Background

1. Under the Migration Act 1958 (the Act), a person who is not an Australian citizen and does not hold a valid visa is an unlawful non-citizen. The Act requires unlawful non-citizens to be detained until they are removed from Australia, granted a visa or removed to a regional processing country. The Department of Immigration and Border Protection (DIBP) administers the Act and the Government’s policy in relation to immigration detention.

2. Immigration detention in Australia occurs in held facilities and community detention, and is collectively known as ‘onshore’ detention. The total onshore detainee population reduced significantly over the period from July 2014 to May 2016—from 6730 to 2228 detainees. As at 31 May 2016, there were 1570 detainees in held detention and 658 in community detention. With the exception of Christmas Island Detention Centre (located in the Indian Ocean 2600 kilometres north-west of Perth) and Yongah Hill Detention Centre (located 100 kilometres east of Perth), all detention facilities are located in capital cities.

3. The department is responsible for providing a range of services to people in immigration detention, including health care. A specialist provider of medical services, International Health and Medical Services (IHMS), has been contracted by the department to deliver health services in held and community detention under several contracts since 2004. The current contract is valued at $438 million over the five year period from December 2014 to December 2019.

Audit objective and criteria

4. The objective of this audit was to assess the effectiveness of the Department of Immigration and Border Protection’s administration of health services in onshore immigration detention.¹ To form a conclusion against this objective, the ANAO adopted the following high-level criteria:

• Was a robust contract in place to support the effective and efficient delivery of health services?
• Were effective arrangements established to monitor health service provision and manage the contractor’s performance?
• Was health service delivery and contractor performance appropriately monitored?

Conclusion

5. The department’s administration of health services in onshore immigration detention has been improved by the strengthening of contractual arrangements with the selected provider of health services. The current contract, which was developed by the department based on a strategic analysis of shortcomings that had arisen under earlier contracts, includes: mechanisms to control the risk of over-servicing and uncontrolled cost escalation; clearly defined deliverables; and a performance monitoring regime containing provisions for the application of penalties and incentives. However, to be able to give assurance that contract objectives are being achieved, there is further scope for the department to improve its administration of health service delivery, primarily through strengthening arrangements for monitoring:

• the quality of the health services that are being delivered; and
• key areas of health service delivery risk (such as services to detainees with mental health conditions).

Supporting findings

Developing the contractual framework

6. The approach developed by the department to coordinate and deliver health services and detainee/facility services in onshore detention incorporated learnings from previous contracts and was appropriate to guide the design of the new detention services contracts. The department developed a common contractual approach aimed at achieving efficiencies and encouraging greater coordination of service delivery. Work was also undertaken by the department to determine the strategic directions that the new contracts should adopt, which included a focus on controlling the cost of services and the risk of over-servicing, and on monitoring outcomes rather than processes. The performance monitoring regime established under the contracts was designed to support the achievement of program outcomes, primarily through the use of financial incentives and abatements to drive contractor performance.

7. The deliverables expected from the health service provider were clearly defined in the contract, but there were weaknesses in the department’s approach to the assessment of risks to the achievement of contractual objectives. The contract presents a balanced mix of outcome-based expectations (such as delivering health services that are responsive to a detainee’s changing medical needs) and more prescriptive requirements (such as a focus on mental health and health screenings throughout the time detainees spend in detention). Several supporting policy documents, referenced in the contract, further define the expected health outcomes. The department’s consideration of risks to the achievement of contractual objectives was, however, primarily focused on addressing risks that arose under the previous contract. A broader analysis of the key risks to achieving the objectives of the health service contract, including those related to the new service delivery model proposed by the contractor, would have better informed the department’s design of the contract and of the performance monitoring arrangements.

8. The 17 performance measures developed by the department to monitor the provision of health services in onshore detention target important aspects of contractor performance and are aligned with the deliverables specified under the contract. However, as at March 2016, only nine of the 17 measures had an appropriate methodology in place to assess contractor performance. The remaining measures were not being effectively monitored by the department, with methodologies that were partially or not implemented. In particular, the key measure to assess the quality of primary health care was yet to be monitored 15 months after the contract was signed. The limited focus on measuring the quality of service delivery and significant delays in finalising measurement and verification activities undermines the assurance that the department obtains in relation to the achievement of contractual objectives.

Monitoring delivery of health services

9. Notwithstanding the weaknesses in the performance measurement framework established under the contract, the department has been applying the risk ratings, incentives and abatements established under the contract to drive service delivery and continuous improvement. The application of the penalty and incentive regime under the new contract has resulted in the contractor being abated over $300 000 in the first six months of operation (approximately two per cent of the contractor service fee value).

10. There are aspects of the delivery of health services in detention where existing monitoring arrangements do not provide a sufficient level of assurance to the department that services are being delivered as intended. These aspects relate most notably to community detention, mental health care, medication management and timely and clinically appropriate access to health services. Specifically, performance information was either not collected, or did not target those areas of greatest risk.

11. The department’s arrangements to support health services in detention are primarily focused on the monitoring of, and response to, issues as they occur. There is insufficient analysis of the information that the department collects, for instance in relation to incident reports and complaints, to inform a more proactive management of issues. The management of key administrative processes that support the delivery of health services and the contractual partnership with the provider should also be more timely. In particular, the finalisation of the policy and procedures manual and the delivery of facility acceptance certificates remained outstanding as at March 2016—12 months after they were scheduled for completion. The department has recognised that there is scope to improve its management of clinical issues relating to the delivery of health services in onshore detention. A centralised health structure, including clinically trained staff, has been established within the department to improve clinical oversight of the health service delivery.

Recommendations

Summary of entity responses

12. The Department of Immigration and Border Protection’s summary response to the proposed report is provided below, while its full response is at Appendix 1.

The Department recognises and appreciates the efforts of the Australian National Audit Office staff who conducted the audit. This audit provides timely assurance over our administration of health services in onshore immigration detention.

The Department agrees with the recommendations of the report and has work underway to continue to improve our administration of these services.

13. International Health and Medical Services (IHMS) was provided with an extract of the proposed report. IHMS’s full response is at Appendix 1.

Introduction

1.1 Immigration detention is a key element of Australia’s migration system. Under the Migration Act 1958 (the Act), a person who is not an Australian citizen and does not hold a valid visa is an unlawful non-citizen. The Act requires unlawful non-citizens to be detained until they are removed from Australia, granted a visa or removed to a regional processing country.

