National Healthcare Agreement Review Report

National Healthcare Agreement

Review Report

July 2012

National Healthcare Agreement Review Working Group

3 July 2012

Table of Contents

1 EXECUTIVE SUMMARY

1.1 A revised National Healthcare Agreement performance framework

1.2 Recommendations

Table 1: Proposed National Healthcare Agreement Performance Framework

Table 2: Original and proposed NHA performance indicators

2 OVERVIEW

2.1 The Federal Financial Relations Framework

2.2 The National Healthcare Agreement

2.3 Concerns regarding the NHA performance framework

2.4 The National Healthcare Agreement Review

3. ANALYSIS OF THE NATIONAL HEALTHCARE AGREEMENT 15

3.1 Addressing the criticisms of the NHA performance framework

3.1.1 A conceptually sound and simplified performance framework

3.1.2 Performance indicators

Table 3: NHA performance indicator analysis

3.1.3 Performance Benchmarks

3.2 Performance and Accountability Framework (PAF)

3.3 Social inclusion and Indigenous health

3.4 Sustainability

3.5 Data specification and data development

3.6 Implementation of a revised NHA performance framework 34

Attachment A: Recommendations from the CRC’s NHA performance reports for 2008-09 and 2009-10,

COAG’s responses and actions taken 35

Attachment B: NHA Review Working Group Terms of Reference

Attachment C: Comparison of original and proposed NHA performance framework

47

49

Attachment D: Revised NHA – Data Sources, Availability and Disaggregation

Attachment E: Cost Benefit Analysis of New Performance Indicators.

Glossary

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61

63

30

31

31

15

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16

17

27

30

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13

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3

5

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1 Executive Summary

1.1 A revised National Healthcare Agreement performance framework

The National Healthcare Agreement (NHA), agreed by the Council of Australian Governments (COAG) in

2008 and updated in August 2011, provides for an integrated approach to improving health outcomes for

Australians and the sustainability of the health system. The agreement defines the objectives, outcomes, outputs and performance measures, and clarifies the roles and responsibilities that guide the

Commonwealth and States and Territories in delivery of services across the health sector.

The original NHA includes a performance framework that consists of one overarching objective, seven long-term objectives, 11 outcomes, 26 progress measures and 15 outputs that are operationalised into 70 performance indicators, along with seven performance benchmarks. These performance indicators and performance benchmarks are reported by the COAG Reform Council (CRC) to demonstrate governments’ performance against the outcomes of the NHA.

The reports of the CRC and a review conducted by the Heads of Treasuries (HoTs) identified scope to improve the overall conceptual adequacy and data quality of the NHA performance framework. It was also recommended that the number of progress measures, outputs and performance indicators be reviewed and substantially reduced.

In February 2011 COAG agreed to review the NHA as part of a broader review of the six National

Agreements under the Intergovernmental Agreement on Federal Financial Relations (IGA FFR). A Working

Group was established to review the performance reporting issues identified by the HoTs Review and reports of the CRC.

The National Healthcare Agreement Review Working Group (the Working Group) established by the HoTs

Review and CRC Recommendations Implementation Steering Group recommends a revised NHA performance framework that includes one objective, seven outcomes, 33 performance indicators and seven performance benchmarks. The proposed performance framework is

 streamlined to provide a direct link between the objective, outcomes and performance indicators;

 refocused by largely removing output measures and using critical indicators of the key outcomes; and

 strengthened by broadening the monitoring of the impact of chronic disease, introducing new measures for mental health and aged care, and taking a more holistic approach to social inclusion by disaggregating all indicators, where possible and appropriate, by social inclusion groups including Indigenous Australians and people with disabilities.

The Working Group based its analysis of the original framework against a conceptual framework developed by the HoTs to assess the conceptual adequacy of all National Agreements. The Working

Group adopted the resulting performance framework as conceptually sound and in this context assessed in detail the performance indicators and performance benchmarks.

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The Working Group took into consideration the importance of indicators to the NHA, the link between indicators and specific outcomes and developed and tested a number of alternative indicators. The

Working Group also endeavoured to substantially reduce the number of performance indicators, while recognising that, relative to other National Agreements, the NHA is very broad, covering health outcomes, the health system, aged care, mental health and social inclusion.

A central issue in the review has been to balance the objective of the IGA FFR in fostering minimalist, high level reporting of outcomes, with the need to monitor the performance of the health system in responding to policy.

In simple terms, the health status of the population reflects the ultimate outcome for the national health system. Thus life expectancy, and the quality of life lived, are the summary indicators of the success or failure of the national health system. However, shorter term measures are required to address the risks that give rise to disease and injury and to optimise resource allocation in the management of disease over a patient’s life. For this reason, the NHA must monitor not just the life-cycle outcomes but also the performance against intermediate outcomes and, in select cases, some outputs that reflect the efficacy of policy settings presently in train.

The Working Group has settled upon a set of indicators that assess health system performance across the entire health care spectrum in areas of national importance, where governments have levers for change.

A key improvement in the recommended revisions to the NHA performance framework has been to place the major chronic disease groups as the central target of health system performance. Chronic diseases account for more than 80 per cent of the burden of disease and injury in Australia. The framework includes measures of cancer, cardiovascular disease and mental disorders – the three leading causes of the total burden of disease in Australia – and Type 2 diabetes – which is projected to become the leading specific cause of disease burden by 2023.

Importantly, the framework also provides for measures of the behavioural risks - tobacco smoking, overweight and obesity, and risky alcohol consumption - associated with these major chronic disease groups across the population as a whole, and with increasing severity for low income earners and those in rural and remote areas, and most particularly for the Indigenous population, for whom these risk factors account for much of the gap in life expectancy compared with non-Indigenous Australians.

Another feature of the revised framework has been to recognise the need to ‘gather up’ the life-cycle outcomes for health status under one outcome, where before they had been dispersed without obvious rationale, and to place them under the first outcome – ‘Australians are born and remain healthy’.

Outcome 1 accordingly captures two types of indicators: those reporting on life cycle health status, and those reporting on behavioural risks.

The revised approach to social inclusion discontinues the earlier approach of applying a very few select indicators to Outcome 6, and instead disaggregates all indicators by Indigenous status, disability status, remoteness and socioeconomic status where possible.

The indicators of service outcomes under Outcomes 2, 3, 4 and 5 are concerned with measuring whether

Australians have timely access to quality, affordable health and aged care services based on their needs, and their experience and satisfaction with these services. Most of these indicators represent the original indicators of the first performance framework, with supplementation in the areas of mental health

(consistent with the 4 th National Mental Health Plan) and in the area of emergency department and elective surgery access (to reflect performance against targets under the NPA on Improving Public

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Hospital Services as well as the long standing indicators of time to treatment in emergency departments and overall time to receipt of elective surgery). The aged care indicators have been revised to better reflect outcomes in that sector, while recognising the need for further data development for the aged care sector as acknowledged by the Australian Government in its statement Living longer, living better.

It was considered necessary to include indicators concerned with monitoring the sustainability of the health system. Sustainability is a difficult concept to measure as it requires an assessment of the capacity of the current health system to be viable in the future and relies on input measures of human, capital and financial resources. The review retained only one indicator for this outcome while recommending further work towards a suitable indicator of financial sustainability.

Table 1 shows the proposed performance framework. Table 2 compares the proposed performance framework with the original performance framework.

1.2 Recommendations

The National Healthcare Agreement Review Working Group (the Working Group) recommends that the

Heads of Treasuries Review and CRC Implementation Steering Group (the Steering Group) recommend that COAG:

1.

agrees a revised NHA performance framework as set out in Table 1 that includes: a.

one overarching objective; b.

seven outcomes; c.

33 performance indicators; and d.

seven performance benchmarks.

2.

notes that the revised performance framework has a substantially reduced number of performance indicators, specifically that it: a.

removes 45 current performance indicators; b.

retains 25 original performance indicators, of which 11 have minor amendments

(identified in Table 2); c.

incorporates 8 new performance indicators; d.

disaggregates all indicators, to the extent it is possible and appropriate, by Indigenous status, disability status, remoteness and socioeconomic status; and

3.

agrees to retain the original 7 performance benchmarks, with the following two amendments: a.

in relation to the benchmark, By 2014-15, improve the provision of primary care and reduce the proportion of potentially preventable hospital admissions by 7.6 per cent over

the 2006-07 baseline to 8.5 per cent of total hospital admissions, to consider resetting the targets once data issues are addressed by the National Health Information Standards and

Statistics Committee (NHISSC) and agreed by the Standing Committee on Health (SCoH); and b.

in relation to the benchmark, By 2017, increase by five percentage points the proportion of Australian adults and Australian children at a healthy body weight, over the 2009

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baseline, to amend the target year to 2018 to align with the smoking performance benchmark that will be sourced from the same survey.

4.

agrees to reconsider the inclusion of the indicators: a.

Waiting times for radiotherapy and orthopedic specialists (but exclude orthopedic specialists and rename to ‘Waiting times for radiotherapy’) against the Better Services outcome, subject to a proposed Radiotherapy Waiting Times Data Set Specification being considered and agreed by SCoH; and b.

Access to services by type of service compared to need as a measure against the social inclusion outcome, subject to data development work being completed and agreed by

SCoH.

5.

agrees to review the measures for emergency department and elective surgery performance by the end of 2013.

6.

agrees to request HoTs provide advice to COAG on a performance indicator measuring the financial sustainability of the healthcare system.

7.

agrees to request SCoH to review and develop where necessary data specifications and costs for: a.

the 8 new indicators and 11 amended indicators, as identified in Table 2; and b.

review all specifications to ensure that indicators in common with the National Health

Performance Authority's (NHPA) Performance and Accountability Framework use the same data sources, standards and methodology where appropriate.

8.

agrees that once endorsed by COAG, the proposed revised NHA performance framework come into effect for 2011-12 CRC reporting, noting that data agencies will supply data for the revised set of indicators where possible as agreed by officials ahead of COAG endorsement.

9.

notes the Commonwealth Government's commitment to establish a data clearing house for aged care at the Australian Institute of Health and Welfare (AIHW) from 1 July 2013 and to expand the

Australian Bureau of Statistics (ABS) Survey of Disability, Ageing and Carers and to increase its frequency from six to three yearly intervals.

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Table 1: Proposed National Healthcare Agreement Performance Framework

Objective: Improve health outcomes for all Australians and ensure the sustainability of the Australian health system

Performance benchmarks

Better Health

Reduce the age-adjusted prevalence rate for Type 2 diabetes to 2000 levels (equivalent to a national prevalence rate of 7.1 per cent) by 2023

By 2018, increase by five percentage points the proportion of Australian adults and Australian children at a healthy body weight, over the 2009 baseline

By 2018, reduce the national smoking rate to 10 per cent of the population and halve the Indigenous smoking rate, over the 2009 baseline

Halve the mortality gap for Indigenous children under five by 2018

Close the life expectancy gap for Indigenous Australians within a generation

Better Health Services

By 2014-15, improve the provision of primary care and reduce the proportion of potentially preventable hospital admissions by 7.6 per cent over the 2006-07 baseline to 8.5 per cent of total hospital admissions

The rate of Staphylococcus aureus (including MRSA) bacteraemia is no more than 2.0 per 10,000 occupied bed days for acute care public hospitals by 2011-12 in each State and Territory

Better Health Better Health Services Sustainability of the

Health System

Australians are born and remain healthy

 Proportion of babies born of low-birth weight

 Incidence of selected cancers



Prevalence of overweight and obesity

 Rates of current daily smokers

 Levels of risky alcohol consumption



Life expectancy

 Infant and young child mortality rate

 Major causes of death



Incidence of heart attacks



Prevalence of type 2 diabetes

 Proportion of adults with very high levels of psychological distress

Australians receive appropriate high quality and affordable primary and community health services

Australians receive appropriate high quality and affordable hospital and hospital related care

Older Australians receive appropriate high quality and affordable health and aged care services

Australians have positive health and aged care experiences which take account of individual circumstances and care needs

Australians have a sustainable health system

 Waiting times for GPs



Waiting times for public dentistry

 People deferring access to selected health care due to cost

 Effective management of diabetes

 Potentially avoidable deaths



Treatment rates for mental illness

 Selected potentially preventable hospitalisations

 Selected potentially avoidable GP-type presentations to emergency departments

Performance indicators

 Waiting times for elective surgery

 Waiting times for emergency department care

 Healthcare associated infections

 Unplanned hospital readmission rates



Survival of people diagnosed with notifiable cancer



Rate of community follow up within the first seven days of discharge from a psychiatric admission

 Residential and community aged care places per 1,000 population aged 70+ years

 Hospital patient days used by those eligible and waiting for residential aged care



