THE STRUCTURES AND PROCESSES

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THE STRUCTURES AND PROCESSES Powered By Docstoc
					     7. THE STRUCTURES AND PROCESSES
       The structures and processes for Program governance have changed over time. It is clear that
       there were strong and robust arrangements when the Program was established. Inevitably,
       however, they were outgrown or overtaken by Program developments and changing governance
       and service arrangements, nationally and jurisdictionally. Suggesting that the early arrangements
       were strong and robust does not imply either that they were ideal or should have been preserved.
       The important message is that those arrangements established a base on which the Program has
       built subsequently.
       The Program’s governance and management trajectory can be described, in a high level
       overview as:
       Phase 1 –             Evidence available to the evaluation is indicative of a strong and active Program establishment phase
       enthusiastic set up   which built rapidly and effectively on the pilot period. It should, however, be noted that the evolution
                             from pilot to full Program generated an ongoing issue. Each jurisdiction built on its pilot governance
                             and management model rather than contribute to the development of a common or consistent national
                             model for governance and management. Some of the diversity which resulted from that threshold
                             decision remains and is identified, by some, as a continuing issue.

                             The features of this phase include:
                             • outcome-driven design
                             • implemented by a core set of individuals who fostered capability across the country
                             • characterised by goodwill and clear political commitment.
       Phase 2 –             As expected, the Program reached maturity while still in a growth phase. Jurisdictions, by and large, had
       maturation, but!      stable operating systems and arrangements and much of the national development work was completed.
                             Tensions emerging from the structures and processes utilised in the start up phase were resolved through
                             restructuring.

                             Paralleling the maturation process were broader changes in the political landscape which had the
                             effect of shifting attention from screening and to some extent jeopardising the consensus on which the
                             Program was based. Resources for national effort were diminishing and there were political tensions
                             about continuing to invest in this approach to screening.

                             The maturation phase of the Program coincided with broader rethinking regarding funding arrangements
                             for commonwealth/State and Territory Programs. This led the Program-specific funding arrangements
                             to be integrated into the Public Health Outcome Funding Agreements (PHOFA). These arrangements
                             provided increased flexibility to States and territories, an attempt to focus on outcome reporting and a
                             more generic funding adjustment process.

                             Taken together these things contributed to:
                             • reduced national capacity to engage in either high level strategy or detailed Program
                               development work
                             • increased dependence on State/Territory Governments for Program leadership.




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      Phase 3 – Declining     The seeds of the third phase of development were sown in the maturation phase as national capacity
      momentum                and focus was reduced.

                              These issues were then reinforced as the new AHMAC structure for national policy making were
                              considered and introduceda. These essentially rational and practical arrangements seem, however, to
                              have perverse and unintended consequences with regard to this Program.

                              As a result, apparently sensible national policy and strategy decisions have been delayed or not made it
                              onto the ‘agenda’. This has:
                              • contributed to an erosion of national consistency as jurisdictions have acted unilaterally to resolve
                                issues, particularly where a nationally agreed policy position was unable to be reached
                              • generated inefficiencies and possibly long term Program issues through jurisdiction by jurisdiction
                                action on major issues such as digital mammography.

      a    The decline in momentum probably began prior to the AHMAC Committee restructure, with the new structure further
           reducing capacity for collaboration and progressing issues of national priority.


      The focus of this report is upon current arrangements. Our focus in assessing current
      arrangements are:
      •    What are the mandates of the existing structures and how adequately are those mandates
           being implemented?
      •    What are the functions that would appropriately be expected to be carried out by each of
           the structures and what is the evidence that they are doing this?


7.1   MANDATES AND AUTHORITIES
      The following chapter provides commentary regarding the performance of each of the key bodies
      with some level of decision making authority for the Program. The bodies examined are:
      •    Ministers
      •    Australian Health Ministers’ Advisory Council
      •    Australian Population Health Development Principal Committee
      •    Screening Subcommittee of APHDPC
      •    National Quality Management Committee of BreastScreen Australia
      •    Department of Health and Ageing
      •    Jurisdictions
      •    Program Managers meetings.