1.2 The Department of Immigration and Border Protection (DIBP) administers the Act and the Government’s policy in relation to immigration detention, including the administration of a network of onshore immigration detention centres. Following the integration of DIBP and the Australian Customs and Border Protection Service from 1 July 2015, the Australian Border Force (ABF) is now responsible for the department’s operational functions, including visa compliance, detention, removals and support for regional processing arrangements. The department’s administration of immigration detention is delivered under Program 1.3–Onshore Compliance and Detention and Program 1.4–Illegal Maritime Arrival Offshore Management, which collectively have estimated expenses of $2.6 billion in 2016–17.²

1.3 Detention occurs in held facilities and community detention. Immigration detention in Australia is collectively known as ‘onshore’ detention, and is administered by the department’s Detention Services Group. The delivery of services in offshore detention centres (at Regional Processing Centres in the Republic of Nauru and in Manus Province, Papua New Guinea) is also administered by the Detention Services Group, but under separate contracts to onshore detention. The examination of the delivery of services in the offshore detention system was not within the scope of this audit.³

Onshore detention

1.4 A person can be an unlawful non-citizen due to:

• arriving in Australia without a valid visa—including Illegal Maritime Arrivals, illegal airport or seaport arrivals, and illegal foreign fishers⁴;
• overstaying a visa—for example, overstaying a tourist or student visa, or being identified and detained as part of an Australian Border Force compliance operation; or
• having a visa cancelled—including those visas cancelled for failure to meet the Act’s character test. These detainees are commonly known as ‘501s’, a reference to the provision of the Act that empowers the cancellation of a visa.

1.5 The total onshore detainee population reduced significantly over the period from July 2014 to May 2016—from 6730 to 2228 detainees. As at 31 May 2016, there were 1570 detainees in held detention and 658 in community detention.

1.6 Over the same period, the profile of the onshore population in detention changed substantially, with the representation of Illegal Maritime Arrivals falling from 91 per cent (6093 detainees) to 53 per cent (1171 detainees), and detainees held under the 501 character provision increasing from two per cent (106 detainees) to 26 per cent (578 detainees).⁵ The population of detainees in onshore detention by detainee category (since July 2014) is shown in Figure 1.1.

Figure 1.1: Detainee numbers by category in onshore held detention, July 2014 to May 2016

Note: The ‘Others’ category includes visa overstayers, illegal foreign fishers, non-immigration cleared air and sea arrivals, stowaways and ship deserters.

Source: ANAO analysis of departmental reports.

1.7 With the exception of Christmas Island detention centre (located in the Indian Ocean 2600 kilometres north-west of Perth) and Yongah Hill detention centre (located 100 kilometres east of Perth), all detention facilities are located in capital cities. Figure 1.2 shows the locations of Australian detention facilities.

Figure 1.2: Immigration detention facilities, May 2016

Note 1: The number of detainees as at 31 May 2016 is indicated between brackets.

Note 2: Immigration detention centres provide accommodation for medium and high risk detainees. Immigration residential housing provides a more domestic detention environment where detainees are able to cook their own food and control many aspects of their household. Immigration transit accommodation provides hostel-style accommodation that includes food services as well as self-catering for snacks. Alternative places of detention are used for minimum risk detainees, in particular families, children and detainees in need of medical treatment.

Source: ANAO analysis of departmental information.

Health service delivery in immigration detention

1.8 The department has a duty of care to prevent any reasonably foreseeable harm to detainees⁶ and is responsible for providing a range of services to detainees, including:

• general services, such as meals, education, recreation and religious activities. These services are delivered by the contracted provider of detainee and facility services⁷;
• care arrangements for unaccompanied minors—delivered by the Australian Red Cross and the contracted provider of detention services; and
• health care.

1.9 Health care services—to detainees located in both held and community detention—are delivered and facilitated by International Health and Medical Services (IHMS), a subsidiary of International SOS.⁸ IHMS has delivered health services in immigration detention under previous contracts since 2004, with the department and IHMS entering into the most recent contract on 11 December 2014. IHMS was selected to deliver health care services in held and community detention following a tender process that commenced in April 2014. The current contract is valued at $438 million over the five-year contract period from 11 December 2014 to 10 December 2019. The contract includes options to extend the term of the contract to 2023.

1.10 The manner in which health care services are delivered in detention under the current contractual arrangements is outlined below.

Audit approach

1.11 The objective of this audit was to assess the effectiveness of the Department of Immigration and Border Protection’s administration of health services in onshore immigration detention.

1.12 To form a conclusion against this objective, the ANAO adopted the following high-level criteria:

• Was a robust contract in place to support the effective and efficient delivery of health services?
• Were effective arrangements established to monitor health service provision and manage the contractor’s performance?
• Was health service delivery and contractor performance appropriately monitored?

1.13 The scope of the audit included an examination of the provision of health services in held detention facilities in Australia, as well as services made available under the community detention program. Given the relatively early stage of implementation of the new contract, the ANAO’s examination was necessarily limited to reviewing establishment activity. The audit did not examine the procurement process for the delivery of health services. Further, the audit did not include an examination of the delivery of health care services in Regional Processing Centres, as these services are delivered under separate contractual arrangements. Where offshore detainees are brought to Australia for a temporary purpose, the administration of health services to these detainees whilst in Australia was examined as part of the audit.

1.14 In undertaking the audit, the ANAO:

• reviewed relevant department and IHMS files and documentation, including policies and procedures, correspondence, performance reports and complaints;
• collected and analysed administrative data relating to the delivery of health services;
• visited a selection of detention facilities;
• interviewed key departmental and IHMS personnel and key external stakeholders; and
• interviewed detainees in held and community detention.

1.15 The audit was conducted in accordance with the ANAO’s Auditing Standards at a cost to the ANAO of approximately $567 000.

Did the department develop an appropriate approach to coordinate and deliver onshore detention services?

2.1 As outlined earlier, International Health and Medical Services (IHMS) has delivered health services in immigration detention since 2004. Over the course of the previous contract (2009–14), a range of changes occurred in the immigration environment, in particular the rapid growth in the number of people in detention and consequent increase in the number of detention facilities. These changes required health services to be adapted and scaled up or down at very short notice. The contract, assessed by the department as prescriptive and lacking flexibility, did not adequately allow for these necessary adjustments. The resulting situation was one where: services delivered did not always match contract specifications; variations to the contracts were formalised sometime after the changes had been implemented; and the department incurred significant additional costs not envisioned at the time that the original contract was endorsed. Performance monitoring was also assessed by the department as being ineffective (for instance, the system of incentives and abatements was not implemented until the final 11 months of the contract period).