Proportion of residential aged care services that are three year re-accredited

 Proportion of residential aged care days on hospital leave for selected preventable causes



Elapsed time for aged care services

 Proportion of aged care residents who are full pensioners relative to the proportion of full pensioners in the general population

Social inclusion and Indigenous health

 Patient experience/ satisfaction

 Full time equivalent workforce per

1,000 population

(by age group)

Australians have a health system that promotes social inclusion and reduces disadvantage, especially for Indigenous Australians

All performance indicators, where it is possible and appropriate to do so, to be disaggregated by Indigenous status, disability status, remoteness area and socio-economic status to assess whether these social inclusion groups achieve comparable health outcomes and service delivery outcomes to the broader population

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Table 2: Original and proposed NHA performance indicators

Recommended modifications Original performance indicators

Outcome 1: Australians are born and remain healthy

1. Proportion of babies born of low birth weight

2. Incidence of sexually transmissible infections and blood-borne viruses

3. Incidence of end-stage kidney disease

4. Incidence of selected cancers

5. Proportion of persons obese

Nil

Remove

Remove

Nil

Amend to align title with NIRA. Rename and report underweight, normal weight, overweight and obese

6. Proportion of adults who are daily smokers

7. Proportion of adults at risk of long-term harm from alcohol

8. Proportion of men reporting unprotected anal intercourse with casual male partners

9. Immunisation rates for vaccines in the national schedule

10. Breast cancer screening rates

11. Cervical screening rates

12. Bowel cancer screening rates

13. Proportion of children with 4th year developmental health check

Amend to align title with NIRA

Amend to align title with NIRA

Remove

Remove

Remove

Remove

Remove

Remove

Move from Outcome 2

Move from Outcome 2

Move from Outcome 6 and renamed to improve comprehensibility

New indicator

New indicator

Proposed performance indicators

New PI 1. Proportion of babies born of low birth weight

New PI 2. Incidence of selected cancers

New PI 3. Prevalence of overweight and obesity

New PI 4. Rates of current daily smokers

New PI 5. Levels of risky alcohol consumption

New PI 6. Life expectancy

New PI 7. Infant and young child mortality rate

New PI 8. Major causes of death

New PI 9. Incidence of heart attacks

New PI 10. Prevalence of Type 2 diabetes

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Original performance indicators Recommended modifications

New indicator

Outcome 2: Australians receive appropriate high quality and affordable primary and community health services

14. Waiting times for GPs Nil

15. Waiting times for public dentistry Nil

16. People deferring access to selected health care due to financial cost

17. Proportion of people with diabetes with HbA1c below 7%

18. Life expectancy

19. Infant and young child mortality rate

Nil

Amend to rename to improve comprehensibility

Move to Outcome 1

Move to Outcome 1

20. Potentially avoidable deaths

21. Treatment rates for mental illness

22. Selected potentially preventable hospitalisations

23. Selected potentially avoidable GP-type presentations to emergency departments

24. GP-type services

25. Specialist services

26. Number of dental services

27. Optometry services

28. Public sector community mental health service

29. Private sector community mental health services

30. Proportion of people with diabetes that have a GP annual cycle of care

Nil

Nil

Nil

Nil

Remove

Remove

Remove

Remove

Remove

Remove

Remove


New PI 11. Proportion of adults with very high levels of psychological distress

New PI 12. Waiting times for GPs

New PI 13. Waiting times for public dentistry

New PI 14. People deferring access to selected health care due to financial cost

New PI 15. Effective management of diabetes

New PI 16. Potentially avoidable deaths

New PI 17. Treatment rates for mental illness

New PI 18. Selected potentially preventable hospitalisations

New PI 19. Selected potentially avoidable GP-type presentations to emergency departments

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Original performance indicators Recommended modifications Proposed performance indicators

31. Proportion of people with asthma with a written asthma plan

32. Proportion of people with a mental illness with GP care plans

Remove

Remove

33. Number of women with at least one antenatal visit in first trimester

Remove

Outcome 3: Australians receive appropriate high quality and affordable hospital and hospital related care

34. Waiting times for elective surgery

35.Waiting times for emergency department care

Retain and also measure against the National Elective Surgery Target (NEST)

Part I targets.

New PI 20. Waiting times for elective surgery

Retain and also measure against the National Emergency Access Target

(NEAT) (revised PI 36) and rename to ‘Waiting times for emergency department care’.

New PI 21.Waiting times for emergency hospital care

36. Waiting times for admission following emergency department care

37. Waiting times for radiotherapy and orthopaedic specialists

Amend to also measure against the National Emergency Access Target and included in PI 35

Consider inclusion following further consideration by SCoH of the proposed

Radiotherapy Waiting Times Data Set Specification, and amend to remove orthopaedic specialists

(Incorporated under New PI 21. Waiting times for emergency

hospital care)

38. Adverse drug events in hospitals

39. Health-care associated Staphylococcus aureas bacteraemia in acute care hospitals

40. Pressure ulcers in hospitals

41. Falls resulting in patient harm in hospitals

42. Intentional self-harm in hospitals

43. Unplanned/ unexpected readmissions of selected surgical admissions

44. Survival of people diagnosed with cancer

45. Rates of services: Overnight separations

Remove

Amend to rename to improve comprehensibility and align with Australian

Commission on Safety and Quality Healthcare (ACSQHC) indicator

Remove

Remove

Remove

Amend to align with ACSQHC indicator

Amend to rename to specify only notifiable cancers

Remove

New PI 22. Healthcare associated infections

New PI 23. Unplanned hospital readmission rates

New PI 24. Survival of people diagnosed with notifiable cancers

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Original performance indicators

46. Rates of services: Outpatient occasions of service

47. Rates of services: Non-acute care separations

48. Rates of services: Hospital procedures

Recommended modifications

Remove

Remove

Remove

Outcome 4: Older Australians receive appropriate high quality and affordable health and aged care services

49. Residential and community aged care places per 1,000 population aged 70+ years

Nil

50. Staphylococcus aureus (including MRSA) bacteraemia in residential aged care

51. Pressure ulcers in residential aged care

Incorporate in New PI 30 below


52. Falls resulting in patient harm in residential aged care and treated in hospital

53. Older people receiving aged care services by type (in the community and residential settings)

54. Aged care assessments completed


Remove

Remove

55. Younger people with disabilities using residential, CACP and

EACH aged care services

56. People aged 65 and over receiving sub-acute services

Remove

Remove

57. Number of hospital patient days used by those eligible and waiting for residential aged care

Nil


New PI 25. Rate of community follow up within first seven days of discharge from a psychiatric admission

New PI 26. Residential and community aged care places per 1,000 population aged 70+ years

New PI 27. Number of hospital patient days used by those eligible and waiting for residential aged care

New PI 28. Proportion of residential aged care services that are three year re-accredited

New PI 29. Proportion of residential aged care days on hospital leave due to selected preventable causes

New PI 30. Elapsed times for aged care services

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Original performance indicators Recommended modifications

Outcome 5: Australians have positive health and aged care experiences which take account of individual circumstances and care needs

58. Patient satisfaction/experience Nil

Outcome 6: Australians have a health system that promotes social inclusion and reduces disadvantage, especially for Indigenous Australians

59. Age-standardised mortality

60. Access to services by type of service compared to need

61. Teenage birth rate

62. Hospitalisation for injury and poisoning

63. Children's hearing loss

64. Indigenous Australians in the health workforce

Move to Outcome 1 and amend to rename ‘Major Causes of Death’ to improve comprehensibility.

Consider re-inclusion following further development as per NIRA recommendation

Remove

Remove

Remove

Remove

Outcome 7: Australians have a sustainable health system

65. Net growth in health workforce (medical practitioners, nurses/midwives, dentists)

66. Public health program expenditure as a proportion of total health expenditure

67. Capital expenditure on health and aged care facilities as a proportion of capital consumption expenditure on health and aged care facilities

68. Proportion of recurrent health expenditure spent on health research and development

69. Cost per casemix-adjusted separation

70. Accredited and filled clinical training positions

Revise

Remove

Remove

Remove

Remove

Remove


New PI 31. Proportion of aged care residents who are full pensioners relative to the proportion of full pensioners in the general population.

New PI 32. Patient satisfaction/experience

New PI 34. Full time equivalent employed health practitioners per

1,000 population (by age group and profession type)

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Original performance benchmarks

Close the life expectancy gap for Indigenous Australians within a generation.

Recommended modification

Retain

Halve the mortality gap for Indigenous children under five by 2018. Retain

Reduce the age-adjusted prevalence rate for Type 2 diabetes to 2000 levels (equivalent to a national prevalence rate5 of 7.1 per cent) by 2023.

By 2017, increase by five percentage points the proportion of Australian adults and Australian children at a healthy body weight, over the 2009 baseline.

By 2018, reduce the national smoking rate to 10 per cent of the population and halve the Indigenous smoking rate, over the 2009 baseline.

By 2014-15, improve the provision of primary care and reduce the proportion of potentially preventable hospital admissions by 7.6 per cent over the 2006-07 baseline to 8.5 per cent of total hospital admissions.

The rate of Staphylococcus aureus (including MRSA) bacteraemia is no more than 2.0 per 10,000 occupied bed days for acute care public hospitals by 2011-12 in each State and Territory.

Retain

Retain and amend target year to 2018 to be consistent with the smoking performance benchmark as data for both benchmarks will be derived from the

Australian Health Survey.

Retain

Retain and reset targets once data development work is completed.

Retain

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2 Overview

Key points

 The current NHA consists of one overarching objective, seven long-term objectives, 11 outcomes, 26 progress measures, 15 outputs and seven performance benchmarks. The progress measures and outputs are operationalised as 70 performance indicators.

 The COAG Reform Council (CRC) identified concerns with the conceptual adequacy and data quality of the NHA performance framework and related indicators. The CRC found that of all the National Agreements, the NHA was least compliant with the design principles of the IGAFFR.

 The CRC recommended a reduction in the number of performance indicators.

 In December 2009, COAG requested that HoTs undertake a review of the implementation of the IGA FFR across existing National Agreements, including the NHA. To improve the quality of current and future agreements, the HoTs Review developed a conceptual framework for performance reporting to analyse the strengths and weaknesses of performance frameworks.

 In September 2011, the NHA Review Working Group (the Working Group) was established to review the performance reporting issues identified.

2.1 The Federal Financial Relations Framework

On 29 November 2008, COAG agreed the Intergovernmental Agreement on Federal Financial Relations

(IGA FFR) which established the overarching framework for the Commonwealth's financial relations with the States and Territories. The framework provides clearer specification of the roles and responsibilities of each level of government so that the appropriate government is accountable to the community.

The objective of the federal financial relations framework is to improve the quality and effectiveness of government services as well as provide a rigorous focus on the achievement of outcomes It seeks to do so by providing clarity about who is responsible for the delivery of those services, allowing flexibility in the delivery of services and increased accountability to the public, as well as by providing incentives for reform. It establishes a foundation for the Commonwealth and the States and Territories to collaborate on policy development and service delivery, and facilitates the implementation of economic and social reforms in areas of national importance.

Under the IGA FFR, National Agreements, including the NHA, set out clear and specific outcomes to be achieved by the Commonwealth and the States and Territories. They outline the role of each party and the responsibilities for which they will be accountable. National Agreements include performance frameworks that provide:

 clear statements of mutually agreed objectives, outcomes and outputs;

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 selected high level performance indicators that inform the community about how governments are progressing towards achieving objectives and outcomes; and

 a limited number of outcomes-focussed performance benchmarks that inform the desired rate of progress against outcomes.

2.2 The National Healthcare Agreement

The NHA defines the objectives, outcomes, outputs and performance measures, and clarifies the roles and responsibilities to guide the Commonwealth and States and Territories in delivery of services across the health sector. The long-term objective of the NHA is to improve health outcomes for all Australians and the sustainability of the Australian health system.

The NHA includes a performance framework that consists of one overarching objective, seven long-term objectives, 11 outcomes, 26 progress measures, 15 outputs and seven performance benchmarks. The progress measures and outputs are operationalised into 70 performance indicators for reporting by the

CRC.

2.3 Concerns regarding the NHA performance framework

COAG Reform Council (CRC)

The CRC has the role of assessing and publicly reporting on the performance of governments against the objectives, outcomes and indicators in National Agreements, including the NHA. In its National

Healthcare Agreement: Baseline Performance Report 2008-09 the CRC commented that “the number of indicators and the structure of the performance reporting framework under the NHA create a degree of complexity that hinders meaningful reporting against the identified objectives”. In particular, the Report identified concerns with the conceptual adequacy and data quality of the performance framework and related indicators.

