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Serious flaws in health services in immigration detention: ANAO report

What are the problems people have in getting proper health care in detention? In September 2016, the Australian National Audit Office (ANAO) released its report into the effectiveness of the delivery of health services in onshore immigration detention. The report identifies key areas of concern in the delivery of health services provided by International Health and Medical Services (IHMS). The IHMS contract with the Department of Immigration and Border Protection from December 2014 to December 2019 is worth $438 million.

What did the auditors find?

The auditors found that there was:

  • inadequate departmental oversight of IHMS’s service delivery
  • frequent delays in providing care to those at high risk of self-harm, and
  • the Department emphasised cost-cutting at the expense of the quality of care.

The ANAO identified problems with the Department’s oversight of community detention, mental health care, and medication management.

What was the report meant to do?

The aim of the audit was to evaluate the effectiveness of the Department’s provision of health services. The audit asked three questions:

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

Aims of the contract

The health service contract aimed to

  • provide an open, accountable and detention health service delivery program offering DIBP ‘value for money’
  • provide people in detention with a range and standard of health care that:
    • is of a standard and delivered in a timeframe which is ‘broadly comparable with that available within the Australian community’
    • takes into account their particular health needs
    • ensures that people in detention can access ‘coordinated, high quality, evidence-based health care’
    • is provided free from discrimination, and with ‘appropriate dignity, humanity, cultural and gender sensitivity and respect for privacy and confidentiality’
    • empowers those in detention to manage and respond to their own health needs, and
    • is of a quality, effectiveness, and efficiency which is constantly improving.

What were the problems?

Inadequate departmental oversight

The audit criticised the Department’s monitoring of the performance of IHMS. As at March 2016, the Department was not effectively monitoring eight of 17 performance criteria. These were only partly implemented or not implemented at all. The audit also criticised the measures themselves for focusing heavily on administrative aspects of service delivery and timeliness.
DIBP fined IHMS over $300,000 in the first six months of a new performance monitoring framework. This included fines of:

  • over $180,000 for a failure to complete incident reports in a timely way
  • around $50,000 for failures to identify and treat active tuberculosis, and
  • around $32,000 for failures to identify and treat other serious communicable diseases.

The report highlighted the Department’s failure to monitor primary health care quality, even 15 months after the signing of the contract. It noted that the Department could not rely on assurances that IHMS was achieving contractual targets, because of its own failure to sufficiently measure the quality of service delivery.

Suicide and self-harm prevention

DIBP does not formally monitor the implementation of  its program to prevent self-harm and suicide in detention. The audit found that IHMS is not complying with this program.

From February to November 2015, 239 detainees were assessed as being at ‘high imminent’ risk of suicide or self-harm. 47% of these instances persisted for more than 72 hours, even though the Department’s program states that people at this risk level have needs which “cannot or should not be managed” in immigration detention.

DIBP’s program also requires clinical reviews for detainees on high imminent risk at least every 24 hours. Instead, at-risk detainees were reviewed every three days on average. Some were reviewed only once or twice every fortnight.

Medication management

IHMS cut costs with a new medication management system. IHMS assumed that no more than 14% of people in detention who needed medication would need this to be administered by a nurse.  In fact, between 19-75% of people needed a nurse to administer the medication.

IHMS requested funding for additional nursing staff hours. The Department agreed only to fund (on average) 43% of the difference between the predicted and actual requirements for nursing staff hours. The audit noted that this would affect the ability of nurses to perform their duties. It would also  create risks of errors in prescribing and dispensing medication.

Cost-oriented approach

The Department’s cost-oriented approach focused on incentives and sanctions to ‘drive efficiency’. The new fixed fee failed to take into account the lessons of the previous contract, which saw under-servicing and improper conduct to meet targets. The audit noted that the Department’s focus on managing costs risked making IHMS prioritise ‘commercial profitability over the delivery of services of adequate quantity and quality’.

Improvements

In January 2016, the Department adopted a centralised health structure, including clinically trained staff, to improve clinical oversight of the health service delivery.
The audit found that Department’s administration of health services in immigration detention in Australia had been improved by strengthening its contractual arrangements with IHMS. The current contract had been revised to include:

  • mechanisms to control the risk of over-servicing and uncontrolled cost escalation
  • clearly defined deliverables
  • a performance monitoring regime containing provisions for applying penalties and incentives for compliance.

It found that the Department could improve its implementation of health service delivery by strengthening its monitoring arrangements in relation to the quality of health services and key areas of health service delivery risk (such as mental health).

The audit acknowledged that the Department had learnt lessons from previous contracts, by focusing on efficiency, coordination of service delivery, controlling the cost of services, the risk of over-servicing, and monitoring outcomes rather than processes.

Recommendations

The audit made two recommendations which were accepted by the Department:

  • that the Department strengthen its monitoring frameworks and practices based on an assessment of risks to the effective delivery of health services, and
  • that the Department analyse complaints and incident reports data and use this information to inform management and operational decision-making.

Read the report

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