2.2 In December 2013, when planning for the re-tendering of the health service contract, the Government indicated, through a letter from the Prime Minister to the Minister for Immigration and Border Protection, its expectation that the total costs and the cost per detainee would be lower in the new contract. In this context, the department developed the following strategic directions to guide the formation of new contracts for health services and for facilities and detainee services:

• an alignment between the two contracts—aimed at better utilising the department’s corporate knowledge, identifying internal process efficiencies, and fostering productive relationships between all service providers;
• a focus on fixed pricing—the new contracts required the service provider to determine a fixed fee to cover all services and activities necessary to meet the health care needs of detainees. Any additional service requests would only be used in exceptional circumstances. This approach was aimed at reducing the risk of ‘over-servicing’;
• a risk-based performance management framework—focused on service delivery and risk management rather than contract compliance; and
• a collaborative approach between service providers and the department—where the department would share its risk by: focusing on outcomes, not processes; understanding commercial complexities; and building mutual trust through sound governance.

2.3 The department’s approach to the delivery of health services and detainee and facility services in onshore detention was also informed by the department’s Risk Management Framework, and by two departmental publications called ‘Lessons Learnt’ relating to better practice in procurement (dated August 2012) and in contract management (dated February 2013). A Joint Service Delivery Assurance Framework was also developed to underpin the new detention services contracts (discussed later in Paragraph 2.5).

2.4 Guided by the identified strategic directions, the department developed the contracts for both service providers (health services and detainee and facility services) during the course of 2014. The contracts included provisions aimed at protecting the interests of the Commonwealth and also offering protections to the service providers, including:

• transition in and out arrangements, which outlined the activities required to occur during the first and last six months of the contract. These provisions were designed to prevent any reduction in service delivery standards or continuity of care for detainees;
• payment arrangements conditional on the provision by the providers of correct and detailed invoices, adjusted monthly to reflect the performance of the providers;
• mechanisms to drive efficiency, including: financial abatements and action plans in the event of performance failures; incentives; and innovation bonuses⁹ (aimed at driving continuous improvement, innovation and cost savings for the department);
• an efficiency dividend of 2.25 per cent and a fixed premium of 0.75 per cent, reducing the health service fee by three per cent annually;
• requirements for program management and administration services, which were designed to support the effective delivery of services;
• a provision to develop a governance framework outlining the respective roles and responsibilities, which was designed to provide an agreed structure for communication and knowledge sharing on issues, policies and decisions at key levels¹⁰; and
• dispute resolution mechanisms, including a provision to refer any dispute that remained unresolved after several levels of escalation to an agreed expert.

Establishment of a performance management regime

2.5 To support the management and assessment of the performance of the service providers, the development of a performance management regime was a key aspect of contract development. The development of a Joint Service Delivery Assurance Framework, which informed the design of the regime, was commenced by the department in 2013. The key objectives of the framework were:

• a balanced approach to performance management, using both incentives and abatements to drive performance and assure program outcomes;
• a reduction in the administrative burden for both the department and service providers;
• the fulfilment of the department’s responsibilities to government by aligning service delivery with the relevant Portfolio Budget Statements outcome; and
• assurance that the needs of detainees were met.

2.6 The contracts for the delivery of services in detention included a performance management model that provided a clear alignment between the department’s program objective at the highest level (as stated in the 2013–14 Portfolio Budget Statements), the key performance indicators (KPIs); and the performance measures. The model is illustrated in Figure 2.1.

Figure 2.1: Performance management model for onshore immigration detention services

Source: Department of Immigration and Border Protection, Request for tender for the provision of onshore immigration detention services, RFT 04/14, Performance management framework, p. 2.

2.7 The KPIs that were developed for inclusion in the two contracts (health services and facilities and detainee services) were designed to align with the department’s key deliverables and to cover the full scope of services to be delivered at each detention facility across all service providers (see Table 2.1).

Table 2.1: KPIs for the contracts to deliver health services, and detainee and facility services in onshore immigration detention

Source: Department of Immigration and Border Protection.

2.8 Under the established Joint Service Delivery Assurance Framework, the contractor was responsible for reporting performance against measures established under the contract in accordance with established reporting deadlines. The department’s role was to review the accuracy of the provider’s reports and conduct a limited number of additional reviews and audits on targeted activities (the operation of the monitoring framework relating to health service delivery is examined later in this chapter).

2.9 On the basis of the approach established, the department completed the procurement and contracting process for the delivery of detainee and facility services in August 2014.¹¹ A similar approach was subsequently adopted by the department to select the contractor for the delivery of health services. An important part of the work required to finalise the health service contract, examined later in this chapter, involved tailoring the core contractual framework to the specific objectives and requirements of health service delivery, including by:

• establishing a statement of the contract deliverables (the Statement of Work); and
• developing performance measures, against which the performance of the contractor would be assessed over the life of the contract.

Did the health service contract establish clear deliverables informed by an assessment of the risks to achieving contractual objectives?

Defining contractual deliverables

2.10 With the endorsement of the current contract, the department has moved away from a prescriptive description of expected deliverables that focused on inputs and processes, towards framing the deliverables in terms of results and outcomes. A focus on results and outcomes better allows for operational flexibility and innovation.¹² Accordingly, the key focus of the contractual objectives is the provision of a standard of care broadly comparable with that available within the Australian community, as outlined in Box 2.

Source: Department of Immigration and Border Protection, Immigration detention health services contract, Clause 10.1, executed 10 December 2014.

2.11 In addition to stating the broad objectives underpinning the delivery of health services, the contract includes a detailed Statement of Work that further defines the deliverables expected from the contractor. In particular, it identifies certain health conditions that require specific attention. Given the particular and well-documented risks of mental health conditions arising in the detention environment, the contract requires the provider to ‘maintain a health care model which is capable of providing appropriate mental health clinical care to detainees’.¹³ The contract also specifies the range of services required that are unique to the detention context (mostly, vaccinations; health screenings; and health assessment at entry into, exit from and movement within the detention network, aimed at identifying and managing public and mental health issues).

2.12 The contract is supported by several companion policy documents that aim to define health care in detention, including:

• Detention Services Manual, specifically Chapter 6: Detention Health;
• Standards for Health Services in Australian Immigration Detention Centres, developed by the Royal Australian College of General Practitioners in 2007¹⁴; and
• Detention Health Framework, A policy framework for health care for people in immigration detention, developed by the then Department of Immigration and Citizenship in 2007.

Assessing risk

2.13 The department was attuned to those risks that were realised under the previous contract, primarily uncontrolled cost escalation. As discussed earlier, a key characteristic of the new contract was the adoption of a fixed-pricing model. Under this model, the service provider is to be paid a fixed fee that is to cover the services and activities necessary to meet the objectives of the contract. More precisely, the amount payable by the department for the provision of health services as defined in the contract consists of fixed fees and pass-through costs (see Table 2.2).

Table 2.2: Contract pricing model

Source: Department of Immigration and Border Protection, Immigration Detention Health Services Contract, Schedule 6 Health services fee.