The CRC noted conceptual issues including:

 the progress measures, outputs and performance indicators do not adequately measure progress against the objectives and outcomes;

 many of the progress measures and outputs are not meaningful as stand-alone measures;

 the relationship between objectives and outcomes is unclear with outcomes often repeating the objective; and

 the performance reporting language (i.e. progress measures and outputs which are operationalised through performance indicators) is not consistent with other National

Agreements.

Additionally, the CRC noted data quality issues around the availability, accuracy, comparability, and timeliness of data.

The CRC went on to recommend that there should be a strong conceptual framework underpinning the

NHA that provides a clear basis for linking the performance indicators with the objectives and

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outcomes. It recommended that the conceptual framework should focus on the achievement of objectives and outcomes and thus be consistent with the agreed reform of federal financial relations.

Within this context, the CRC recommended that the number of performance indicators should be reviewed and potentially substantially reduced, based on their importance to achieving the identified outcomes and objectives, the availability of robust data and data development priorities. COAG’s responses to the CRC Recommendations in the NHA performance reports are at Attachment A.

Heads of Treasuries (HoTs) analysis

In December 2009, COAG requested that HoTs undertake a review of the implementation of the IGA

FFR across existing National Agreements and National Partnerships. To improve the quality of current and future agreements, the HoTs Review developed a conceptual framework for performance reporting to analyse the strengths and weaknesses of performance frameworks for National Agreements and

National Partnerships.

In their analysis of the NHA, the HoTs Review reaffirmed the CRC’s criticisms of the conceptual inadequacy and data limitations of the NHA performance framework and found that of all the National

Agreements, the NHA was least compliant with the design principles of the IGAFFR.

2.4 The National Healthcare Agreement Review

At its meeting of 13 February 2011, COAG agreed that the underlying reform principles of the IGA FFR continues to provide a strong foundation for progressing COAG’s agreed reform agenda and achieving better policy and service delivery outcomes for all Australians. COAG also agreed to take forward the key recommendations of the HoTs Review and reports from the CRC and consider improvements to the governance and performance reporting frameworks under the six National Agreements.

Following this, the HoTs Review and CRC Recommendations Implementation Steering Group (the

Steering Group) was established. The Steering Group developed separate Working Groups, comprising senior officials from First Ministers’, Treasuries and select Portfolio Agencies, to undertake reviews of the performance reporting frameworks of the National Agreements.

In September 2011, the NHA Review Working Group (the Working Group) was established to review the performance reporting issues identified by the HoTs Review and reports of the CRC. In line with COAG’s decision, the Working Group would conduct the review of the NHA against the conceptual framework, as developed and recommended by the HoTs Review. 1

The Working Group met five times between September 2011 and May 2012 to develop and agree in principle on a revised performance framework and set of indicators. In undertaking this task, the

Working Group received technical advice from the Australian Institute of Health and Welfare (AIHW), the Australian Bureau of Statistics (ABS), the CRC and the Productivity Commission (in its role as

Secretariat for the Review of Government Service Provision).

1 The Heads of Treasuries Conceptual Framework for Performance Reporting is available online at: www.federalfinancialrelations.gov.au

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3. Analysis of the National Healthcare Agreement

Key points

 The Working Group recommends a revised performance framework that directly links the objective, outcomes and performance indicators.

 The Working Group recommends 34 performance indicators be included in the revised performance framework.

 Of the original 70 performance indicators, the Working Group recommends removing 44 and retaining 26. The Working Group also recommends introducing 8 new indicators to better serve the outcomes.

 To better assess whether social inclusion groups achieve comparable health and service delivery outcomes, all indicators will be disaggregated to the extent it is possible and appropriate, by Indigenous status, disability status, remoteness area and socioeconomic status.

 The Working Group recommends retaining the seven performance benchmarks.

3.1 Addressing the criticisms of the NHA performance framework

The review has addressed criticisms of the conceptual inadequacies of the NHA through simplification of the structure of the performance framework and through better alignment of the performance indicators with the outcomes.

3.1.1 A conceptually sound and simplified performance framework

The Working Group applied the HoTs conceptual framework to analyse the NHA performance framework. The following structural changes are recommended to simplify the performance framework and address the conceptual inadequacies identified by the CRC and HoTs:

 retaining the overarching objective of the current framework;

 removing the duplication between the current long-term objectives and outcomes by reclassifying the current long-term objectives as outcomes and deleting the current outcomes;

 removing the outputs and progress measures;

 retaining performance indicators that link to the outcomes and associated performance benchmarks; and

 retaining the current performance benchmarks.

This revised structure of the NHA performance framework better meets the intent of the IGA FFR by streamlining the framework to align the objective, outcomes and performance indicators. This clarifies the relationship between the objectives, outcomes, and performance benchmarks.

See Attachment C for concordance between original and proposed NHA performance frameworks.

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3.1.2 Performance indicators

Further to the initial analysis of the NHA performance framework outlined above, the Working Group considered the Commonwealth Treasury’s assessment of the existing performance indicators in terms of their conceptual adequacy against the new objective and outcomes and their underlying data quality and availability, using the HoTs Review conceptual framework.

As well as considering the merits of the individual indicators, the Working Group also assessed the appropriateness of the NHA indicator set as a whole to ensure it was conceptually robust. A key consideration was whether there were major gaps in the indicator set after the removal of existing indicators. The Working Group endeavoured to recommend an indicator set that provides sufficient measures of performance and sufficient public accountability of the outcomes of the NHA.

The Working Group noted the independent review of the NHA performance indicators undertaken by the Chair of the National Health Information Standards and Statistics Committee (NHISSC),

Dr David Filby.

It is important to note that the recommendation to remove an indicator from the NHA does not mean that it is not important or that the data should no longer be collected. There is a range of performance reporting on government service delivery and activity outside of the IGA FFR which provides transparency and public accountability on the level of government service provision and outcomes. This includes the National Health Reform Agreement (NHRA) Performance and Accountability Framework, the National Indigenous Reform Agreement, the Report on Government Services, the National Health

Performance Framework and the Aboriginal and Torres Strait Islander Health Performance Framework.

The Working Group also notes however, that while consideration was given to whether a performance indicator is reported elsewhere, it was also recognised that the NHA should capture a holistic perspective of the Australian healthcare system and use those performance indicators which best illuminate the outcome, regardless of whether they are reported elsewhere.

The following section outlines the Working Group’s recommendations of performance indicators and places these within the revised performance framework. The analysis is drawn from work by the

Commonwealth Treasury, the Working Group and Dr Filby, as well as the technical advice of AIHW, the

ABS, the COAG Reform Council, the Productivity Commission and Australian Commission on Safety and

Quality in Health Care (ACSQHC).

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Table 3: NHA performance indicator analysis

Outcome 1 – Australians are born and remain healthy

It is proposed that the scope of this outcome be modified to include indicators of population-level outcomes for health status and the determinants of health. When considering the performance indicators within this outcome, it is important to note that change in most health outcomes is gradual. It is acknowledged that the indicators under this outcome reflect performance of the health system over long periods and that the selected indicators do not necessary lend themselves to annual reporting.

The proposed indicators under this outcome measure health status (mortality and health conditions) and the determinants of health.

Performance indicator

PI 1 - Proportion of babies born of low birth weight

PI 2 – Incidence of sexually transmissible infections and bloodborne viruses

PI 3 – Incidence of end-stage

kidney disease

PI 4 – Incidence of selected cancers

PI 5 – Proportion of persons obese

Analysis

Retain as a strong measure of the outcome. This indicator is a good determinant of health as low birth weight babies are at greater risk of dying during the first year of life and are prone to ill health thereafter.

This indicator is expected to be reported under the PAF.

Remove. In the interest of reducing the number of performance indicators, this indicator has been replaced by indicators measuring chronic diseases that have a greater contribution to the total burden of disease. The NHA

Working Group notes that this indicator is important as it measures a significant public health threat.

Remove as small counts and lags in data availability limits the usefulness of this indicator.

This is a health condition of particular concern to Indigenous Australians and is reported under the Aboriginal and Torres Strait Islander Health

Performance Framework.


Retain as a measure of a health condition that contributes greatly to the total burden of disease in Australia.

The Working Group notes that there is a lag in the availability of data and that the quality of Indigenous identification varies between jurisdictions.


Retain but change to ’Prevalence of overweight and obesity’ to report the prevalence of overweight, underweight, normal weight and obesity separately in addition to the combined prevalence. This will also align the indicator with revised NIRA PI 5. This indicator is a measure of a modifiable health determinant that contributes greatly to the total burden of disease in Australia.

Data are based on survey data and are only collected three yearly and six yearly for Indigenous Australians, however three-yearly provision of this information is adequate as the risk factors are unlikely to change rapidly at

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PI 6 – Proportion of adults who are daily smokers

Retain but align with revised NIRA PI 3 - Rates of current daily smokers. This indicator is a measure of a modifiable health determinant that contributes greatly to the total burden of disease in Australia.

Data are based on survey data and are only collected three yearly, however three-yearly provision of this information is adequate as the risk factors are unlikely to change rapidly at the population level.


PI 7 – Proportion of adults at risk of long-term harm from alcohol the population level.


PI 8 – Proportion of men reporting unprotected anal intercourse with

casual male partners

PI 9 – Immunisation rates for vaccines in the national schedule

Retain but align with revised NIRA 4 - Levels of risky alcohol consumption.

This indicator is a measure a modifiable health determinant that contributes greatly to the total burden of disease in Australia.

Data are based on survey data and are only collected three yearly and six yearly for Indigenous Australians, however three-yearly provision of this information is adequate as the risk factors are unlikely to change rapidly at the population level.

Remove as there are no national data and no data development work planned.

PI 10 – Breast cancer screening

rates

Remove as this is an output measure and more suitable outcomes-focussed indicators exist - Potentially avoidable deaths (potentially preventable deaths amenable to immunisation) and Selected potentially preventable

hospitalisations (vaccine preventable).


Remove as this is an output measure and more suitable outcomes-focussed indicators exist – Incidence of selected cancers and Survival rate of people

diagnosed with cancer.

The NHA Working Group notes that this is an important indicator as screening programs are delivered to detect disease early to improve health outcomes.


PI 11 – Cervical screening rates

PI 12 – Bowel cancer screening

rates







In addition, this indicator has considerable data issues as it only measures

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PI 13 – Proportion of children with

4th year developmental health

check

New PI – Incidence of heart attacks

New PI – Prevalence of type 2 diabetes screening rates under the National Bowel Cancer Screening Program.

Addressing this data gap would require the development and implementation of a new data collection to measure other bowel cancer screening programs.



Remove as this is an output measure that has considerable data issues as it only measures Commonwealth-funded activities under the MBS.

Addressing this data gap would require the development and implementation of a new data collection to measure the state and territory-funded activities.

The NHA Working Group notes that this is an important indicator as the

Healthy Kids Check promotes early detection and early intervention.


Include as a measure of a health condition that contributes greatly to the total burden of disease in Australia. The measure utilises existing data collections and thus introduces no extra collection cost to the system.

This indicator measures incidence of a health condition that contributes greatly to the burden of disease.

A similar indicator is expected to be reported under the PAF.

Include as a measure of a health condition that contributes greatly to the total burden of disease in Australia. The measure utilises existing data collections and thus introduces no extra collection cost to the system. This

PI links to an existing performance benchmark.

New PI – Proportion of adults with very high levels of psychological distress



Include as a measure of a health condition that contributes greatly to the total burden of disease in Australia. The measure utilises existing data collections and thus introduces no extra collection cost to the system.


Outcome 2: Australians receive appropriate high quality and affordable primary and community health

services


PI 14 – Waiting times for GPs

Analysis

Retain as a measure of whether care was delivered at the appropriate time.


PI 15 – Waiting times for public dentistry

Retain as a measure of whether care was delivered at the appropriate time and is of particular relevance to vulnerable groups.

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PI 16 – People deferring access to selected health care due to financial cost

PI 17 – Proportion of people with diabetes with HbA1c below 7%

PI 18 - Life expectancy

PI 19 - Infant and young child mortality rate

PI 20 - Potentially avoidable deaths

PI 21 - Treatment rates for mental illness

PI 22 - Selected potentially preventable hospitalisations

PI 23 - Selected potentially avoidable GP-type presentations to emergency departments

PI 24 - GP-type services

While there has previously been no data for this indicator, data from the

2011-12 PEx survey and a public dental waiting times national minimum data set may produce additional data.

Retain as a measure of whether care was affordable, noting that this indicator does not reflect the nuances of the range of other socio-economic factors that may influence people in deferring access to health care.

Retain as a measure of whether care was appropriate, but change to

‘Effective management of diabetes’ to make the indicator more comprehensible to the public.

Data from the Australian Health Survey (AHS) will be available in late 2013.

Retain but move to Outcome 1. Life expectancy is the best single measure of health outcomes.


