Primary care is an integral part of Victoria's health system—it includes services such as general practice, pharmaceutical services, allied health, and community nursing. In Victoria, the state and Commonwealth governments both fund the provision of primary care.
Community health services are essential to Victoria's primary care network. They deliver a range of state- and Commonwealth-funded programs, including the state-funded Community Health Program (CHP). There are 85 community health services located in rural, regional and metropolitan Victoria. These operate under two distinct legal and governance arrangements:
- Fifty-five community health services operate as part of regional or metropolitan Victorian public health services. These 'integrated' community health services are subject to the accountability frameworks of the broader health service.
- Thirty registered community health services operate as companies limited by guarantee. To receive state government funding, they must register as a community health service under the Health Services Act 1988.
The CHP aims to provide effective healthcare services and support to Victoria's priority populations. These populations receive priority access to services because they are socially or economically disadvantaged, experience poorer health outcomes, and have complex care needs or limited access to appropriate healthcare services.
The Department of Health and Human Services (DHHS) administers the CHP through funding paid to community health services. DHHS's central office and divisions—North, South, East and West—are responsible for delivering the CHP. Each division operates several regional offices that are located across the state.
This audit examined whether the CHP effectively contributes to good healthcare outcomes for Victoria's priority populations. We analysed DHHS's management of the CHP, focusing on their strategic direction, access and demand management, and performance monitoring.
The CHP is a valuable tool for DHHS to keep Victoria's priority populations well, out of hospital, and productive in society. However, maximising these benefits requires DHHS to analyse demand and unmet need, and evaluate program outcomes.
DHHS does not regularly monitor whether the CHP's limited service hours are being provided primarily to Victoria's priority populations or what outcomes these services are delivering. Nor does it know where there is demand for the CHP or the extent of this demand across Victoria.
DHHS's funding model and distribution methods are based on historical data as opposed to analysis of changed population demographics. This may affect community health services' ability to deliver timely, effective and appropriate care to Victoria's priority populations. The community health services we audited do not necessarily promote their services due to lack of capacity.
DHHS's limited insights mean it is missing an important opportunity to take a more strategic approach when funding community health services, informed by a broad understanding of health service needs and utilisation across the spectrum of care services.
Recognising this, DHHS is currently progressing a number of projects to improve the CHP. These include considering a new funding model and making improvements to the Community Health Minimum Dataset (CHMDS) and use of its data. It will be necessary for DHHS to carefully monitor the results of this work and use that information to refine the program. Though the CHP's budget is very small in comparison to that for acute care services, there is a clear opportunity for DHHS to realise a significant return on its investment through effective preventative and primary health care services for the most disadvantaged Victorians.
Long-term health strategies
DHHS has two long-term strategies relevant to the CHP—Health 2040: Advancing health, access and care (Health 2040) and the Victorian public health and wellbeing plan 2015–19 (PHW Plan). DHHS has also released the Statewide design, service and infrastructure plan for Victoria's health system 2017–2037 to operationalise Health 2040.
The CHP's objective to provide effective healthcare services to Victoria's priority populations aligns with DHHS's long-term health strategies for better health, access and care. However, DHHS's ability to measure the CHP's effectiveness or contribution to DHHS's strategic directions is limited because DHHS does not have outcome measures or relevant data.
Evidence base for the CHP
DHHS's Community health integrated program guidelines have strong theoretical underpinnings and emphasise person-centred care. While DHHS has a range of demographic information, it does not incorporate on-the-ground information, such as indices of disadvantage or demographic data, into the CHP's evidence base. This limits DHHS's ability to translate theory into practice and deliver effective healthcare services to the right people in the right place at the right time.
DHHS should strengthen its evidence base by using population health data and information from the CHMDS. DHHS demonstrated this approach when identifying sites for the expansion of its Healthy Mothers, Healthy Babies Program.
Funding for the CHP
DHHS implemented a new funding model in 2007. Since then, DHHS has not reviewed the CHP's funding. As a result, DHHS cannot assure itself that its funding model supports the achievement of the CHP's objectives. DHHS has not reviewed:
- the unit price, to ensure that it reflects the true cost of providing one hour of service delivery
- the total amount of funding for the CHP
- the distribution of the CHP's funding across community health services.
DHHS's executive board has approved a proposal to undertake further research, analysis and sector engagement to inform any future funding reform options.
Access and demand
Timely access to the CHP is important—it ensures that disadvantaged people who cannot afford privately funded primary care receive the treatment that they need. Timely treatment means individuals can have better health, avoid hospital admissions and participate in society.