2.14 The department considered that the advantage of this pricing model was that it provides additional protections against the provider delivering services that are not necessary (risk of over-servicing). Under the fixed-price model, the contractor would not be paid for doing so. The department expects to realise considerable savings through the use of this model, as it shares with the provider the risk of escalating and uncontrolled costs. The contractor has estimated that the model will deliver savings of around 30 per cent over the life of the contract.

2.15 The department did not undertake a structured assessment of the risks to the achievement of the objectives set for the new health service delivery contract, in particular those relating to the model proposed to reduce the overall cost of the contract. While the management of cost was a clear focus, other risks, for example the risk of under-servicing by the contractor—that is where the provider prioritises commercial profitability over the delivery of services of adequate quantity and quality—received less focus. This was despite issues relating to under-servicing arising under the previous contract. In September 2015, the department concurrently conducted an internal review and commissioned a consulting firm to conduct a separate review into alleged improper conduct by the contractor relating to the provision of health services in immigration detention under the previous contract. It also focused on the inadequacy of the department’s contract management practices.¹⁵ Based on the findings of these reviews, the department concluded that some allegations were partially verified. In particular, it found that the allegation that the contractor at the time (IHMS) was ‘failing to deliver health services to an accepted standard, which could impact on the health outcomes of detainees’, was partially verified. The department concluded that:

The level of ‘comfort’ around the provision of healthcare, or what constitutes ‘appropriate’ are ambiguous terms. From both a reputational risk perspective, and to satisfy its duty of care, the department should be assured that the provision of care, including adequate vaccinations rates are in line with Australian community expectations. It is recommended that [going forward] the Detention Health Services Branch include rigorous compliance monitoring as part of the broader performance management of the Immigration Detention Health Services Contract.¹⁶

2.16 Given the issues that arose in relation to the provision of care under the previous contract (due in part to the lack of sufficient rigour in compliance monitoring practices by the department) the appropriateness of the proposed service delivery model should have received more attention during the design of the pricing model, performance measures and compliance arrangements. This issue will require careful regular and ongoing monitoring and management by the department over the life of the current contract.

Has the department established appropriate arrangements to monitor progress against established performance measures?

2.17 The initial seven high level KPIs developed by the department were designed to cover both health services, and detainee and facility services, and address the general goals of service delivery in detention more broadly (outlined earlier in Table 2.1). One of these KPIs—KPI 2: Health, Medical and Counselling—is directly relevant to the key objective of the health service delivery contract. The department subsequently developed 17 specific performance measures in late 2014 to be used to assess the performance of the contractor in achieving the department’s expected health objectives.

2.18 The development of specific performance measures by the department was important, as these were to be used to frame the data that was to be collected and used to monitor performance over the life of the health service contract. They were also to provide the basis for determining abatements and incentives, and authorising payments. To effectively underpin oversight of contractor performance, these measures should target the key risks to meeting the outcomes of the contract, and effectively support the timely and accurate monitoring of the quality of service delivery.

Appropriateness of performance measures

2.19 The ANAO reviewed the 17 performance measures and examined the underpinning methodologies developed by the department to assess progress against each measure (see Table 2.3). The measures targeted important aspects of contractor performance and were aligned with the deliverables specified under the contract. The ANAO’s analysis indicated that, by March 2016 (15 months after the contract commenced), the department’s progress in bedding down a robust performance monitoring framework has been limited. In addition to delayed implementation for a number of the measures, the measures developed by the department were not balanced. Specifically, the measures were heavily weighted towards administrative aspects of service delivery (16 of 17 measures)—with a strong focus on timeliness.

Table 2.3: Analysis of the health service contract’s performance measures, as at March 2016

Note a: Integrated primary health care includes nurse and general practitioner consultations, dental and optical services, medication supply and administration, and referral to allied health and specialist services as required.

Note b: Health induction assessments occur when a person enters detention, and are designed to identify any health conditions that could pose a threat to public health. They also establish whether a detainee has any health conditions, including mental health conditions, which require treatment or the development of an ongoing health treatment plan.

Note c: Other serious communicable diseases include hepatitis B and C, HIV and syphilis.

Note d: Chronic diseases included in the measure are asthma, diabetes and hypertension.

Note e: IHMS, Health data set April-June 2015, p.22.

Note f: Fitness to travel assessments must occur prior to a detainee traveling, including when being removed from Australia. The purpose of the assessment is to certify that a person is fit to be moved from their current place of detention, including, if applicable, whether they meet airline criteria for travel.

Source: ANAO analysis of departmental information.

2.20 As indicated by the ANAO’s analysis, of the 17 measures developed by the department for inclusion in the contract, nine had appropriate methodologies established to inform an assessment of performance as at March 2016. Specifically, the measures were relevant, the assessment methodology was aligned to the intent of the measure, and the monitoring arrangements were operational. The department’s approach to monitoring performance against the remaining measures was not sufficiently robust. The planned methodologies were partially or not implemented, because the department: had not finalised the tools required to assess the measures; or had not consistently followed the protocol agreed upon with the contractor to request the health services. In particular, the quality of health service delivery was not being effectively monitored. Further, for a number of measures, the planned activities to verify the contractor’s reported performance had yet to be implemented. As a consequence, the department is not well placed to effectively monitor the delivery of health services.

Assessing quality

2.21 The contract includes one measure that is directed at assessing the quality of service delivery—Measure 2B: Quality integrated primary health care. The department plans to audit the contractor’s performance against this measure using departmental medical officers to examine a sample of detainee health care records (five per cent of all clinical records relating to a specific health event) and make clinically-based judgements as to the quality and appropriateness of the health care provided. However, the tool being developed by the department to undertake these audits—the Departmental Medical Audit Tool—was yet to be finalised by the department as at March 2016.

2.22 The draft version of the tool, which was reviewed by the ANAO, comprised:

• a large spreadsheet containing 25 modules, such as ‘GP consultation’, ‘triage’ or ‘women’s health’. Each module included approximately 10 criteria, which totalled to over 250 criteria to be assessed;
• an approach to reviewing the quality of health care based on episodic health events rather than continuity of patient care. For example, the tool was designed to select a patient to review the quality of nurse consultations received by that patient in isolation from previous or latter medical interventions to treat the specific and any related conditions;
• an approach centred on the review of the electronic heath care records, with no face-to-face discussion with the contractor’s clinicians; and
• a level of duplication in the information verified (for instance, the detainee identifiers are verified for each module).

2.23 The delayed finalisation of the auditing tool has compromised the department’s ability to assess the quality of health care delivery and undermined its ability to determine whether contractual obligations are being fully met.

Use of self-reporting

2.24 The performance measurement framework is primarily based on contractor self-reporting, where the contractor reports its performance against the measures in a Monthly Performance Report (using a spreadsheet developed by the contractor and approved by the department). When balanced with risk-based verifications by the department, this approach is designed to support efficiencies and to place the responsibility of meeting performance expectations on the contractor.