Retain but move to Outcome 1 and align with revised NIRA PI 2 - Under five mortality rate by leading cause (which reports <1, 1-4 and 0-4 years), noting small jurisdictions may be unable to provide reliable data. This indicator is a measure of whether Australians were born healthy and mortality rates for Indigenous children under five years is a COAG target.


Retain and align with ACSQHC. This indicator is a measure of the quality of primary and community care and hospital and hospital related care.


Retain as a proxy measure of access to appropriate care with the 4 th

National Mental Health Plan target for treatment rates set at 12% of population. Data linkage work is currently underway.


Retain and align with ACSQHC. This indicator is a measure of hospital admissions that could have been prevented through the provision of appropriate primary and community care.


Retain, with further data development undertaken to address the identified data issues.

This indicator cannot currently distinguish presentations which may have been explicitly referred by a GP to the emergency department and may be limited by the unavailability of information on the diagnosis/presenting problem of the patient. Further, not all hospitals are covered by the data source.


Remove as this is an output measure that, while relevant to contextual analysis, does not inform progress against the outcome.


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PI 25 – Specialist services

PI 26 – Dental services

PI 27 – Optometry services

PI 28 – Public sector community

mental health services

Remove as this is an output measure that, while relevant to contextual analysis, does not inform progress against the outcome. This indicator also has considerable data issues as this indicator is considered a proxy measure as it only measures specialist activity under the MBS.


Remove as this is an output measure that, while relevant to contextual analysis, does not inform progress against the outcome. This indicator also has considerable data issues due to the irregularity of the survey and high relative standard errors.

This indicator is reported in AIHW publications on dental health.


This indicator is expected to be reported in future editions of the Aboriginal and Torres Strait Islander Health Performance Framework.


This indicator is reported in the AIHW annual publication Mental Health

Services in Australia.

PI 29 – Private sector community

mental health services

PI 30 – Proportion of people with diabetes that have a GP annual

cycle of care




Remove as this is an output measure with only a partial link to the outcome as the indicator only refers to the management of a specific type of management. A more suitable outcomes-focussed indicator exists to measure whether the management of people with diabetes is effective –

Effective management of Type 2 diabetes.


PI 31 – Proportion of people with asthma with a written asthma

plan

Remove as this is an output measure with only a partial link to the outcome. A more suitable outcomes-focussed indicator exists to measure whether the management of people with asthma is effective in keeping them out of hospital – Selected potentially preventable hospitalisations

(asthma).


PI 32 – Proportion of people with a

mental illness with GP care plan

Remove as this is an output measure with only a partial link to the outcome and there are measurement issues in terms of describing the full range of coordinated care for people with mental health issues beyond Medicare GP plans.



PI 33 – Number of women with at least one antenatal visit in first

Remove as this is an output measure and more suitable outcomes-focussed indicators exist –Proportion of babies born of low birth weight and Infant

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trimester and young child mortality rate. There is also concern around whether one antenatal visit is a sufficient indicator for whether care needs are met.

The NHA Working Group notes that this indicator is particularly important for Aboriginal and Torres Strait Islander women and will be reported under the NIRA.



Performance indicator Analysis

PI 34 – Waiting times for elective

surgery

PI 35 – Waiting times for emergency department care

Retain and also measure against the National Elective Surgery Target

(NEST) Part I targets.

The existing indicator measures the median and 90th percentile and monitors overall progress in reducing waiting lists regardless of the categories of urgency for elective surgery, and focuses on the length of the tail in waiting lists. This is critical in identifying the position of those who have been waiting longest for surgery. At least in the foreseeable future data on the NEST indicator will not be nationally comparable. The NEST is distinctly aligned with reward funding arrangements to improve elective surgery performance and does not measure long-standing trends. The

NEST Part 1 indicator shows only the proportion of patients meeting the clinically recommended treatment times and does not show the trends in time to treatment within urgency categories. The deficiencies in the NEST methodology are such that, on the advice of the Expert Panel that developed the methodology, COAG has commissioned development of a new indicator to provide robust comparison of jurisdictional performances in reducing waiting lists and satisfying clinical targets for time to treatment.

Retain and also measure against the National Emergency Access Target

(NEAT) (revised PI 36) and rename to ‘Waiting times for emergency department care’.

The NEAT is distinctly aligned with reward funding arrangements to improve performance, not to measure long-standing trends. Despite the introduction of the NEAT, there is an ongoing need to report whether the existing indicator is being met, as time to treatment remains a key measure of access to urgently required emergency department care, noting that members of the public are particularly interested in emergency department waiting times. In recommending the NEAT, the Expert Panel noted it should not be an end in itself, but a tool to drive process and system change and measure progress of such improvements. By contrast, the existing indicator has long been the published measure of emergency department performance and improvement over time. There is also strong media and community interest in reports of emergency department waiting times.

PI 36 – Waiting times for admission following emergency department care

PI 37 – Waiting times for

Retain but align with the National Emergency Access Target and combine with PI 35 Waiting times for emergency department care.

Reconsider after a decision is made by SCoH on whether to implement a

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radiotherapy and orthopedic specialists

PI 38 – Adverse drug events in

hospitals proposed Radiotherapy Waiting Times Data Set Specification. If reincluded exclude orthopedic specialists and rename to ‘Waiting times for

radiotherapy. This indicator is a measure of whether care was delivered at the appropriate time.

Remove as there are currently no data for reporting and this is not an

ACSQHC-endorsed safety and quality indicator.

PI 39 – Health-care associated

Staphylococcus aureas bacteraemia in acute care hospitals

PI 40 – Pressure ulcers in hospitals Remove as there are currently no data for reporting and this is not an

ACSQHC-endorsed safety and quality indicator.

PI 41 – Falls resulting in patient

harm in hospitals

Remove as this indicator has considerable data issues and is not an

ACSQHC-endorsed safety and quality indicator. Data development would be required to restrict the count to hospitals as it is currently recorded for

‘health service area’ and improve coding as more than a quarter of records have missing codes for ‘place of occurrence’.

This indicator is reported in the AIHW annual publication Australian

hospital statistics.

PI 42 – Intentional self-harm in

hospitals

Retain but renamed to Healthcare associated infections to improve comprehensibility and align with ACSQHC. This indicator is a measure of the safety and quality of hospital care and is endorsed for use as a performance indicator by the ACSQHC.


PI 43 – Unplanned/ unexpected readmissions following selected surgical admissions

Remove as this indicator has considerable data issues and is not an

ACSQHC-endorsed safety and quality indicator. The data may underestimate intentional self-harm in hospitals as around 30 percent of records of such separations did not specify the place of occurrence.

This statistical information is reported in the AIHW annual publication

Australian hospital statistics.

Retain as a measure of quality of care but renamed to Unplanned hospital

readmission rates. Data development work will be undertaken around definitions to align it with the ACSQHC measure, which will be finalised for

2013 CRC reporting. Include readmissions for relevant mental health conditions.


PI 44 – Survival of people diagnosed with cancers

PI 45 – Rates of services:

Overnight separations

Retain but change to ‘Survival of people diagnosed with notifiable cancers’.

This indicator is a measure of quality of care. The measure could be improved by separately reporting relative survival by major types of cancer, aligning the types of cancer with current PI 4 Incidence of selected

cancers.

AIHW advises that State/Territory estimates for this indicator can be produced when these estimates are next updated.


Remove as this is an output measure that, while relevant to contextual analysis, does not inform progress against the outcome or align with the

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PI 46 – Rates of services:

Outpatient occasions of service

PI 47 – Rates of services: Non-

acute care separations

PI 48 – Rates of services: Hospital

procedures revised performance framework.



Remove as this is an output measure that, while relevant to contextual analysis, does not inform progress against the outcome or align with the revised performance framework.









New PI – Rate of community follow up within first seven days of discharge from a psychiatric admission

Include. This indicator is the best existing lead measure of the quality of post-discharge care.




PI 49 - Residential and community aged care places per 1,000 population aged 70+ years

PI 50 – Staphylococcus aureus

(including MRSA) bacteraemia in

residential aged care

PI 51 – Pressure ulcers in

residential aged care

PI 52 – Falls resulting in patient harm in residential aged care and

treated in hospital

PI 53 – Older people receiving

aged care services

PI 54 – Aged care assessments

Analysis

Retain as a proxy measure of access to residential and community aged care services.

Remove as currently no data for reporting. The Working Group has recommended a new indicator Proportion of residential aged care days on

hospital leave due to selected preventable causes to replace this indicator.

Remove as currently no data for reporting. The Working Group has recommended a new indicator Proportion of residential aged care days on

hospital leave due to selected preventable causes to replace this indicator.

Remove as this indicator has considerable data issues and the Working

Group has recommended a new indicator Proportion of residential aged

care days on hospital leave due to selected preventable causes to replace this indicator.

Remove as this an output measure that, while relevant to contextual analysis, does not inform progress against the outcome.

Remove as this an output measure that, while relevant to contextual analysis,

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completed

PI 55 – Younger people with disabilities using residential, CACP

and EACH aged care services does not inform progress against the outcome.

Remove as this an output measure that, while relevant to contextual analysis, does not inform progress against the outcome. This indicator is covered by the National Disability Agreement and does not align with the revised performance framework.


PI 56 – Number of people aged 65 and over receiving sub-acute services

PI 57 – Number of hospital patient days used by those eligible and waiting for residential aged care

Retain as a proxy measure of whether care was delivered in the appropriate setting.

New PI – Proportion of services that are three year re-accredited

New PI – Proportion of residential aged care days on hospital leave due to selected preventable causes

Include as a measure of the quality of aged care. It is expected this indicator will incorporate measures relating to aged care associated infections (Staphylococcus aureus bacteraemia or an alternative infection

of more relevance to aged care) falls and pressure ulcers previously in PIs

50-52. The measure utilises existing data collection and thus introduces no extra cost to the system.

New PI – Elapsed times for aged care services

Include as a proxy measure of the quality of aged care services. The measure utilises existing data collection and thus introduces no extra cost to the system.

New PI – Proportion of aged care residents who are full pensioners relative to the proportion of full pensioners in the target population

Include as a proxy measure of whether care was delivered at the appropriate time. The measure utilises existing data collection and thus introduces no extra cost to the system. Possible referral for further data development to move to an indicator of waiting times.

Include as an indicator of the affordability of aged care. The measure utilises existing data collection and thus introduces no extra cost to the system.

Outcome 5: Australians have positive health and aged care experiences which take account of individual

circumstances and care needs

The Working Group notes that there is no measure of patient experience of aged care services.


PI 58: - Patient

satisfaction/experience

Analysis

Retain as a measure of patient experience with the health system. This indicator currently does not measure the patient experience within aged care.

A working group co-chaired by DoHA and the ACSQHC under the auspices of the National Health Information Standards and Statistics Committee

(NHISSC) has been established to oversee patient experience indicator work.


Outcome 6: Australians have a health system that promotes social inclusion and reduces disadvantage,

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especially for Indigenous Australians

This outcome is concerned with ensuring Australia’s health system promotes social inclusion and reduces disadvantage, especially for Indigenous Australians. The Working Group has sought to strengthen reporting against this outcome by including people with a disability as a social inclusion group and proposing to disaggregate all indicators, to the extent it is possible and appropriate, by Indigenous status, disability status, remoteness area and socio-economic status to assess whether these groups achieve comparable health outcomes and service delivery outcomes to the broader population.

The Working Group recommends that Performance Indicator 60 - Access to services by type of service compared

to need be considered for re-inclusion after data development, consistent with the NIRA recommendation for the same indicator.

Performance indicator Analysis

PI 59 – Age-standardised mortality Retain but rename to ‘Major causes of death’ and move to Outcome 1.The

NHA Working Group notes that this indicator may not be easily comprehended by the average person, however the change in name should mitigate this.


PI 60 – Access to services by type

of service compared to need

PI 61 – Teenage birth rate

PI 62 – Hospitalisation for injury

and poisoning

PI 63 – Children's hearing loss

PI 64 – Indigenous Australians in

the health workforce

Reconsider following data development work to better measure access and need. The indicator currently measures utilisation of services against selfreported health status.

It is recommended that the NHA review adopt a similar approach to the

NIRA review and remove this indicator and reconsider its re-inclusion once a conceptually sound measure is developed.


Remove as teenage birth rates are largely attributable to societal and individual factors that are outside the control of the health system and more suitable outcomes-focussed measures concerned with healthy births exist –Low birth weight babies and Infant and young child mortality rate.

The NHA Working Group notes that this indicator is particularly important for Aboriginal and Torres Strait Islander women and is currently reported in the Overcoming Indigenous Disadvantage report.

Remove as this an output measure that, while relevant to contextual analysis, does not inform progress against the outcome.