                  BreastScreen Australia Evaluation – Governance & Management Project January 2009                                       47
     Ministers
     Ministers have primary responsibility for Program performance but also considerable dependence
     on the public administration structures and systems which are established to support them and
     then implement decisions.
     Very few BreastScreen Australia issues have been the subject of ministerial discussion since the
     start of the Program. One area of ministerial attention was the discussion of whether there should
     be national investment in promotion following the end of the Sara Henderson communication
     campaign.
     The key issue that may have benefited from the consideration by Ministers is a strategy to
     reduce the systematic failure to meet Program participation-related objectives. There is a strong
     argument that Ministers should have been consulted sometime after the five year period set for
     the participation target to be met. No evidence has been found as to why Ministers were not
     consulted on this issue or to explain why Ministers who would, in most cases, have been aware of
     the issue in their own jurisdiction did not ensure that the matter was raised at the national level.
     It seems that, overall, Ministers have responded appropriately to the advice flowing from Program
     management. While it is clear that funding levels relative to population growth and the agreed
     target of 70% participation by women in the target group have been eroded over time, there
     have been substantial competing demands for health investment coupled with limited compelling
     evidence as to the consequences of not ensuring Program growth.

     Australian Health Ministers’ Advisory Council (AHMAC)
     As the primary adviser to Health Ministers, AHMAC has a broad remit and faces substantial
     demands. The revised AHMAC working structure introduced in 2006 represents a logical and
     focussed structure for managing the diverse workload expected by Ministers and the public.
     This evaluation raises two issues regarding the role and structures of AHMAC as they affect
     BreastScreen Australia. They are:
     1.   The implications of the advisory construct which underpins the national health
          policy infrastructure
          The AHMAC structure is inherently ‘advisory’ because Ministers hold definitive decision
          making responsibility. The advisory structure however also needs both a leadership mindset
          and an ability to make decisions about matters which are not appropriate for consideration
          by Ministers. As outlined earlier, Ministers have rarely been consulted on policy, resourcing or
          strategy for the Program. This emphasises the importance of public sector leadership.
          In the context of this Program it seems that this tension has not been well resolved. It is not
          clear whether AHMAC members have been aware of the diminution in national leadership
          capacity consequent upon the structure they authorised. The feedback from stakeholders
          gained during discussions in this evaluation suggests it is likely that AHMAC has had no
          cause for concern as the committees on which they rely for advice did not perceive that there
          was a problem requiring AHMAC intervention.



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          2.      The capacity of the structure to deliver the level and character of governance
                  and management required by programs such as BreastScreen Australia.
                  The AHMAC structure necessarily depends upon committees to drive the work program and
                  it is not clear that such mechanisms have the capacity to act upon the range of issues and
                  activities required.
                  This issue is pursued through the discussions on the relevant committees which follows.
          Prior to this evaluation, it was also too early in general terms to be investigating whether there
          were issues resulting from the restructuring done in 2006. It is possible that the problems now
          beginning to emerge in the BreastScreen Australia Program are unusual or unique. However,
          it does seem likely that there is a growing disjuncture between the policy and strategic advice
          function of AHMAC structures on one hand and the program and management functions
          embedded in national screening programs on the other.

          Australian Population Health Development Principal Committee (APHDPC)
          As a Principal Committee to AHMAC, the APHDPC has a wide remit of high priority issues
          including chronic disease management and prevention; governance of the Australian Better Health
          Initiative; obesity issues; and injury prevention. The Committee is responsible for developing and
          implementing detailed operating and business management arrangements.
          Within the Terms of Reference, the APHDPC is responsible for (among other things):
                  “Identifying and advising AHMAC on new and emerging population health issues, including
                  disease trends, new technology and interventions, in consultation with other relevant bodies
                  including Principal Committees as appropriate;
                   Overseeing national activities and strengthening health development infrastructure and
                  capacity nationally, including workforce, information and standards;
                  Considering population health, chronic disease and child health and wellbeing issues which
                  may impact on Aboriginal and Torres Strait Islander health outcomes.”16.
          From information provided and interviews undertaken in the course of this evaluation, it appears
          that very few BreastScreen Australia Program related issues have been raised with the APHDPC by
          the Screening Subcommittee or its predecessors.17 It is, however, clear that reporting and advice
          from the Screening Subcommittee (see below) have been dealt with appropriately. This leaves
          open the question of whether the APHDPC should have been more proactive in engaging with
          breast screening issues. This evaluation is not in a position to comment given that we have had no
          access to data to allow consideration of the workload and other demands which have shaped the
          work of the Committee.




16   APHDPC Terms of Reference http://www.ahmac.gov.au/site/membership.aspx#other accessed 1 September 2008
17    Examples of issues that have been raised include the incorporation of digital mammography standards into the accreditation framework, the
     proposal to continue the Sara Henderson Campaign and the BreastScreen Australia Evaluation.