2.25 Prior to approving the final version of the contractor’s spreadsheet in July 2015, the department conducted a limited range of validations to ensure that the wording of performance measures and of the associated methodologies was reflected accurately in the spreadsheet. The department did not validate the data capture method or the data treatment within the spreadsheet. Given the reliance that is placed on the spreadsheet, there would be merit in the department reviewing the data capture and treatment methods.

2.26 The contractor’s Monthly Performance Report is to be reviewed by the department using the following four approaches:

• the audit of supporting documentation (for instance, a sample of medical request forms are collected to verify Measure 1A: Timely provision of primary health care), observations from on-site departmental staff, and the review of incident and complaint reports;
• a program of reviews targeting specific issues, to be determined by the department;
• the proposed Departmental Medical Audit Tool (discussed earlier), which is to be applied quarterly; and
• a proposed Health Service Provider Records Review Tool (which aims to determine, on a monthly basis, whether relevant fields of the contractor’s electronic health care record system are completed accurately—this tool is designed to assess performance against Measure 2A).

2.27 Of these four approaches:

• only the first approach (audits of supporting documentation) had been operational from the commencement of the performance regime under the contract (July 2015);
• one targeted review had been conducted in November 2015 (review of clinician records); and
• both the Departmental Medical Audit Tool and the Health Service Provider Records Review Tool remained under development as at March 2016.¹⁷

2.28 There is considerable scope for the department to strengthen its risk-based monitoring arrangements under the health service delivery contract. When coupled with strengthened monitoring of the quality of the health service delivery, the department will be better placed to determine the extent to which contractual objectives are being achieved.

Has the department established effective performance management practices?

Performance measurement activity

3.1 The department’s primary means of assessing the contractor’s performance is against the 17 performance measures established in the contract, notwithstanding the weaknesses outlined in Chapter 2. Each measure is assigned a risk rating based on the likelihood and consequences of a performance failure. To manage poor performance, failure against a performance measure in a given month results in the accumulation of abatement points, the number of which is dependent on the scale of the failure and the risk rating assigned to the performance measure. The number of abatement points accumulated in a given month results in a deduction in the performance fee payable to the contractor in that month, where one abatement point equals approximately $1.¹⁸

3.2 To encourage high performance, incentive credit points are also awarded where monthly performance against a particular performance measure exceeds the contract’s benchmark expectations. Incentive credit points offset abatement points and reduce the amount that the contractor would otherwise be penalised. For example, where the contractor’s performance in a month results in 1000 abatement points and 400 incentive credit points, the abatement amount would be approximately $600.

3.3 The performance measurement system also comprises additional mechanisms to assist the department to evaluate the contractor’s performance against contractual obligations (see Table 3.1).

Table 3.1: Key elements of the performance measurement system

Source: ANAO analysis of departmental information.

3.4 The Monthly Performance Report, together with action plans (in case of performance failures) and excusable performance failures submissions (if applicable), are to be received by the department within 10 business days of the end of each month. The department has five business days in which to raise any issues with the contractor relating to the report and request any clarifications, if needed, before endorsing the report. The endorsement of the report triggers the payment of the fixed fee. The department’s verification of Monthly Performance Reports is to be based on a series of processes, outlined in Figure 3.1.

Figure 3.1: Monthly performance reporting process

Source: ANAO analysis of departmental information.

Results after six months of operation

3.5 The monitoring under the performance measurement framework (‘business-as-usual’ operation) commenced in July 2015. In the first six operating months of the abatement and incentive regime, all but one of the reported performance measures experienced an instance of failure resulting in abated or withheld points. Table 3.2 outlines the abatement, withholding and incentive points accrued for each performance measure in the analysed period.

Table 3.2: Instances of performance failures, July to December 2015

Note a: Performance Measure 2B and 3 were not operational in the period reviewed. Accordingly, the results for these measures are shown as N/A.

Source: ANAO analysis of Monthly Performance Reports.

3.6 Abatement and withholding points were applied in relation to most performance measures. Table 3.2 shows, however, that much of the accrual of abatement points is attributable to a small number of significant failures, with 265 510 of the 280 209 abatement points in the period (95 per cent) attributable to failures of measure 11 (Timely completion of incident reports) primarily, 5A (Identification and treatment of active tuberculosis) and 5B (Identification and treatment of serious communicable diseases (other than active tuberculosis). This is in part indicative of the high risk rating assigned to the measures, meaning that abatement points are applied immediately and cannot be withheld and credited back in the following month if the performance expectation is subsequently met or exceeded. Where the risk rating and abatement threshold is lower, performance failures do not necessarily result in large abatements. For example, Performance Measure 1A was failed at facilities on 15 per cent of occasions, yet improved performance in subsequent months meant that 1250 abatement points were re-credited. Good performance against this measure at some facilities (earning 1896 incentive points) resulted in further mitigation of poor performance.

3.7 To encourage a remedial response from the contractor in the event of performance failures, abatement points, offset by incentive points, result in the reduction in the fee payable in a given month. As presented in Table 3.3, between July and December 2015, the contractor incurred 149 performance failures, leading to over $300 000 in abatement (approximately two per cent of the value of the contractor service fee for the same period).

Table 3.3: Abatement values, July to December 2015

Note a: The abatement value and the number of abatement points do not directly equate. This occurs because the final abatement figure includes points withheld in previous months being applied to the current month, and the deduction of incentive points.

Source: ANAO analysis of departmental information.

3.8 While the financial value of abatements decreased by 80 per cent between July and December 2015, the number of individual failures in the same period did not reduce as sharply. This occurred because the abatement value attached to a performance failure is dependent on the extent of the failure; the corresponding risk rating; and whether a multiplier factor is applied.¹⁹ There is potential, therefore, for a large number of failures to produce a small abatement value, and conversely for a small number of high-risk failures to produce a large abatement value. It is appropriate to address the greatest risks by assigning to those risks the heaviest abatement. While decreasing abatement value is an indicator of an overall improvement in performance, the number of individual failures with a lower risk rating may remain at similar levels.

3.9 The contract includes a provision for the quarterly review of risk ratings, which should take into account historic performance failures, effectiveness of risk mitigation strategies (action plans) and the department’s own observations. This review process is designed to ensure that risk ratings remain appropriate and, if not, to modify the ratings to reflect the change in risk profile. As at March 2016, these reviews had not been conducted. The department advised that it is working to enhance the current risk rating process, in consultation with the contractor.