The NHA Working Group notes that this indicator is particularly important for Aboriginal and Torres Strait Islander people and is reported under the

Aboriginal and Torres Strait Islander Health Performance Framework.

Remove as small counts and lags in data availability limits the usefulness of this indicator.

The NHA Working Group notes that this is a health condition of particular concern to Indigenous Australians and is reported under the Aboriginal and

Torres Strait Islander Health Performance Framework.

Remove as it is an input measure with moderate data issues. Reliable data are only available every five years from the Census and there are data constraints around identifying the Indigenous health workforce in the

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National Health Labour Force Survey and the selected scope of professions and health occupations measured.

The Working Group notes that this is an important indicator that potentially provides some insight into access to care for Indigenous

Australians and is reported under the Aboriginal and Torres Strait Islander

Health Performance Framework.



PI 65 – Net growth in health workforce (medical practitioners, nurses/midwives, dentists)

PI 66 – Public health program expenditure as a proportion of

total health expenditure

PI 67 – Capital expenditure on health and aged care facilities as a proportion of capital consumption expenditure on health and aged

care facilities

Remove as the indicator is difficult for the public to understand and it is difficult to interpret as there is no particular ‘correct’ level of the indicator.

PI 68 – Proportion of recurrent health expenditure spent on

health research and development

PI 69 – Cost per casemix-adjusted

separation

Analysis

Retain but amend to Full time equivalent workforce per 1,000 population

(by age group).

Remove as there is no clear link to the outcome and the direction of change that represents progress is unclear. There is also a lag between data collection and availability.

Remove as there is no clear link to the outcome and the direction of change that represents progress is unclear.

Remove as the indicator does not link well with the outcome, being reflective of efficiency rather than sustainability. The indicator is also difficult to use in time series analyses due to changes in coding systems, overall mix of cases being performed and the effects of inflation.


PI 70 – Accredited and filled

clinical training positions

Remove as there are no data and no data development work planned.

Additionally, the direction of change that represents progress is difficult to understand against the outcome of a sustainable health system.

Note the Working Group recommends HoTs undertake further work to identify a suitable financial sustainability indicator.

3.1.3 Performance Benchmarks

As part of the work of the Review, the Working Group reviewed the Performance Benchmarks to ensure their relevance in the revised performance framework. The performance benchmarks provide an indication of the standard of service expected or the level of improvement expected in service delivery over a specified period. They address areas of particular concern to governments, which if left unchecked will have profound consequences for individuals, the health system and the economy at large. They relate to:

 closing the gap in health outcomes between Indigenous and non-Indigenous Australians;

 tackling the large and increasing burden of chronic disease and its associated risk factors;

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 strengthening preventive and primary health care to keep people healthy and out of hospital; and

 improving the safety and quality of hospital care.

As the Performance Benchmarks have been agreed to by COAG, the Working Group agreed that they should be retained unless:

 a strong argument could be made for their removal;

 the performance indicator related to the benchmark had been removed from the performance framework; and/or

 the benchmark was past its reporting date and no longer relevant.

The Working Group recommends that the seven performance benchmarks are retained; with one recommended for modification. The Working Group also notes the data limitations of one benchmark.

The Working Group notes that the 2011 NHA identifies, as priority areas for effort over the near-term, the need to develop performance benchmarks relating to avoidable hospital presentations to emergency departments and timely access for eligible older people to aged care services. It is not until the existing measure of avoidable hospital presentations to emergency departments is improved that an appropriate baseline and target can be considered. Development of a benchmark concerning timely access to aged care services will need further consideration in the context of the aged care reforms.

1. Close the life expectancy gap for Indigenous Australians within a generation.

The Working Group recommends this performance benchmark be retained.

On 20 December 2007, COAG agreed to a partnership between all levels of government to work with

Indigenous communities to achieve the target of closing the gap on Indigenous disadvantage. This performance benchmark is one of six national targets agreed by COAG for closing the gap on Indigenous disadvantage.

2. Halve the mortality gap for Indigenous children under five by 2018.


This performance benchmark is one of six national targets agreed by COAG for closing the gap on

Indigenous disadvantage.

3. Reduce the age-adjusted prevalence rate for Type 2 diabetes to 2000 levels (equivalent to a national prevalence rate of 7.1 per cent) by 2023.


Type 2 diabetes is projected to become the leading specific cause of disease burden by 2023 and the financial burden associated with treating Type 2 diabetes is predicted to quadruple by 2033.

2 While no data have been available for reporting against this performance benchmark, it will be possible to derive

2 Goss J 2008. Projection of Australian health care expenditure by disease, 2003 to 2033. Cat. no. HWE

43.Canberra: AIHW.

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an estimate of Type 2 diabetes from the Australian Health Survey using a method consistent with the baseline estimate derived from the 1999-2000 AusDiab survey.

4. By 2017, increase by five percentage points the proportion of Australian adults and Australian children at a healthy body weight, over the 2009 baseline.

The Working Group recommends this performance benchmark be retained and the target date revised to be consistent with the smoking performance benchmark, as data for both benchmarks will be sourced from the Australian Health Survey.

It is not yet known when the Australian Health Survey will be conducted so the 2018 target date is an approximate at this point in time and may require adjusting at a later date.

Overweight and obesity is a major risk factor for Type 2 diabetes, cardiovascular disease and certain cancers. Prevalence rates for overweight and obesity are on the rise and if current trends continue approximately 75% of the population are expected to be overweight or obese in 2025.

3

5. By 2018, reduce the national smoking rate to 10 per cent of the population and halve the

Indigenous smoking rate, over the 2009 baseline.


Tobacco smoking is a major risk factor for cardiovascular disease and numerous cancers, and is the leading cause of preventable death and ill health in Australia.

4

6. By 2014-15, improve the provision of primary care and reduce the proportion of potentially preventable hospital admissions by 7.6 per cent over the 2006-07 baseline to 8.5 per cent of total hospital admissions.

The Working Group recommends this performance benchmark be retained, noting the targets will require resetting following the completion of data development.

Preventive and primary health care are integral to an effective and efficient health system. Early intervention and treatment in the community keeps people healthy and out of hospital, and has significant economic benefits.

The Working Group notes that the CRC has not reported against this benchmark since its baseline report due to significant data issues. Namely, changes in coding practices and standards over time, particularly relating to the coding of diabetes complications, have interrupted the time series analysis making it impossible to assess progress toward meeting this benchmark as originally intended.

Data development work is underway through NHISSC to revise the benchmark and the associated indicator to meet longer term needs. The Working Group recommends that the target and baseline are reconsidered by NHIPPC, in consultation with SCoH, following this work.

7. The rate of Staphylococcus aureus (including MRSA) bacteraemia is no more than 2.0 per 10,000 occupied bed days for acute care public hospitals by 2011-12 in each State and Territory.


3 National Preventative Health Taskforce 2009. Australia: the healthiest country by 2020 – the road map for action. Canberra: Commonwealth of Australia.

4 AIHW 2012. Risk factors contributing to chronic disease. Cat No. PHE 157. Canberra: AIHW.

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The Working Group notes that this benchmark expires at the end of 2011-12 and that all jurisdictions have readily met the target. The Working Group considers that the benchmark be retained for 2013 CRC reporting. A more challenging target could be considered, in consultation with the Australian

Commission on Safety and Quality in Health Care, for future reporting.

Healthcare associated infections are largely preventable, cause significant harm to patients, and use up valuable healthcare resources.

3.2 Performance and Accountability Framework (PAF)

The Performance and Accountability Framework is the reporting mechanism of the National Health

Performance Authority (NHPA). Once established, it will support local level and service focussed reporting on the performance of every hospital, Local Hospital Network and Medicare Local. The Terms of Reference for the NHA Review includes that the Working Group is to have regard to the NHRA and in particular the objectives, principles and requirements of the PAF.

The Working Group has sought to the extent possible to re-focus the NHA performance framework on outcomes, consistent with the IGA FFR. The PAF serves a wider reporting remit including a focus on local level reporting, and is expected to report a range of outputs and intermediate outcomes that are included in the original set of 70 NHA indicators.

The NHPA data plan was not available at the time of the NHA Review Working Group finalising its recommendations. The Working Group recommends that NHISSC be asked to review the NHA indicator specifications and ensure the data sources, standards and methodology are consistent with related

NHPA indicators where appropriate.

3.3 Social inclusion and Indigenous health

The Working Group noted the criticisms from the CRC report NHA: Baseline performance report for

2008-09, in particular recommendation 1(g), to consider broader measures of social inclusion for reporting equity in health outcomes. The Working Group agreed that the best approach to measuring this outcome is for all performance indicators, where it is possible and appropriate to do so, will be disaggregated by Indigenous status, disability status, remoteness area and socio-economic status to assess whether these social inclusion groups achieve comparable health outcomes and service delivery outcomes to the broader population.

3.3.1 Disability

The 2011 NHA states that consideration should be given to the inclusion of disability-related policy and reform directions and performance indicators in relevant reviews. The NHA Working Group notes the importance of disability measures.

However, it should be noted that information on disability status is sparse in health data collections.

ABS population surveys including the Patient Experience Survey and the Australian Health Survey are the few exceptions where disability status is captured. Hence, in the short term, disaggregation by disability status would be limited to performance indicators based on these data sources (see

Attachment D for disaggregation levels per indicator). In the longer term, at the request of the

Community, Housing and Disability Service Ministers, the AIHW developed and piloted an identifier for

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people with a disability in administrative data collections, including health. The project, including pilots, is scheduled to be completed by June 2013 when a final and approved identifier should be available for implementation.

3.4 Sustainability

Analysis of the existing performance indicators under Outcome 7 identified considerable conceptual issues and data limitations with regards to measuring the sustainability of Australia’s healthcare system.

These limitations constrained the usefulness of the existing indicators in reporting on progress against this Outcome in the NHA.

The Working Group noted the importance of measuring the sustainability of the health system and assessing the overall performance of the healthcare system over time. Further, it was noted that there are conceptual difficulties in establishing indicators directly measuring progress in any single period given the need to also consider aspects of future performance.

The Working Group has agreed only one sustainability indicator measuring health workforce. The

Working Group agreed that a performance indicator measuring the financial sustainability of the healthcare system would provide a valuable account of its overall sustainability, however there was not unanimous agreement amongst the Working Group to a specific indicator.

As such, the Working Group recommends that the Steering Group request the Heads of Treasuries undertake further work to provide advice to COAG which considers the development of an appropriate indicator and whether such an indicator would be viable, noting that this may increase the number of indicators.

3.5 Data specification and data development

The proposed performance indicator set includes 8 new indicators that require data specification. A further 12 of the current indicators require revisions to data specifications to reflect the amendments recommended by the Working Group.

The Working Group recommends that the Standing Council on Health, through the National Health

Information and Performance Principal Committee (NHIPPC) and its subcommittee, the National Health

Information Standards and Statistics Committee (NHISSC) develop data specifications and costs for the new proposed indicators and amended existing indicators, and review all specifications to ensure that indicators in common with the NHPA use the same data sources, standards and methodology where appropriate.

The Working Group notes that five indicators in the revised performance framework will not be reportable in 2013 (Table 4).

Table 4: Data development - expected year of reporting


Prevalence of type 2 diabetes

Expected year of CRC reporting

2014 – following the release of results from the National

Health Measures Survey component of the Australian

Health Survey in late 2013.

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Effective management of diabetes

Waiting times for radiotherapy

Proportion of aged care residents who are full pensioners relative to the proportion of full

pensioners in the target population

Proportion of residential aged care days on hospital

leave due to selected preventable causes

Table 5: Performance indicator data status

2014 - following the release of results from the National

Health Measures Survey component of the Australian

Health Survey in late 2013

Contingent on SCoH decision on the implementation of a radiotherapy waiting times data collection

2014 – following data development work to collect pension status of aged care recipients in late 2013

2014 – following data development work to collect information on reason for hospital leave in late 2013


Data collected and specified

Data collected but needs to be specified

Needs to be developed


Proportion of babies born of low birth weight

Incidence of selected cancers

Proportion of persons obese and overweight

Proportion of adults who are daily smokers

Levels of risky alcohol consumption

Life expectancy

Infant and young child mortality rate

Major causes of death

√

√

√

√

√

√

√ (spec revised to include overweight and healthy weight categories)

√ (spec revised to reflect title change)

√ (spec revised to reflect title change)

√ (new spec)

√ (new spec)



Proportion of adults with very high levels of psychological distress

√ (new spec)


Waiting times for GPs

√


√ (new spec)

People deferring access to selected health care √

Effective management of diabetes √ (new spec)

Potentially avoidable deaths √


√

√ (data linkage work underway)

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Data collected and specified

Data collected but needs to be specified

Needs to be developed

Selected potentially preventable hospitalisations

Selected potentially avoidable GP-type presentations to emergency departments

√

√


Waiting times for elective surgery

√ (spec to include NEST)

Waiting times for emergency department care

√ (spec to include NEAT)

Waiting times for radiotherapy

Health-care associated infections

Unplanned hospital readmission rates

√

√ (spec to align with ACSQHC indicator)

√ (spec to align with ACSQHC indicator)

√ (spec revised to reflect change in title)

√ (contingent on SCoH decision)

Survival of people diagnosed with notifiable cancers

Rate of community follow up within first seven days of discharge from a psychiatric admission

√ (new spec)


Residential and community aged care places per

1,000 population aged 70+ years

√

Number of hospital patient days used by those eligible and waiting for residential aged care

√

√ (new spec)


Proportion of aged care residents who are full pensioners relative to the proportion of full pensioners in the target population

√

√

Proportion of residential aged care days on hospital leave due to selected preventable causes

Elapsed times for aged care services √ (new spec)


Patient satisfaction/experience

√

Outcome 6: Australians have a health system that promotes social inclusion and reduces disadvantage, especially for

Indigenous Australians


Full-time workload equivalent per 1,000 population by age group

√ (new spec)

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A cost and benefit analysis of the proposed new performance indicators has been provided at

Attachment E.

