changes. This might involve establishing a combined AMSANT, DHF and DoHA capacity or increasing the capacity of individual partners in the NT with strong inter-agency protocols and processes for efficient and effective policy development
  • implementing the NT AHF communications strategy. This will support a more consistent and coherent approach between partners so consistent messages are communicated to stakeholders about the reforms.

Recommendation 8-In further reforming the NT remote health system, the NT AHF partners 
should consider:

  • further expanding the scope of PHC to include a wider range of services
  • taking responsibility for linking health development with the wider social determinants of health
  • adopting a stronger focus on people-centred care and the patient journey through the health system.
Future reforms need to be consistent with current Australian Government health reforms.

Recommendation 9-Under the direction of the NT AHF, re-scope the regionalisation process and the NT AHF partners’ expectations to more clearly identify:

  • the tasks involved
  • the actions and resources required
  • who should undertake the work
  • a delivery time frame that is consistent with the communities’ wishes.
This exercise should consider the following components of regionalisation:
  • the merger of ACCHOs and building community capacity to contribute to the planning and governance of health services
  • decentralisation and a move to community control of DHF clinics
  • establishing and supporting new regional structures
  • repositioning the system’s policy capacity to focus on the issue of implementation.

7.2.3 Health workforce

There are a range of significant workforce issues across the NT remote PHC sector. The evaluation focused on the RAHC as a specific service delivery model. We found that:
  • the RAHC has added to the workforce capacity in the NT; however, it has not yet had a consistent impact across all sectors, it is uncertain about which needs it is addressing, and there are widely different views on its value
  • the RAHC model focuses on one workforce issue: the provision of health professionals for short-term placements in remote communities. There is a lack of coordination with other workforce planning and development initiatives
  • a lack of workforce data across the NT PHC system and limited information on other models of workforce service delivery makes it difficult to judge the effectiveness and efficiency of the RAHC model
  • many longstanding workforce issues remain a challenge, and workforce continues to be one of the key barriers to improving PHC services in remote communities. These issues include concern over AHW training arrangements, staff accommodation shortages, high staff turnover and reliance on casual staff.

Recommendation 10-Develop a comprehensive workforce strategy for the NT remote PHC sector including strategies to increase Aboriginal employment in the PHC sector. The strategy will need to reflect new and proposed regional service delivery models, including the responsibilities of regional ACCHOs.

Recommendation 11-Address the current inadequacies within the system for recruiting, training and supporting AHWs.

Recommendation 12-The future of the RAHC model should be considered by the three NT AHF partners within the context of the wider workforce issues in the NT to ensure a coordinated approach to workforce issues across the system (such as for DHF/ACCHO sectors, short-term/permanent and clinical/non-clinical) and within the context of the future recruitment needs of the 14 proposed regionally-based Aboriginal controlled PHC services.

7.2.4 Financing

This building block covers the level of funding in the health system and how funding is managed. The key findings are listed below:
  • EHSDI investment has been substantial-around $89 million to 30 June 2010, including around $48 million on service expansion, $15 million on capital and infrastructure and $11 million on workforce including the RAHC
  • although the EHSDI benchmark funding methodology is not an accurate reflection of the costs required to deliver PHC services to remote communities, the use of a transparent funding model has partly reduced inequitable resource allocations at a regional level
  • despite the gains made under the EHSDI there remains a substantial gap between current funding levels and the level of resourcing needed to provide a full range of core PHC services
  • the time frames to get money on the ground have not always allowed for well-developed plans and this has led to inefficiencies in EHSDI spending. For example, funding for more staff has not always been aligned to infrastructure funding for housing
  • the multiple contracts and funding sources have overburdened health service providers with reporting requirements and contractual negotiations.

Recommendation 13-Consideration should be given to establishing a health service purchasing body that funds all health services in the NT and consolidates PHC funding so that providers only report to a single program funding source.

This will address issues associated with the inefficiencies of multiple contracts and funding sources.

Also see recommendations 5 and 6.
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7.2.5 Information

This building block covers the production, analysis, dissemination and use of information on health determinants, health systems performance and health status. We have also included two recommendations on the use of data (based largely on the CHCI evaluation) and on the future monitoring and evaluation of the EHSDI (based on the analysis in Section 7.3).

Our main findings are the following:
  • some progress has been made in implementing the EHSDI CQI strategy, including the employment of two lead CQI Coordinators, the development and endorsement of a CQI model and the recruitment of regionally based CQI Facilitators
  • the CQI process has documented support for its ability to improve health service delivery and contribute to health outcomes. Investment in CQI should be continued
  • introducing and implementing the system-wide NT AHKPIs has been a remarkable achievement
  • while there is comprehensive coverage in the collection and reporting of NT AHKPIs, the integrity of the data is not currently sufficient to allow for accurate reporting across the system
  • there is cautious enthusiasm for the NT AHKPIs among health service providers, although their use is currently hindered by lack of understanding and guidance on how to interpret and use the results to inform health service planning
  • in gathering information on health service processes and outputs, the NT AHKPIs will be a useful tool for performance reporting and accountability
  • at present the NT AHKPIs monitor activities and quantifiable outputs but do not provide data on the impacts or health outcomes of such activities. Because of this they cannot provide sufficient data to evaluate the performance of health services in terms of their impact on Aboriginal health
  • the NT AHKPIs have different value to different audiences. They are useful to middle management, such as the PHRG, who will be well aware of the context of the data. Government officials value their potential to establish benchmarks for measuring progress towards health system goals and to provide an evidence base for policy decisions
  • the NT AHKPIs could be made more useful by expanding the scope of the indicator set to include outcome and impact measures, and supplementing the numerical data with contextual explanation.

Recommendation 14-Continue to invest in CQI, giving priority to providing training for all levels of health service staff, developing resources and tools for supporting its use and undertaking a formative evaluation of the CQI program to determine future development and investment.

Recommendation 15-Once the integrity of the NT AHKPI data at the system level can be assured, the NT AHF should use the data to supplement a more contextualised description (including of the likely impact of any other factors on service activities and health outcomes), to report to decision makers on the population health needs of remote Aboriginal communities and the progress of services in responding to these needs.

This is in addition to the primary use of the data to report to health boards and communities.

Recommendation 16-Ensure there is sufficient capacity at all levels of the PHC system (centrally, regionally and locally) to enable the effective use of data.

This should take into account:
  • developing data access protocols in partnership with ACCHOs
  • refocusing the orientation of data collections to enable and promote the use of data at all levels of the PHC system
  • supporting health services to use data on a broad range of PHC and social support services (not only clinical data) for planning and reporting.
Recommendation 17-The NT AHF partners should engage with key stakeholders across the NT PHC system to identify the purpose of, and priority questions for, future monitoring and evaluation of the different elements of the system reform.

This should take into account:
  • the existing EHSDI goals and objectives, the PHRG’s health systems planning framework and this report’s evaluation findings
  • stakeholders’ current expectations of program success criteria and anticipated program outcomes
  • establishing specific indicators to monitor the progress of key elements of the reform program (such as efficiency indicators for regionalisation and workforce and funding indicators).
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