                          BreastScreen Australia Evaluation – Governance & Management Project January 2009                                        49
              Screening Subcommittee
              The Screening Subcommittee (SSC) is a sub committee of the APHDPC. It holds a critical place in
              the governance and management machinery of the Program.
              The Committee’s Terms of Reference includes an overall role statement:
                      “The Screening Sub Committee’s role is to provide advice to the APHDPC on emerging
                      population screening issues and other screening issues; to provide leadership and direction
                      to the National Cervical Screening Program and BreastScreen Australia and to provide advice
                      in relation to the National Bowel Cancer Screening Program.”
              In this context specific requirements include (among other provisions):
                      “To oversee generic issues related to national screening programs, including specifically,
                      but not limited to, monitoring and evaluation, policy development, implementation, and
                      communication and recruitment strategies.
                      To provide leadership and national direction on policy, implementation and monitoring
                      of existing joint screening programs, BreastScreen Australia and the National Cervical
                      Screening Program”18
              In acting upon these terms of reference the Committee has undertaken a range of tasks. The
              preparation of the Population Based Screening Framework referred to in the Background and
              Context chapter of this report is an important output from the Committee.
              It is possible to interpret the requirements of the Terms of Reference outlined above as establishing
              a mandate for the Subcommittee to provide an active and broadly based governance role.
              However, several Committee members who were consulted held the view that the Subcommittee’s
              advisory status:
              •       Preclude or substantially limit its responsibility for Program governance
              •       Limited its scope for active leadership.
              This represents a problem in so far as active leadership and governance decision making are
              required in order to achieve quality outcomes for women and consistent approaches across
              jurisdictions over time.
              As identified above there are two dimensions to this issue. The proposition that the advisory
              status meant that the committee had no or only limited responsibility creates a near vacuum in
              national leadership and raises fundamental questions about ongoing capacity to sustain a national
              infrastructure. The implications of this depend upon judgement regarding the importance of
              national leadership and decision making at this point in the Program’s trajectory.
              If the reporting relationship with AHMAC limits but does not exclude leadership responsibility,
              important but less fundamental questions are raised.
              From the evaluators’ perspective, the proposition that the SSC has no Program governance
              responsibility would reflect a failure to accept the requirements of the terms of reference. The
              notion that AHMAC reporting expectations limit scope is more reasonable but also problematic.

     18   Screening Subcommittee, Operating Guidelines October 2006.



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As noted earlier little reference has been made to Ministerial authority over the life of the Program.
In such a context, leadership responsibilities necessarily fall to committees of public servants and
the effects of limited leadership is inevitably felt over time.
Even if the SSC actively accepted the broader mandate of full governance obligations that have
been outlined above, two further questions require attention. They are:
1.    Capacity – could the Screening Subcommittee have done what is required or is the task too
      big? Furthermore, does the SSC have the right skills and knowledge for this task?
      Program leadership, particularly one involving joint-jurisdictional, sensitive and important
      policy questions is a substantive task even in a context of substantial devolution of
      operational responsibility to States and territories. Committees with diverse tasks and limited
      support are likely to struggle with this task. Committee based joint-jurisdictional leadership,
      to be effective, would require a robust and stable operating environment and clear
      processes for formulating policy at a minimum. This Program has relatively stable operations
      in all States and territories and an effective quality assurance program. Yet there are key
      challenges evidenced in the ongoing and unresolved policy issues around the Program and in
      the introduction of digital mammography. These high level examples are the important tip of
      an iceberg of national issues which could reasonably be said to require attention.
      In the sweep of national health issues, the urgency with which they need attention and the
      limited resources available the current level of effort provided to support breast screening
      may be appropriate. The lens of one Program evaluation is necessarily limited and skewed.
      That said, it is incumbent on such an evaluation to point out the discontinuity between the
      terms of reference and performance and the risks imposed by current arrangements.
      The Screening Subcommittee’s membership represents a strong mix of jurisdictional and
      content knowledge appropriate to the range of issues for which it has responsibility. A more
      detailed engagement with this particular Program, were that to be a priority, may require
      additional jurisdictional and clinical input. The terms of reference provide the committee with
      the capacity to access clinical advice regarding specific issue but do not appear to authorise
      ongoing input. Either approach, used proactively, may provide the Committee with insights
      about issues and policy options emerging within the Program.
2.    Resourcing – what kind of secretariat function (and does it require separation from
      the Department of Health and Ageing for credibility and ability) is required to deliver the
      governance and management required?
      Comments received during this evaluation are suggestive of resource pressures on DoHA,
      limiting its capacity to meet existing demands for supporting the SSC. A more proactive
      interpretation of the committee’s mandate would further test the limits of this capacity.
      The Department also has a structural conflict of interest, as it is obligated to serve its
      Minister’s interests and to act as a neutral secretariat in an environment where contested
      policy options are inevitable. Further comment is made on this issue in the section
      specifically focussing on the role of DoHA below.