Please note there may be issues in producing reliable jurisdiction or sub-jurisdiction estimates from population surveys and administrative data sets due to small samples or populations. As per current practice, for selected indicators affected numbers and rates may need to be suppressed and issues outlined in data quality statements.

3.6 Implementation of a revised NHA performance framework

The NHA reporting cycle for 2013 has commenced. NHISSC is currently developing and reviewing specifications for the original set of 70 NHA indicators and seven benchmarks at the request of the

Steering Committee for the Review of Government Service Provision (SCRGSP).

If COAG endorses the Working Group’s recommendations before end December 2012, the CRC has requested the SCRGSP to collate data according to the revised NHA performance framework for reporting by the CRC in 2013. Consequently, the SCRGSP has endorsed a parallel data supply process whereby data custodians supply data for the original and revised performance frameworks until such time COAG decides on a revised performance framework. This additional reporting requirement will potentially impede efforts to develop specifications and supply data for the new and revised indicators proposed by the Working Group.

The Working Group recommends that the CRC report on the revised NHA performance framework in

2013, to the extent that this is possible, and for data custodians to only supply data to the SCRGSP for indicators and benchmarks included in the revised framework.

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Attachment A: Recommendations fro m the CRC’s NHA performance reports for 2008 -09 and 200910, COAG’s responses and actions taken

Recommendation COAG Response Action taken/proposed

Recommendations from the COAG Reform Council’s NHA: Baseline performance report for 2008-09

1. The COAG Reform Council recommends that COAG confirm that administrative data provided for each report should relate to the relevant reporting year.

2 a) The COAG Reform Council recommends that COAG notes the issues in relation to conceptual adequacy and data quality and refers them to the Heads of Treasuries

Committee on Federal Financial Relations for further consideration and prioritisation, in consultation with the National Health Information Standards and

Statistics Committee—a subcommittee of the

Australian Health Ministers’ Advisory Council.

b) In particular, to better realise the intent of simple and transparent public accountability, the council recommends:

(i) there should be a strong conceptual framework underpinning the National Healthcare Agreement providing a clear basis for linking the performance indicators with the desired outcomes.

Agreed.

Both administrative and survey data are supplied for

NHA reporting purposes.

In the case of administrative data, efforts continue by state/territory and national health data custodians to improve the timeliness of key health datasets (e.g. through improved automation of national validation arrangements). There has been an increase in the number of indicators for which relevant reporting years have been made available (e.g. elective surgery and emergency department waiting times data are now available for the relevant reference period).

Noted. COAG, as mentioned above, agreed that the working group would review the performance framework of the National

Healthcare Agreement, in conjunction with the development of the Performance and

Accountability Framework under the National

Health Reform Heads of Agreement, with a completion date of no later than 31 December

2011.

A review of the framework was undertaken by COAG with reference to the Heads of Treasuries conceptual framework.

The proposed revised performance framework is simplified, consisting of just one objective linked to seven outcomes with performance indicators supporting monitoring progress of the outcomes.

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Recommendation

(ii) the conceptual framework should be consistent with the agreed reform of federal financial relations—a shift from

Commonwealth prescription of State and Territory service delivery to a focus on the achievement of objectives and outcomes

(iii) within this context, the number of progress measures, outputs and performance indicators should be reviewed and potentially substantially reduced based on their importance to achieving the identified outcomes and objectives, the availability of robust data and data development priorities

(iv) the use and structure of performance language needs to be internally consistent within the National

Healthcare Agreement, and with other National

Agreements

(v) once measures are established, data development be prioritised according to the extent to which data are available, accurate, comparable and timely. Further, an assessment of the anticipated speed of change in health outcomes is required, and an assessment of the cost and benefits of obtaining appropriate estimates, to confirm if more frequent collection is justified for those measures which are not supported by annual data

3. The COAG Reform Council notes that, under the new

National Health and Hospitals Network Agreement agreed by COAG (with the exception of Western

Australia), the Australian Commission on Safety and

Quality in Health Care will develop new clinical safety and quality standards across primary care and public hospitals. The council supports this development, but recommends that appropriate standards apply across the care continuum, including aged care.

4 a. The COAG Reform Council recommends that COAG notes the issues in relation to the performance reporting framework relevant to each objective as listed below and

COAG Response

Noted.

Action taken/proposed

Proposed framework is consistent with IGA FFR.

There has been a substantial reduction in the number of indicators as a result of this review.

The revision of the framework has aligned the language in the agreement with the IGA FFR.

Data development work has been prioritised in the review.

The work of the ACSQHC has been considered in the review and indicators aligned.

Noted and referred to the working group to consider as part of its review of the agreements outlined above.

These issues have been considered in the review.

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Recommendation refers them to the Heads of Treasuries Committee on

Federal Financial Relations for further consideration and prioritisation, in consultation with the National Health

Information Standards and Statistics Committee. b.

Objective: Prevention

(i) rationalise the number of sexually transmissible diseases and blood-borne viruses reported to support high-level performance reporting

(ii) consider inclusion of appropriate measures which report prevention activity, such as exercise and health eating, and the extent to which Australians have access to education to make healthy choices

COAG Response

(iii) improve the availability and accuracy of survey collections to report data under the prevention objective, particularly once disaggregated by

Indigenous and socio-economic status

(iv) Improve the accuracy of data on childhood obesity. c. Objective: Primary and community health

(i) Consider inclusion of more meaningful measures of primary and community health, and the performance of the Commonwealth Government in this area.

(ii) Consider inclusion of measures which report on the affordability and quality of primary and community care.

(iii) Improve availability of data under the primary care


The Working Group recommends removing this indicator.

The Working Group considered measuring Fruit and

vegetable intake and physical activity; however this is an intermediate measure of obesity, which is captured in the PI Prevalence of overweight and obesity (formerly

titled Proportion of persons obese).

This is only possible given extra funding to increase sample size and/or frequency.

The new Australian Health Survey may improve availability and accuracy of data in this area.

Outcome 2 includes meaningful measures of appropriate, high quality and affordable primary and community health.

The proposed NHA performance indicator set includes the following measures of affordability and quality:

 PI People deferring access to selected health care

due to cost

 PI Effective management of diabetes

 PI Selected potentially preventable hospitalisations

Data are available from the ABS Patient Experience

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Recommendation objective noting that four performance indicators have no data available.

COAG Response

(iv) Improve the ability to report Medicare data disaggregated by Indigenous status.

(v) Improve comparability of data for potentially preventable hospitalisations noting differences in data collection in Western Australia.

(vi) Improve the ability to report potentially avoidable deaths and life expectancy for Indigenous Australians and make cross-jurisdictional comparisons.


Survey to populate three of the four indicators that previously had no available data - Waiting times for GPs;

Waiting times for public dentistry, and People deferring access to selected health care due to cost.

The National Health Measure Survey component of the

Australian Health Survey will be the future data source for the indicator Effective management of diabetes.

Indigenous status information can now be reported for

Medicare data following collaborative work by the

Department of Health and Ageing and the Australian

Institute of Health and Welfare on a methodology for adjusting Indigenous status information recorded on a voluntary basis in Medicare data.

NHISSC recommended supply of supplementary measures for 2012 CRC reporting. These supplementary measures attempt to account for changes in ICD-10-AM codes and Australian Coding Standards that affected comparability of the indicator over time and across jurisdictions in coding, most notably in relation to recording of diabetes complications.

A NHISSC working group is considering further refinements to this indicator to support comparable reporting in the longer term.

Work is being undertaken to improve indigenous identification in deaths data.

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Recommendation d. Objective: Hospital and hospital related care

(i) Consider inclusion of measures which report that hospital care is both affordable and appropriate.

(ii) Investigate ways to meaningfully report output data for the purposes of cross-jurisdictional comparisons.

COAG Response

(iii) Improve availability of data under the hospital and hospital related care objective noting that four performance indicators have no data available.

(iv) Improve data quality for key measure of safety and quality in hospitals.


New Outcome 3 is concerned with ensuring Australians receive hospital and hospital related care that is appropriate and high quality. The Working Group notes that there are no measures of affordability.

For indicators based on counts only in the first cycle of

NHA reporting (ie. PI 52, PI 56) rates have subsequently been supplied to support cross-jurisdictional comparison. Wherever possible, all output data are presented according to the required social inclusion disaggregations, providing some indication of access by population groups. Further work would be required to develop methodologies for adjusting output data to account for jurisdictional differences (e.g. need for care, care models, cross-border flows)

A Radiotherapy Waiting Times Data Set Specification has been developed and is being considered by Standing

Council on Health in terms of feasibility of implementation.

Comparable data for PI Staphyllococcus aureus

(including MRSA) bacteraemia were supplied for the third reporting cycle.

Further development of PI Unplanned/ unexpected readmissions following selected surgical admissions has continued under the auspices of NHA reporting and

MyHospitals reporting and relating to readmissions to the same hospital (currently reported) and any hospital within the state (the desirable long-term measure).

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Recommendation

(v) Ensure hospital data are representative of all hospitals and all performance indicators are able to report data for all hospitals if necessary.

COAG Response

(vi) Allow for more timely reporting of hospitals data— currently data are available for the year prior to the baseline reporting year.

(vii) Develop a more timely and regular measure of cancer survival e. Objective: Aged care

(i) Consider inclusion of aged care measures which report if aged care services are meeting demand for these services.


A subset of hospital-related performance indicators is not representative of all hospital activity as they do not include data for private hospitals. In addition, the agreed scope of the outpatient, elective surgery and emergency department datasets is Peer Group A and B hospitals only (e.g. waiting times for emergency departments and elective surgery). All jurisdictions provide data according to the agreed scope for these collections. Any extension to remaining hospitals should be considered on a cost-benefit basis recognising the significant costs of pursuing the last small percentage of hospital activity.

From the second reporting cycle onward, more timely data have been available for elective surgery and emergency department waiting times. Such gains in timeliness have not been achieved for other hospital administrative datasets, which include coded diagnosis/procedure and financial data.

It would require funding to update these data in a more timely and frequent manner. Production of more regular survival estimates should take into consideration the statistical possibility of detecting changes in cancer survival rates at more regular intervals.

The Working Group recommends a new indicator

Elapsed time for aged care services. As it stands, this indicator is not a measure of waiting time or demand for services. Data development work is required to measure

40 | P a g e

Recommendation

(ii) Consider inclusion of measures which report appropriateness and affordability of aged care services, and choice and transitions within and across the sector.

(iii) Consider the appropriateness of the output—number of young people with disabilities accessing aged care services—under the aged care objective of the

National Healthcare Agreement.

(iv) Improve availability of key quality-related performance indicators—incidence of pressure ulcers and rates of Staphylococcus aureus bacteraemia in residential aged care.

COAG Response

(v) Develop rates for two key aged care performance indicators to allow comparisons to be made across jurisdictions. f. Objective: Patient experience

(i) Develop appropriate and timely measures of patient experience to report on this objective.

Action taken/proposed reason for delayed uptake.

The Working Group recommends new aged care indicators that measure whether older Australians receive access to quality and affordable aged care services.

The Working Group recommends removing this indicator as it does not inform progress against the outcome.

The Working Group recommends a new quality-related indicator Proportion of residential aged care days on

hospital leave due to selected preventable causes that will measure hospitalisations relating to Staphylococcus aureus bacteraemia, falls and pressure ulcers

The indicator Falls in residential aged care resulting in

patient harm and treated in hospital has been presented as a rate of resident-occupied place days for 2011 and

2012 CRC reporting.

An appropriate denominator is not available from current data collections to report a rate for the indicator

Young people with disabilities accessing aged care

services.