While DHHS can monitor who accesses the CHP, it does not do this regularly. Therefore, DHHS has limited oversight of whether services are provided to priority populations. DHHS's analysis of current or unmet demand for the CHP is limited and it does not know whether the CHP provides priority populations with effective, timely and sufficient care.
DHHS's key guidance document for managing access to the CHP is Towards a demand management framework for community health services. DHHS has not reviewed this guidance since its publication in 2008.
All the community health services we audited managed client intake in accordance with DHHS's guidance. Community health services commented that they update the tools used to prioritise clients to reflect current research. Community health services do this work in isolation from each other, duplicating effort, and do not receive specific funding for this.
DHHS is currently evaluating future health demand in the northern growth corridor by examining health risk factors, such as smoking and education levels. It has also commenced a project to examine demand in community health services by using past data and future population estimates.
Performance and quality
DHHS's performance management system
While DHHS has some tools to monitor quality, the CHP's current measuring, monitoring and reporting system focuses on outputs and lacks performance measures that assess whether care was timely and effective. As a result, DHHS cannot provide assurance through its current performance management system that the CHP delivers good healthcare outcomes for Victoria's priority populations. DHHS's sole performance measure—the number of service hours delivered—provides little insight into the efficiency, effectiveness or equity of care.
Process-based indicators evaluate the implementation of care as opposed to its outcomes.
In 2014–15, DHHS piloted a set of process-based indicators to evaluate the client's administrative journey from admission to discharge. DHHS stopped collecting this data in 2016–17, following feedback from the sector that the data collection method imposed significant administrative burden on community health services. DHHS is addressing some of its data issues through a wide‑reaching improvement project and, after consulting with the sector, has begun to embed some of the process-based indicators into the CHMDS.
DHHS's management of community health services
DHHS uses a standardised performance monitoring framework to govern registered community health services. However, DHHS's divisions apply certain elements of the framework inconsistently, which leads to variances in performance management across agencies.
Adding further variation to performance management in the sector, DHHS lacks a specific performance monitoring framework for integrated community health services. This limits DHHS's oversight of integrated community health services, which may, in turn, limit its ability to identify and address performance issues in a timely and effective manner.
As the CHP's performance measures focus solely on quantity, DHHS has limited oversight of the program's effectiveness and impact beyond community health services' accreditation cycles. DHHS is currently extending its knowledge of the CHP's quality through the collection of process-based indicators and the Victorian Healthcare Experience Survey (VHES), which assesses client satisfaction. While both tools provide insight regarding the provision of care and represent a step in the right direction, DHHS must ensure that the results of the survey are shared and used in a productive manner to yield value for the sector.
We recommend that the Department of Health and Human Services:
1. link its key strategic documents—such as Health 2040: Advancing health, access and care and the Victorian public health and wellbeing plan 2015−19—to the Community Health Program (see Section 2.2)
2. ensure it collects purposeful data to monitor that CHP funded services are provided to the identified priority populations (see Section 3.4)
3. review its CHP unit pricing to ensure that it meets the cost of providing services to Victoria's priority populations (see Section 2.4)
4. develop a more sophisticated funding model by identifying and understanding the different service needs, demand and priorities for community health service locations across Victoria, to inform the quantum and distribution of funding (see Section 2.4)
5. in conjunction with community health services, regularly review and revise the demand management framework and clinical priority tools to ensure that they reflect optimal practice (see Section 3.3)
6. have internal and publicly available quality performance measures that assess program equity and client satisfaction, while working towards outcome measures for the Community Health Program (see Section 4.3)
7. provide divisional offices with guidance that standardises their monitoring of community health services (see Section 4.5).
Responses to recommendations
We have consulted with DHHS, Bendigo Health, East Wimmera Health Service, Monash Health, Peninsula Health, Bendigo Community Health Service, cohealth, Gippsland Lakes Community Health, Latrobe Community Health Service, North Richmond Community Health and Orbost Regional Health. We considered their views when reaching our audit conclusions. As required by section 16(3) of the Audit Act 1994, we gave a draft copy of this report to those agencies and asked for their submissions or comments. We also provided a copy of the report to the Department of Premier and Cabinet.
The following is a summary of those responses. The full responses are included in Appendix A.
DHHS acknowledged that the audit provides an opportunity to build on existing initiatives supporting community health services, especially for disadvantaged Victorians. DHHS accepted all our recommendations and provided an action plan detailing how these recommendations will be implemented, including its intention to form a Community Health Taskforce to consult with the sector and assist DHHS to implement the recommendations.
cohealth responded and was supportive of our recommendations, noting that their implementation will require resourcing for both DHHS and the community health sector.