           BreastScreen Australia Evaluation – Governance & Management Project January 2009              51
                     The loss of broadly based input to the Program, that was reflected in the NAC, eroded
                     through ASAC and effectively abolished with the restructure which created the SSC, is
                     keenly felt. The absence of a national mechanism for clinical and user input is also an
                     issue, although reflective of the decision to make all AHMAC committee representation
                     jurisdictionally based and appoint external advisors ‘as necessary’.19
              In summary it appears that:
              •      The SSCs interpretation of its role has limited the scope for effective national governance
              •      A somewhat more active engagement in leadership and implementation management would
                     have required: either different membership; and/or a more active sub committee structure
              •      Greater secretariat capacity would also have been required.
              Chapter 10.4 of this report provides preliminary commentary regarding options for future
              governance and management.

              National Quality Management Committee
              The NQMC is a critical part of the national governance and management infrastructure of the
              Program. Program objective number 5 is “to fund through State Coordination Units only Screening
              and Assessment Services which are accredited according to agreed National Accreditation
              Standards and to ensure that those standards are monitored and reviewed by appropriate State
              Accreditation Committees”. Comment on this objective has already been made in Chapter 6 of this
              report. The comments which follow are complementary to this analysis.
              The NQMC is responsible for:
              •      Development and maintenance of the NAS. The NAS are the minimum standards that must
                     be met to be an authorised service within the Program.
              •      The accreditation process. The detailed review process ensures all services are assessed on
                     a regular basis to confirm compliance with national standards and/or identify weaknesses in
                     individual services. The NQMC has approved a risk based approach to accreditation in which
                     better performing services are accredited for longer than others. The standard includes five
                     levels of accreditation. They are:
                     i.     Four years with commendation – the highest quality of service
                     ii.    Four years –a high quality service
                     iii.   Two years – a good quality service
                     iv.    Two year with high priority recommendations – a good quality service needing to work
                            on particular issues to improve performance on specific standards
                     v.     Provisional accreditation for new services or those re-entering the Program
              •      Development of tools to support services and the accreditation process




     19   AHMAC Meeting 9 June 2006, Agenda Item 5.1.5 AHMAC Committees – Governance and Operating Guidelines



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          The NQMC is supported in this work by State and Territory Committees which work directly with
          services20 and assessment teams drawn from across jurisdictions, functions and disciplines.
          The scope of work involved in accreditation is broad and substantial. Given the extensive and
          rigorous nature of the standards, the number of services and the diversity of issues which emerge
          in managing such a national infrastructure, considerable effort is required.
          From a governance and management perspective, there are three perspectives which can be
          brought to bear in assessing the operation of the NQMC and the processes it administers.
          They are:
          1.      The quality of the outputs. As noted above this evaluation is not in a position to reflect
                  directly upon the quality of the standards. The assessment of the Program’s performance
                  against its objectives however provides an indirect perspective. This suggests there has been
                  strong performance as the weaknesses in achievement of specific objectives appear to result
                  from factors other than Program quality.
          2.      Effectiveness of the process. There are numerous models for quality assurance which
                  might have been chosen. The NQMC seems to have chosen a structured process which is
                  rigorous, transparent, risk based and embedded in Program practice rather than external
                  requirements. This set of constructs provides powerful support for well informed but
                  contested standards and accreditation processes.
          3.      Customer satisfaction. Accreditation is a sensitive process. It exposes management and
                  clinical practice to external scrutiny against clear but sometimes challenging standards. This
                  is a context which can readily attract defensiveness and criticism. In the case of this Program
                  however there is broad support for the standards and the process.
          As noted in the point above, the NAS and the processes associated with it has attracted persistent
          and broadly based support. There is a widespread view, shared in large measure by the evaluators,
          that the NQMC and the outputs it has generated represent a core and fundamentally effective
          part of the national governance and management machinery. Given the questions about the role
          and capacity of the SSC it is perhaps the only truly effective part of the decision making machinery.
          There are a range of issues regarding the number, range and significance of some standards and
          about the details of the accreditation process. These are important questions and seem to reflect
          the normal debate which should go on regarding an important aspect of the Program’s operation
          rather than reflecting a major issue. Detailed evaluation of the BreastScreen Australia accreditation
          system (and indirectly the NQMC) is the focus of a separate evaluation.
          The construction and membership of the NQMC (and the State and Territory equivalents) involves
          people with substantial roles in Program management and thus raises questions of objectivity and
          self interest. No evidence of these risks manifesting themselves has been found in the course of
          this evaluation project although it was not a focus of the work undertaken of the data reviewed21.
          Active ongoing monitoring of this risk is, however, justified.
20 Note that at least two jurisdictions (NT, SA) have struggled to find accreditation/advisory committee members over the past few years as suitable
   candidates were too stretched or unwilling to contribute. People interviewed from those jurisdictions stated that they have substituted these
   formal mechanisms with informal mechanisms which have been no more or less effective in achieving accreditation and ongoing management of
   standards.
21 Two jurisdictions mentioned that they hand picked assessment teams based on their ability to understand to their particular demographic and
   operational challenges but stated that this had no effect on the actual outcomes of the assessment, just on the quality of advice received on how