The Working Group recommends removing these two indicators.

Data is now partly available (for health but not aged care).

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Recommendation g. Objective: Social inclusion and Indigenous health

(i) Consider broader measures of social inclusion for reporting equity in health outcomes.

COAG Response

(ii) Report socio-economic status at a finer level, such as

SEIFA deciles or vintiles, to support a better understanding of social gradients where they occur.

(iii) Improve the availability and accuracy of data to report on the social inclusion objective, particularly when data are disaggregated by State and Territory.

(iv) Improve ability to disaggregate data by Indigenous status, socio-economic status and remoteness under this objective.

(v) Improve the timeliness and accuracy of data reliant on the National Health Survey and the National

Aboriginal and Torres Strait Islander Health Survey for the purposes of reporting on social inclusion outcomes. h. Objective: Sustainability

(i) Develop measures which meaningfully report the sustainability of the healthcare system and the extent to which it can respond and adapt to future need.

(ii) Improve availability of data for the performance indicator which reports accredited and filled clinical training positions.


The Working Group has sought to strengthen reporting against this outcome by proposing to disaggregate all indicators, to the extent it is possible and appropriate, by Indigenous status, disability status, remoteness area and socio-economic status.

From the third reporting cycle onwards, SEIFA deciles have been supplied wherever possible.

This is only possible given extra funding to increase sample size and/or frequency



The Working Group proposes the inclusion of the indicator Full time equivalent workforce per 1,000

population (by age group) as a measure of workforce sustainability and recommends HoTs provide advice to

COAG on a performance indicator measuring financial sustainability.

Health Workforce Australia to further develop information in this area.


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Recommendation

(iii) Improve the ability to meaningfully compare data across jurisdictions.

COAG Response Action taken/proposed

Data development in the area of health workforce, including the National Registration and Accreditation

Scheme, will improve availability of this information in future.

(iv) Consider expanding the scope of reporting for cost per casemix-adjusted separation to include all hospitals, reporting by hospital type, to enable more complete reporting of the efficiency of the health system as a whole. i. Performance benchmarks

(i) Develop jurisdictional benchmarks to transparently report State and Territory progress towards meeting national performance benchmarks.

(ii) Develop a measure to report the performance benchmark—within five years implement a nationally consistent approach to activity-based funding for public hospitals.

(iii) Improve availability of data for the performance benchmark—reduce the age-adjusted prevalence rate for type 2 diabetes to 2000 levels within 15 years.

(iv) Improve the quality of data to report the performance benchmark on the rate of Staphylococcus aureus bacteraemia

Recommendations from the National Healthcare Agreement: Performance report for 2009-10

The CRC has been provided with NEHIPC advice about the difficulties in using this indicator for time series comparisons and expanding the scope of the measure.


Jurisdictional benchmarks and trajectories have not been developed for the NHA.

No longer applicable – this benchmark was removed in the 2011 revision of the NHA.

This data can be sourced from the 2011-13 Australian

Health Survey – future biomedical data is subject to funding approval.

Comparable data are now available for this benchmark.

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Recommendation

1 (a) The COAG Reform Council recommends that COAG endorse the following priorities for improving the performance reporting framework for the National

Healthcare Agreement

 more frequent provision of survey data, subject to an analysis of benefits and costs

COAG Response

Agreed, subject to the outcomes of the review of the NHA agreed by COAG on 13 February

2011, noting that this review should duly consider the benefits and costs of this recommendation.


Considered as part of the NHA review.

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(b) The COAG Reform Council recommends that COAG endorse the following priorities for improving the performance reporting framework for the National


 ensuring the objectives, outcomes, progress measures and outputs form a conceptually adequate framework for measuring performance

Agreed The proposed performance framework provides a conceptually adequate framework.

(c) The COAG Reform Council recommends that COAG endorse the following priorities for improving the performance reporting framework for the National


 enhancing the ABS Patient Experience Survey in sample size and scope

(d) The COAG Reform Council recommends that COAG endorse the following priorities for improving the performance reporting framework for the National


 increasing the number of indicators that can be reported on by area of remoteness, with a focus on those identified.

2. The COAG Reform Council recommends that COAG refer

Agreed. COAG notes that the sample of the ABS

Patient Experience Survey (PExS) has increased from 7,000 households in 2009 to approximately

27,000 in 2010-11 and subsequent surveys. The scope of the 2010-11 and subsequent PExS has also expanded to collect information on dental and hospital –related care, and to include new questions on, for example, whether health professionals listened carefully to, showed respect for, and spent enough time with patients.

Agreed

Agreed

Enhanced data have been supplied for the second and third reporting cycles.

Further funding is required to consider the feasibility of methodology to produce mortality performance indicators disaggregated by remoteness (Current PIs 3,

18, 19, 59). Data are not available by remoteness for current PI 39 or PI 45 as the data collections do not include geographical information. Small numbers and methodological issues prevent remoteness disaggregations for current PI 59.

Completed.

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these priorities (see Recommendation 1), along with the recommendations made in the council‘s 2008-09 baseline report, to the review of the National Healthcare Agreement agreed by COAG on 13 February 2011.



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Attachment B: NHA Review Working Group Terms of Reference

Preamble

At its meeting on 13 February 2011, the Council of Australian Governments (COAG) agreed that the underlying reform principles of the Intergovernmental Agreement on Federal Financial Relations

(IGA) continue to provide a strong foundation for progressing COAG’s agreed reform agenda and achieving better policy and service delivery outcomes for all Australians. COAG established a Heads of Treasuries (HoTs) Review and COAG Reform Council (CRC) Recommendations Implementation

Steering Group to review and improve implementation of the IGA.

At a subsequent meeting on 19 August 2011, COAG endorsed the CRC’s recommendation to ensure that the objectives, outcomes, progress measures and outputs form a conceptually adequate framework for measuring performance.

Role and Purpose

The Working Group has been established by the HoTs Review and CRC Recommendations

Implementation Steering Group to address the performance reporting issues associated with the

National Healthcare Agreement (NHA) identified by the HoTs review and reports of the CRC, to reinforce COAG’s commitment to enhancing performance and public accountability.

Term

The Terms of Reference are effective from May 2011 and continue until the review is complete (due

30 April 2012, final recommendations to be back to the Steering Group by 15 April 2011).

Membership

Membership will consist of Senior Officers from First Ministers’, Treasuries and relevant portfolio agencies from the Commonwealth and the States and Territories.

The Secretariat for the Steering Committee for the Review of Government Service Provision, the

COAG Reform Council, the Australian Bureau of Statistics and the Australian Institute of Health and

Welfare are invited to attend as observers.

Key Tasks

The Working Group will:

 review the performance framework in the NHA using the conceptual framework developed by the HoTs review as per the process outlined below, which will include consideration of: o within the current scope of the NHA,, refine the objectives, outcomes, progress measures and outputs needed to ensure they form a conceptually adequate framework for measuring performance, o the number and appropriateness of performance indicators (indicators should be limited to those necessary to measure performance and inform the public about progress), o the links between performance indicators and outcomes, o the role of the NHA performance framework in supporting the achievement of the COAG closing the gap targets, including measuring the achievement of Indigenous outputs and outcomes, o what is the minimum data and frequency of collection required to demonstrate performance

(including the ability to identify Indigenous Australians within data collections and to further disaggregate data by geo-location), in consultation with relevant data agencies and committees such as the Australian Institute of Health and Welfare (AIHW), the Australian

47 | P a g e

Bureau of Statistics (ABS), and the National Health Information Standards and Statistics

Committee, o the cost of developing data to support the indicators against the benefit to public accountability arising from better data, and o potential updates to the roles and responsibilities ascribed to the Commonwealth and the

States to ensure that accountabilities reflect the new National Health Reform Agreement;

 respond to relevant recommendations from the HoTs review and CRC reports;

 have regard to the NHRA and in particular the objectives, principles and requirements of the

Performance and Accountability Framework (PAF) under that agreement, including:- o the primary role of CRC reporting, being to report on whole of health system outcomes, national trends and comparisons of performance across jurisdictions, as distinct from the primary role of National Health Performance Authority reporting, being to report on the performance of the health system at the local level (the local level indicators should ideally link to the higher order health outcomes in the NHA);

 have regard to other concurrent work, such as some National Partnership Agreements that might be affected by changes to NHA performance indicators and the Australian Health Ministers’

Conference (AHMC) working party looking at the rationalisation of data provision and reports;

 have regard to possible disability indicators;

 have regard to any recommendations arising from the review of the performance framework of the National Indigenous Reform Agreement (NIRA) which draws indicators from the NHA;

 have regard to aligning definitions across the range of health and hospital reporting that is undertaken by jurisdictions, such as the AIHW’s Australian Hospital Statistics;

 seek advice as required from ministerial council data groups, data agencies, the Secretariat to the



Steering Committee for the Review of Government Service Provision and the CRC; and provide advice and recommendations for action to the HoTs Review and CRC recommendations

Implementation Steering Group.

Meetings



The Working Group will meet as required.



Meetings will be chaired jointly by the Department of the Prime Minister and Cabinet and the

Queensland Department of Premier and Cabinet.



The Commonwealth will provide secretariat support for the Working Group.



As many meetings as possible will be held via telepresence.

Process

1.

Consider the roles and responsibilities ascribed to the Commonwealth and States under the NHA, consistent with the NHRA.

2.

Initial analysis of the NHA performance framework against the HoTs conceptual framework, taking into consideration: o the PAF under the NHRA; and o any relevant recommendations from the CRC, the HoTS review and the Steering Committee for the Review of Government Service Provision.

3.

Analysis of existing performance indicators and performance benchmarks that are identified as poor quality (at step 2) against the HoTs Review Conceptual Framework’s guiding principles for rationalisation or change.

4.

Analysis of additional and alternative performance indicators and performance benchmarks against a framework for prioritisation, including consideration of the costs and benefits of new or expanded data collections.

5.

Consider the overall appropriateness and proportionality of any revised performance framework.

6.

Draft recommendations and a report with supporting analysis (including a response to the CRC’s recommendations).

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Attachment C: Comparison of original and proposed NHA performance framework

Original NHA performance framework Proposed NHA performance framework

Overarching objective:

Improve health outcomes for all Australians and ensure the sustainability of the Australian health system

Seven long-term objectives:


















Australians have a health system that promotes social inclusion and reduces disadvantage, especially for Indigenous

Australians




Outcomes



Children are born and remain healthy



Australians have access to the support, care and education they need to make healthy choices



Australians manage the key risk factors that contribute to ill health



The primary healthcare needs of all Australians are met effectively through timely and quality care in the community



People with complex care needs can access comprehensive, integrated and coordinated services



Australians receive high quality hospital and hospital related care that is appropriate and timely



Older Australians receive high quality, affordable health and aged care services that are appropriate to their needs and enable choice and seamless, timely transitions within and across sectors



All Australians experience best practice care suited to their needs and circumstances informed by high quality health information



Patients experience seamless and safe care when transferring between settings



Indigenous Australians and those living in rural and remote areas or on low incomes achieve health outcomes comparable to the broader population



Australians have a sustainable health system that can respond and adapt to future needs

Objective:

Improve health outcomes for all Australians and ensure the sustainability of the Australian health system

Outcomes:


















Australians have a health system that promotes social inclusion and reduces disadvantage, especially for

Indigenous Australians




Remove current outcomes as these often repeat the objective and the current relationship between the objectives and outcomes is unclear

26 progress measures 15 outputs

Remove current progress measures and outputs as these are operationalised through the performance indicators and are therefore superfluous

70 performance indicators Retain performance indicators that link to the outcomes and support, where relevant, performance benchmarks (see Table 3, p17)

Seven performance benchmarks* Retain performance benchmarks

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Attachment D: Revised NHA – Data Sources, Availability and Disaggregation

Performance indicators Sub-indicator measures


Data sources, availability and disaggregation

Proportion of babies born of low birth weight

Incidence of notifiable cancers

Prevalence of overweight and obesity

Incidences of:











Melanoma

Bowel cancer

Lung cancer

Cervical cancer

Breast cancer



Data source and availability:

AIHW National Perinatal Data Collection (NPDC) / annual

Disaggregation potentially by:



State/territory



Indigenous status



Remoteness



Socio-Economic Indexes for Areas (SEIFA)




Australian Cancer Database / annual



ABS Estimated resident population / quarterly




State/territory



Indigenous status



Remoteness

 SEIFA




ABS Australian Health Survey / 3 years



ABS Australian Aboriginal and Torres Strait Islander Health Survey /

6 years




State / territory

 Indigenous status

 Remoteness

 SEIFA



Disability status

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Rates of current daily smokers

Levels of risky alcohol consumption

Infant and young child mortality rate

Sub-indicator measures Data sources, availability and disaggregation







ABS Australian Aboriginal and Torres Strait Islander Health Survey /

ABS National Aboriginal and Torres Strait Islander Social Survey – rotating 3 years




State / territory



Remoteness



SEIFA



Indigenous status



Disability status


 ABS Australian Health Survey / 3 years

 ABS Australian Aboriginal and Torres Strait Islander Health Survey / 6 years




State / territory





Remoteness



SEIFA



Indigenous status

Disability status


 ABS birth/death registrations collection / annual



ABS Estimated resident population (total population) / quarterly




State and Territory (3-year aggregates)



Age (3-year aggregates)



Indigenous status (5-year aggregates)

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Age-standardised mortality



Proportion of adults with very high levels of psychological distress





ABS cause of death collection / annual






ABS Indigenous experimental estimates and projections / periodic




State / territory

 Remoteness (currently national level only)

1.