Action plans, excusable performance failures and the innovation bonus

3.10 The completion of action plans following a performance failure provides an opportunity for the contractor to identify the cause of failures and for the department to assess and endorse the proposed remedial action. In the period July to December 2015, the contractor submitted 45 action plans in response to its performance failures in that period.²⁰ The remedial actions proposed included: further staff education; process improvements and reviews; increased monitoring of timeframes; and increased quality control from senior staff. The department approved 44 of the 45 action plans submitted, and advised the ANAO that on-site departmental officers were responsible for following up the plans’ implementation.²¹

3.11 Three applications for excusable performance failures were made by the contractor in the period from July to December 2015, all of which were approved by the department. The excused failures occurred at three detention facilities and related to a range of performance measures:

• an IT failure at one site (requiring all medical notes to be hand written for three days);
• a failure by another service provider (resulting in complaint acknowledgement letters not being delivered to detainees within the contractual timeframes); and
• a detainee population increase at one site (resulting in the actual number of detainees in the reporting month being 58 per cent higher than that predicted by the department, causing the failure of three performance measures).

3.12 In addition to the abatement and incentive scheme, the performance framework encourages continuous improved performance from the contractor through the availability of an innovation bonus (outlined earlier in Table 3.1). In the period from July to December 2015, the contractor did not seek an innovation bonus. As performance of the contract and the performance framework achieves greater maturity, the innovation bonus scheme has the potential to play a greater role in improving the quality and efficiency of health service delivery.

Is the department effectively monitoring whether health services are being provided in accordance with contractual requirements?

Monitoring health service delivery in community detention

3.13 As at May 2016, there were 658 people in community detention across Australia. Primary considerations when determining community detention placements are safety and health status. Those detainees that are considered for community detention are generally families with children, unaccompanied minors and people who have specialist health or physical needs that are difficult to meet in immigration detention facilities. Community detainees live in rented accommodation and receive an allowance for daily living costs. While detainees are not permitted to enter into paid employment, they can engage in volunteering activities. Children are able to attend school in their local area. The department engages community service organisations to support detainees with their administrative and welfare needs, including access to health care.

3.14 All health care costs of community detainees are funded by the department. Detainees access health services through medical practices located in the community. Referrals for other services must be provided through the public health system, apart from exceptions which are pre-approved by the department.

3.15 The health service contractor’s role in relation to delivery of health care to people in community detention consists primarily of:

• developing and maintaining a network of doctors, pharmacists and other health care providers that detainees must use when accessing healthcare;
• issuing health care cards that allow detainees cashless access to health services; and
• managing referrals to secondary and tertiary health care providers.

3.16 The contractor is paid a daily rate to deliver services to people in community detention, with all other costs (such as pharmaceuticals, general practice and specialist services) being passed-through to the department.

3.17 A key element in the contractor’s responsibilities to ensure continuity of care between held and community detention is the preparation of a health discharge assessment for detainees leaving a detention facility. Once an assessment has been prepared, detainees are to be provided with a ‘health discharge summary package’ that is to include a summary of the detainee’s health status (in English and, if necessary, in the detainee’s preferred language) and a 28-day supply of prescribed medication. Once in community detention, detainees are expected to take their health discharge summary to their first medical consultation. Continuity of care is also supported by the requirement for doctors in the community to provide all detainee clinical notes to the contractor. These clinical notes must be attached to the detainee’s electronic health care record that is maintained by the contractor.

3.18 The performance measures established under the contract, as outlined in Chapter 2, primarily relate to the delivery of health services in held detention. These measures are not well suited to measure the contractor’s performance in delivering health care in community settings. Performance measures monitoring the delivery of community detention health services, for example continuity of care between held and community detention, have not been developed.

3.19 As required by the contract, the contractor has conducted, in September 2015, a sample-based review of community detention health care arrangements. The review verified, in particular, that all detainees in the sample had been issued recall appointments to conduct a six-monthly medical review. However, the absence of performance measures directly relevant to the services that the contractor must deliver to people in community detention, when coupled with the separation of responsibilities across departmental divisions²², adversely impacts on the assurance that the department has that community detention health services are being delivered as intended.

Delivery of mental health services, including the prevention of self-harm and suicide

3.20 The department’s policy framework for health care in immigration detention, including the Detention Health Framework and the Detention Services Manual, indicates that people who enter immigration detention have a higher prevalence of risk factors for mental illness than those in the general population.²³ A range of risk factors, including mental illness, are involved in the development of self-harm and suicidal behaviours. Medical research has also identified a link between length of time spent in detention and mental health, with people detained for 24 months or more found to have rates of new mental illness 3.6 times higher than those who were released within three months.²⁴ As at 31 May 2016, 62 per cent of detainees in facilities had been detained for longer than six months, and 25 per cent for longer than 24 months.²⁵

3.21 The Psychological Support Program for the Prevention of Self-Harm and Suicide is the department’s principal mechanism to treat the risk of suicide and self-harm in detention. It is designed to deliver a clinically recommended approach for the identification and support of detainees assessed as being at risk of self-harm and suicide. These detainees are provided with ‘supportive monitoring and engagement’ that is intended to keep them safe and encourage their re-integration into the wider community in immigration detention. The three risk levels and a summary of the instructions for treating the risk are outlined in Table 3.4.

Table 3.4: Management of self-harm risk levels

Source: Department of Immigration and Border Protection, Detention Service Manual, Chapter 6 – Detention Health, Psychological Support Program, pp. 15–17.

3.22 The program does not limit the duration of ongoing and moderate monitoring, but does establish clear time limits on the management of high imminent self-harm risk. A person who remains at high imminent risk for more than:

• 24 hours, must be assessed by an independent mental health professional for consideration of ongoing risk of self-harm, including whether the person should be transferred to a community-based health service for further assessment; and
• 72 hours, is indicative of having a set of complex needs that cannot or should not be managed in the immigration detention environment.

3.23 The data obtained from the contractor by the ANAO indicates that, between 1 February and 9 November 2015, 327 detainees were placed under supportive monitoring and engagement. As outlined in Table 3.5, 239 detainees²⁶ were assessed as high imminent risk on at least one occasion, representing a total of 407 instances of placement at that risk level. Of these instances, 47 per cent were placed at this risk level for longer than 72 hours and seven per cent more than one month. This analysis indicates that the clinically recommended approach set out in the Psychological Support Program for the Prevention of Self-Harm and Suicide was not being followed for a large number of detainees.

Table 3.5: Time under supportive monitoring and engagement for each instance of placement, 1 February to 9 November 2015

Source: ANAO analysis of contractor data. Percentages have been rounded.

3.24 The program also requires detainees on high imminent risk to be clinically reviewed every 24 hours at a minimum. On average, for the period 1 February to 9 November 2015, detainees on high imminent risk received a clinical review every three days. Further, there were discrepancies between detainees, with the majority of detainees reviewed less frequently than prescribed under the program (all detainees situated above the diagonal line on Figure 3.2), and with some detainees reviewed very infrequently (once or twice every fortnight).