 National Hospital Morbidity Data and death data / annual




State/territory



Remoteness



SEIFA



Indigenous status





2.

s s s years




State / territory



Remoteness



SEIFA





Indigenous status

Disability status

3.

 ABS Australian Health Survey / 3 years

 ABS Australian Aboriginal and Torres Strait Islander Health Survey / 6 years


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Performance indicators Sub-indicator measures Data sources, availability and disaggregation

 State / territory



Remoteness



SEIFA



Indigenous status



Disability status


Waiting times for GPs



 within 4 hours; more than 4 hours but within 24 hours; and

 more than 24 hours




ABS Patient Experience Survey / annual




State / territory



Remoteness

 SEIFA


 ABS Patient Experience Survey / annual



Public dental waiting times data set specification / annual (possible future data source if implemented)


People deferring access to selected health care due to cost

Effective management of diabetes





GP, medical specialist,

 dental care,

 prescribed medication,

 pathology; and

 imaging tests




State/territory



Remoteness



SEIFA


 ABS Patient Experience Survey / annual




State / territory



Remoteness



SEIFA







ABS Australian Aboriginal and Torres Strait Islander Health Survey / 6

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Potentially avoidable deaths


Selected potentially preventable hospitalisations

Sub-indicator measures



Public,



Private, and

 Combined Medicare Benefits

Scheme and Department of

Veterans’ Affairs

 Vaccine preventable conditions;

 acute conditions;

 chronic conditions; and

 and all potentially preventable hospitalisations.

Data sources, availability and disaggregation years




State/territory



Remoteness (ABS to investigate when data available)



SEIFA (ABS to investigate when data available)



Indigenous status

 Disability (ABS to investigate when data available)


 ABS Causes of Death Collection / annual



ABS Estimated resident population (total population) / quarterly







State and territory



Indigenous status




Private Mental Health Alliance Centralised Data Management Service

/ annual

 Medicare (MBS) data / monthly



State/territory community mental health care data / annual




State/territory



Remoteness



SEIFA



Indigenous status


 National Hospital Morbidity Database (NHMD) / annual

 ABS Estimated resident population (total population) / quarterly



ABS indigenous experimental estimates and projections / periodic


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 State/territory



Indigenous status



Remoteness



SEIFA

 Peer group; and

 triage category




National Non-admitted Patient Emergency Department Care

Database / annual

Selected potentially avoidable GP-type presentations to emergency departments


 State/territory



Remoteness



SEIFA



Indigenous status





National Elective Surgery Waiting Times Data Collection / Annual



National Hospital Morbidity Database / annual

Waiting times for elective surgery

Calculated overall and for each indicator procedure.

Waiting times for emergency hospital care



Waiting times for emergency department care by triage category;

 Waiting times for admission following emergency


 State/territory

 Remoteness



SEIFA



Indigenous status



Peer group




National Non-admitted Patient Emergency Department Care

Database / annual

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Performance indicators Sub-indicator measures department care


Waiting times for radiotherapy

Health-care associated Staphylococcus aureas bacteraemia in acute care hospitals

Unplanned/ unexpected readmissions of selected surgical admissions

Calculated separately for each of the specified procedures.



Includes unplanned hospital readmission rates for patients discharged following management of depression and schizophrenia

Survival of people diagnosed with notifiable cancers


 State/territory



Remoteness



SEIFA



Indigenous status




Radiotherapy Waiting Times Data Set Specification (possible future data source if implemented)




State/territory



Remoteness



SEIFA



Indigenous status




State / territory infection surveillance data / annual



State / territory admitted patient data / annual


 State/territory








State/territory



Remoteness



SEIFA



Indigenous status



Peer group


 AIHW National Mortality Database / annual

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 Remoteness



SEIFA

 sex




State/territory admitted patient and community mental health care data











State/territory

Remoteness

SEIFA

Indigenous status


Residential and community aged care places per

1,000 population aged 70+ years




Australian Government Department of Health and Ageing and Aged

Care data warehouse / annual




 ABS Indigenous experimental estimates and projections / periodic




State/territory



Remoteness





Number of hospital patient days used by those eligible and waiting for residential aged care




State/territory



Remoteness

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Sub-indicator measures

 Staphylococcus aureus (including

MRSA) bacteraemia in residential aged care



Pressure ulcers in residential aged care



Falls resulting in patient harm in residential aged care and treated in hospital


 SEIFA



Indigenous status







• State and Territory

• Remoteness

• SEIFA


 Australian Government Department of Health and Ageing and Aged



• State/territory

• Remoteness

• SEIFA

• Indigenous status






Elapsed times for aged care services (as per

ROGS)

Proportion of aged care residents who are full pensioners relative to the proportion of full


• State/territory

• Remoteness

• SEIFA







59 | P a g e

Performance indicators pensioners in the target population.


 ABS Estimated resident population / quarterly





• State/territory

• Remoteness

• SEIFA



Patient satisfaction/experience





GP explained prescription;

Health care professional explained test;



Waited longer than acceptable for GP appointment; and



Waited longer than acceptable for medical specialist appointment

Data source and availability:



ABS Patient Experience Survey / annual








State / territory

Remoteness

SEIFA

Outcome 6: Australians have a health system that promotes social inclusion and reduces disadvantage, especially for Indigenous Australians

All performance indicators, where it is possible and appropriate to do so, to be disaggregated by Indigenous status, disability status, remoteness area and socio-economic status to assess whether these social inclusion groups achieve comparable health outcomes and service delivery outcomes to the broader population.


Net growth in health workforce (by age group)

Net growth for:

 medical practitioners;

 nurses/midwives; and

 dentists.




National Health Workforce Data Survey / annual




State/territory



Age group

60 | P a g e

Attachment E: Cost Benefit Analysis of New Performance Indicators.

The Working Groups Terms of Reference state that any consideration of new or alternative performance indicators should include ‘consideration of the costs and benefits of new or expanded data collections’.

Table 1 lists the new performance indicators recommended by the Working Group for inclusion in the

National Healthcare Agreement. As indicated in column 2, all of these indicators are based on existing data collections. All new indicators would require specification development work to either develop new or refine existing indicator specifications for NHA purposes. Three of the new indicators - Incidence of heart

attacks, Proportion of residential aged care days on hospital leave due to selected preventable causes and

Elapsed time for aged care services require data development work.

Given this, the cost involved in including these indicators in the NHA is minimal, with the improvements to the NHA performance framework from their inclusion outweighing the small data development costs. The introduction of these indicators may involve a human resource burden; however the significant overall reduction of indicators will also significantly reduce the human resources burden placed on States and

Territories.

Table 1 – New Indicators with Data Sources

New performance indicator

Data already collected




Y

Y

Data source/Frequency

National Hospital Morbidity Data and National

Mortality Database/ Annual

ABS Estimated resident population (total population) / Quarterly

ABS Indigenous experimental estimates and projections / Periodic

Australian Health Survey (AHS), / TBD

Aboriginal and Torres Strait Islander Health

Survey (ATSIHS) (Indigenous population)/ TBD

Proportion of adults with very high levels of psychological distress Y

Australian Health Survey / 3 years

National Aboriginal and Torres Strait Islander

Health Survey / 6 years


Y

State/territory admitted patient and community mental health care data / annual

Outcome 4: Older Australians receive appropriate high quality and affordable health and aged care

services

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Y

Aged Care Standards and Accreditation Agency / annual


Elapsed times for aged care services

Proportion of aged care residents who are full pensioners relative to the proportion of full pensioners in the target population

Y

Y

Y

Australian Government Department of Health and Ageing and Aged Care data warehouse / annual

Australian Government Department of Health and Ageing’s Aged Care Assessment Program

Minimum Data Set / annual

Australian Government Department of Health and Ageing’s Aged Care Data Warehouse / annual

Department of Human Services (Centrelink)

Pensions Database / annual

Australian Government Department of Veterans’

Affairs Client Data Base

Frequency: Annual (based on ongoing data collection)

Data custodian: Department of Veterans’ Affairs


Full time equivalent workforce per 1,000 population (by age group).

Y National Health Workforce Data Survey/ annual

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Glossary

NPDC

PAF

SEIFA

SCoH

STIs

NA

NHA

NHISSC

NHMD

NHPA

NNDSS

ABS

ACSQHC

AIHW

BBV

COAG

CRC

HoTs

IGA FFR

MBS

MRSA

Australian Bureau of Statistics

Australian Commission on Safety and Quality in Health Care

Australian Institute of Health and Welfare

Blood Borne Viruses

Council of Australian Governments

Council of Australian Governments (COAG) Reform Council

Heads of Treasuries

Inter-Governmental Agreement on Federal Financial Relations

Medicare Benefits Scheme

Methicillin-resistant Staphylococcus aureus

National Agreements

National Healthcare Agreement

National Health Information Standards and Statistics Committee

National Hospital Morbidity Database

National Health Performance Authority

National Notifiable Diseases Surveillance System

National Perinatal Data Collection

Performance Accountability Framework

Socio-Economic Indexes for Areas

Standing Council on Health

Sexually Transmissible Infections

63 | P a g e

National Healthcare Agreement Review Report

National Healthcare Agreement

Review Report

July 2012

National Healthcare Agreement Review Working Group

Table of Contents

1 EXECUTIVE SUMMARY

2 OVERVIEW

3. ANALYSIS OF THE NATIONAL HEALTHCARE AGREEMENT 15

12

3

1 Executive Summary

1.1 A revised National Healthcare Agreement performance framework

1.2 Recommendations

2 Overview

2.1 The Federal Financial Relations Framework

2.2 The National Healthcare Agreement

2.3 Concerns regarding the NHA performance framework

2.4 The National Healthcare Agreement Review

3. Analysis of the National Healthcare Agreement

3.1 Addressing the criticisms of the NHA performance framework

3.2 Performance and Accountability Framework (PAF)

3.3 Social inclusion and Indigenous health

3.4 Sustainability

3.5 Data specification and data development

3.6 Implementation of a revised NHA performance framework

Attachment A: Recommendations fro m the CRC’s NHA performance reports for 2008 -09 and 200910, COAG’s responses and actions taken

Attachment B: NHA Review Working Group Terms of Reference

The Working Group will:

Attachment C: Comparison of original and proposed NHA performance framework

Attachment D: Revised NHA – Data Sources, Availability and Disaggregation

Attachment E: Cost Benefit Analysis of New Performance Indicators.

Glossary

Related documents

Products

Support

National Healthcare Agreement Review Report

National Healthcare Agreement

Review Report

July 2012

National Healthcare Agreement Review Working Group

Table of Contents

1 EXECUTIVE SUMMARY

2 OVERVIEW

3. ANALYSIS OF THE NATIONAL HEALTHCARE AGREEMENT 15

12

3

1 Executive Summary

1.1 A revised National Healthcare Agreement performance framework

1.2 Recommendations

2 Overview

2.1 The Federal Financial Relations Framework

2.2 The National Healthcare Agreement

2.3 Concerns regarding the NHA performance framework

2.4 The National Healthcare Agreement Review

3. Analysis of the National Healthcare Agreement

3.1 Addressing the criticisms of the NHA performance framework

3.2 Performance and Accountability Framework (PAF)

3.3 Social inclusion and Indigenous health

3.4 Sustainability

3.5 Data specification and data development

3.6 Implementation of a revised NHA performance framework

Attachment A: Recommendations fro m the CRC’s NHA performance reports for 2008 -09 and 200910, COAG’s responses and actions taken

Attachment B: NHA Review Working Group Terms of Reference

The Working Group will:

Attachment C: Comparison of original and proposed NHA performance framework

Attachment D: Revised NHA – Data Sources, Availability and Disaggregation

Attachment E: Cost Benefit Analysis of New Performance Indicators.

Glossary

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