Figure 3.2: Number of clinical reviews received by detainees while on high imminent risk of self-harm, 1 February–9 November 2015

Note: Data points above the diagonal line represent detainees who received less than the required number of clinical review (every 24 hours).

Source: ANAO analysis of contractor data.

3.25 The contractor’s performance in implementing the department’s key program to prevent self-harm and suicide in detention, the Psychological Support Program, is not formally monitored by the department.²⁷ The data collected from the contractor and analysed by the ANAO raises questions regarding the level of compliance with the department’s program requirements, where detainees remain under supportive monitoring and engagement for significantly longer than, and are not reviewed by a clinician as frequently as, prescribed under the program.

3.26 In addition, as discussed in Chapter 2, there are weaknesses in established performance measures relating to mental health:

• Measure 2B, which is aimed at assessing the quality of primary health care including mental health, was not operational as at March 2016; and
• Measure 4 monitors one aspect of mental health care (timeliness of screenings).

Health service triage

3.27 The basic health needs, for people living in the community, can be addressed with simple home remedies and medications or by visiting a pharmacist. People in detention facilities must be seen by a nurse or a doctor for almost all of their health care needs, including the most basic.²⁸

3.28 In its response to the request for tender, the contractor addressed the department’s expectation of reduced costs of health care delivery by indicating that the new service delivery model would result in savings to the Commonwealth of 30 per cent over the life of the contract when compared to the previous contractual arrangements. These savings depended on three key assumptions for the future health service delivery model:

• a transition from an ‘on-demand’ model to one where appointments are triaged by clinical priority and allocated on an as-available basis;
• a medication management system where the majority of detainees on medication would receive a fortnightly ‘Webster pak’²⁹ and self-administer medication; and
• a nurse-led health service, with operating hours of on-site clinics no greater than 9 am to 5 pm, Monday to Friday, with a telephone advice service available after hours.

3.29 When a detainee in held detention wishes to see a doctor or a nurse, they must fill in a medical request form, providing a short explanation of the reason for their request.³⁰ The detainee places the completed medical request in a locked box located in a communal area of the facility. The box is required to be emptied once a day by contractor staff, with a nurse to triage the requests based on the information provided on the form and if necessary information contained in the detainee’s health record. There are four triage categories³¹:

• Category 1: immediate response;
• Category 2: response within 24 hours;
• Category 3: response within 7 days; and
• Category 4: response within 14 days.

3.30 The ANAO examined the triage categories assigned to consultations requested by detainees across all detention facilities between July and October 2015 to identify relevant trends and determine whether there were any issues arising from the triaging process (see Figure 3.3).

Figure 3.3: Triage categories per facility, 1 July to 31 October 2015

Note: The data describe the triage categories, not the actual time taken to provide medical consultations. For instance, a request may have been assigned a triage Category 4, but the consultation may have been provided after five days only.

Source: ANAO analysis of contractor data provided to the department.

3.31 There were significant variations identified between categories assigned to detainee requests across detention facilities. The facilities with smaller numbers of consultation requests (Brisbane, Perth, Melbourne, Maribyrnong and Adelaide) had a large majority of their medical requests triaged as Category 3. By contrast, the number of consultations triaged as Category 4 was significantly higher in facilities where the overall number of requests is higher (Yongah Hill, Christmas Island and Villawood).

3.32 The department indicated that the variations observed by the ANAO in relation to triage assessments may be caused by a number of factors, such as the differing nature of the detainee populations across sites leading to varied levels of medical needs. The department has not, however, analysed triaging data and is, therefore, not well positioned to determine the underlying causes of triage variation between centres. Given the importance of the triaging process both as a means to target medical interventions in a clinically appropriate manner and also to drive efficiencies in the delivery of health services, there is scope for the department to undertake analysis of triage data to determine any emerging trends or issues.

Medication management

3.33 Detainees in held facilities access prescribed medication in one of two ways:

• Self-administered—where appropriate, detainees may be permitted to administer their own medication. In these cases, detainees receive a Webster-pak that they are required to store securely, and take their medication as prescribed; or
• Nurse-administered—if self-administration is deemed inappropriate (for instance because of risks of self-harm, non-compliance or misuse of medications), detainees must present to the on-site clinic at set times, as often as required by the medication regime (morning and/or midday and/or evening), where a nurse administers the prescribed medication.

3.34 The arrangements established under the contract relating to the administration of medication were based on the assumption that no more than 14 per cent of detainees on medication would require their medications to be nurse-administered, with the remainder self-administering. Any significant increase in this percentage would trigger a ‘complexity factor’ and enable the contractor to submit an ‘additional service request’ to the department. Further, the service delivery model is one where clinics operate between 9 am and 5 pm weekdays.³² The contractor is expected to distribute evening and weekend medications as required and at no extra cost, as long as the extended hours required are limited to the hours needed to attend to 14 per cent of detainees on prescribed medication.

3.35 Over the first 12 months of the contract, the number of detainees needing to receive nurse-administered medication was well above the expected 14 per cent in most detention centres. In detention centres in Melbourne, Sydney, Brisbane, Perth and Darwin, between 19 and 75 per cent of detainees received administered medication at some point during the period.

3.36 In response to the increased demand for nurse-administered medication, the contractor submitted 10 additional service requests between May and November 2015, requesting funding for additional nursing staff hours (between 50 and 170 additional hours per week were requested). The department agreed to fund a portion of the hours: between 9 and 84 per cent of the hours requested (on average 43 per cent).

3.37 In a paper provided to the department in December 2015, the contractor flagged the risks associated with medication administration. The paper indicated that a percentage of detainees receiving nurse-administered medication significantly above the 14 per cent costed in the contract could mean that the pre-determined number of nurses allocated to each site would not be able to absorb the additional workload without an impact on their daily duties. The increased percentage could also impact on how safely the medication is delivered, with risks including prescribing and dispensing errors.³³

3.38 The department informed the ANAO that the approval of services requests has enabled the contractor to deploy additional resources for medication rounds across most detention centres until mid-May 2016. While this approach helps to ensure the provision of nurse-administered medication over the short-term, it does not address the underlying risks identified by the contractor arising from the larger than expected number of detainees requiring nurse-administered medication. Further, the original design of the contractual approach to both detainee and facilities management and health delivery was based on the use of additional services requests only in exceptional circumstances. The number and nature of additional services requests relating to medication management indicates that further work is required by the department in this area.

Are the department’s administrative arrangements to support the delivery of health services effective?

3.42 While the provision of health care is performed for the most part by the contractor, the department receives funding of $7.6 million and 59 full time equivalent employees (for 2015–16) have been allocated for the department’s administration of health services in immigration detention.³⁴ In addition to the management of the detention health service contracts, the funding is also used to develop detention health policy and capability, administer operational matters (including maintaining a network of on-site detention health liaison officers), and provide advice relating to detention health to support departmental, parliamentary and public scrutiny activities.

Management of incident reports and complaints

Incident reports

3.43 The department regards incident reporting as essential for the interpretation, analysis and response to incidents, and subsequently, the facilitation of reporting incidents to the Minister and other stakeholders. In the period from July to October 2015, the department received 2029 reports of health incidents³⁵ occurring in onshore detention facilities from the contractor. A sample of these incident reports were reviewed by the department to assess compliance with the contract’s submission requirements relating to timeliness. The creation of incident reports by the contractor and the subsequent scrutiny of timeliness by the department involve substantial administrative effort. While noting the recent work by the department to strengthen clinical oversight of health service delivery, discussed later in this section, there would be benefit in the department formally capturing key learnings and insights from incident reports. Such analysis could provide useful additional insights into the contractor’s performance, assist the department to identify emerging trends or issues, and further inform improvement opportunities.

Complaints management

3.44 The department requires the contractor to administer a complaints and feedback management system. This requirement is in line with the department’s stated commitment to an ‘open and accountable culture that is fair, lawful and reasonable’. It is also consistent with the department’s view that systematic reporting and analysis of complaints and feedback allows for service delivery areas to utilise feedback for the development of business plans and improvement programs.³⁶ Notwithstanding these objectives, the relevant performance measure in the contract relating to complaints management only involves an assessment of timeliness in which the contractor responds to complaints from detainees in relation to health services in detention—not the adequacy of the response.³⁷

3.45 In the period from July to October 2015, the contractor provided 527 acknowledgements or responses to detainee complaints, 512 (97 per cent) of which met contractual timeframes. While the timeliness in responding to complaints is an important indicator of an effective complaints handling regime, the use of complaint data to improve programs and services is also important. There is scope for the department to more effectively utilise health care delivery related complaints information to better inform oversight of contracted service delivery.³⁸

Policy, procedure and process development

Policy and Procedures Manual

3.49 Under its contract with the department, the contractor is required to develop and implement a detailed Policy and Procedures Manual for the performance of health services in onshore detention. The contract requires that the manual: describe operational and clinical policies, procedures and processes necessary and appropriate for the day-to-day delivery of health care to detainees; contain effective guidance and support to contractor staff; adapt policies and procedures as appropriate for detainees in held and community detention; comply with departmental policy and relevant professional bodies; and be evidence-based. Components of the manual include policies and procedures ranging from chronic disease management and antenatal care to storage of vaccines and hand hygiene guidelines. Under the contract, the finalisation of the manual is subject to acceptance by the department.

3.50 The completion of the manual was to form part of the parties’ transition strategy and was expected, in accordance with contractual requirements, to be completed in March 2015. As at March 2016, the manual remained incomplete with 18 of its 183 components yet to be finalised. The delay in finalising agreed policies and procedures, some 15 months after the commencement of the contract, meant that health care services were being delivered outside of an agreed policy and procedural framework—increasing the risk to effective and appropriate delivery.

3.51 The department advised the ANAO in March 2016 that it had decided to vary the manual’s acceptance process. Under its revised clinical governance framework, the department determined that it was the contractor’s responsibility to determine policies and procedures that would be required to meet the requirements of the contract. The department’s role would be to undertake targeted audits to assess the established policies and procedures against relevant clinical benchmarks. On this basis, the department advised that it had considered the milestone met and released the held $850 000 payment to the contractor. As at June 2016, the department was yet to complete any audits of the contractor’s policies and procedures.

Acceptance testing of health services

3.52 As noted earlier, there was a six-month acceptance period following the commencement of the contract in December 2014 during which incentives or abatements were not applied as a result of performance against the measures. This period was to be used by the contractor to develop those processes, procedures, documentation, training and records that were required to carry out the required level of health care. At the expiry of this period, the department was expected to conduct acceptance testing for each facility and against the 17 performance measures, and if appropriate, issue acceptance certificates to the contractor.

3.53 The department conducted acceptance testing in detention facilities during April 2015. Subsequently, in June 2015, at the request of the department, the contractor submitted a range of corrective action plans for the four areas of operation that did not meet the department’s expectations. In March 2016, the department advised the ANAO that the process to issue acceptance certificates was on-going in relation to two measures: coverage availability and preventative health services.

3.54 The delayed finalisation or approval of processes supporting the delivery of health services has reduced the department’s capacity to gain assurance that health services are delivered according to contractual requirements. The department should work with the contractor to refine existing arrangements to ensure more timely resolution of operational and contractual issues. Such an approach would be in keeping with the ‘partnering relationship’ based on shared values and mutual trust and commitment, with an overriding concern for the wellbeing of detainees, which the parties committed to in the Partnering Charter included in the contract.

Clinical governance of health services in detention

3.55 In May 2015, the department’s Independent Health Advisor completed a review of the department’s health-related functions. The review identified particular challenges for the department, including that there had been a ‘significant and rapid increase in the quantity, complexity and sensitivity of health related issues within the detention framework’, requiring a substantial understanding of complex health problems and a capacity to rapidly respond to complex health issues. The review also identified a lack of oversight or monitoring of the clinical aspects of service delivery. Until January 2016, there was limited expertise within the relevant branch of the department with responsibility for detention health service delivery to provide clinical governance over decisions relating to health care delivery in detention settings. There were no staff employed in a clinical capacity and decisions that needed clinical expertise were submitted for ad hoc advice from the department’s Chief Medical Officer or the Independent Health Advisor.³⁹

3.56 In response to the review, a centralised health structure—the Health Services and Policy Division—led by a First Assistant Secretary in the role of Chief Medical Officer for the department and Surgeon-General for the Australian Border Force, was created in January 2016. The new division is responsible for the department’s health functions, including health service delivery in detention functions. In addition, the position of the Assistant Secretary, Detention Health Services Branch, was filled by a clinically qualified officer in February 2016. The review also recommended that clinical capacity within the branch be enhanced through the engagement of medical officers to support the health service contract in relation to audit and assurance, clinical policy support and the provision of medical advice. Further, clinically trained officers are to be deployed throughout the detention network to augment the existing network of non-clinical Health Liaison Officers. The new governance model provides an opportunity for the implementation of a strategic and clinician-led approach to the provision of health services for detainees and improved clinical oversight over the management of the contractor’s performance.

Appendix 1: Entity responses

Department of Immigration and Border Protection

International Health and Medical Services