                          BreastScreen Australia Evaluation – Governance & Management Project January 2009                                             53
               There are also issues regarding the model and criteria for membership of the NQMC.
               These relate to:
               •       The balance of expert and jurisdictional representation required on the NQMC itself. The
                       NQMC has clear criteria which privilege Program experience for good reasons. Given the
                       diversity of jurisdictional Program arrangements and developmental circumstances there is
                       also an argument for ensuring representation of those differences. This should not lead to
                       weakening standards but may lead to more effective considerations of the implications of
                       options and final decisions.
               •       The processes for appointing accreditation teams to undertake jurisdictional Program
                       reviews. There were numerous comments regarding the administrative processes required in
                       order to establish accreditation teams. Much of the inefficiency evident in these comments
                       related to the lack of national infrastructure to track who had been involved in which
                       accreditations and who would therefore be available and appropriate to participate in future
                       processes. Consideration should be given to more effectively resourcing this process in the
                       post evaluation period.

               Department of Health and Ageing (DoHA)
               DoHA attracts considerable criticism for its contribution to the governance and management of the
               Program. Much of this seems misplaced. DoHA is too often blamed for:
               •       Broader budget and public policy decisions which rest with other parts of the Australian
                       Government or the polity
               •       The failure of national Program leadership because it is the visible entity rather than because
                       it has a mandate for leadership in its own right22.
               DoHA does, however, have a critical role as one of the partners in national governance and
               management. The secretariat function to the SSC and APHDPC is vital both to service these
               Committee’s requirements and in proactively raising issues which require attention. We judge that
               DoHA has struggled to fulfil these functions because of:
               •       Resource constraints within the Department generally
               •       Diminished support for the Program within DoHA
               •       Disconnection from Program operation arising from the lack of appropriate
                       connection between Program Managers and both DoHA and their respective
                       State and Territory officials.




          to manage these challenges on an ongoing basis.
     22    In original conception, it may have been intended to have a role of the National Coordination Unit and therefore an intended mandate of
          leadership, akin to the role of State and Territory Coordination Units. Within the national program statements (eg. the NAS, policies and statement
          of objectives), meeting minutes and decisions we have viewed we have not seen any explicit articulation of this.



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Some of the initiatives taken by DoHA, in the absence of effective joint-jurisdictional leadership by
the structures created for this purpose, have not been well regarded more because of their source
rather than their substance. While some of these criticisms are justified it is important to note:
•     The existing Program machinery is a direct result of decisions actively supported at the
      highest level of health policy in all jurisdictions. They are not impositions of the Australian
      Government. Disconnection of Program Managers and reduced mechanisms for stakeholder
      input are direct consequences of these decisions not the result of DoHA failure.
•     The effectiveness of any machinery in a federation in which all jurisdictions protect and
      advance their own interests as they see fit and where there is an inevitable tension between
      State and Territory Governments and the Australian Government.
There are also potential concerns regarding the capacity of DoHA to manage the internal tensions
between a neutral secretariat function and its own legitimate policy issues. Some stakeholders
believe that DoHA has managed some issues to either prevent their exposure within the national
decision making machinery or to guide an outcome which met the organisation’s interests and
effectively preordain an outcome on behalf of the States and territories. Such problems are:
•     Important because they erode trust
•     Difficult to prevent or avoid when a secretariat function is embedded in an organisation with
      such strong policy and resourcing interests.
It does however seem clear that DoHA the organisation, as distinct from the staff directly involved
in supporting BreastScreen Australia, has been too passive and disengaged from Program issues.
Budget management decisions beyond the scope of this review have also had a deleterious effect
on DoHA’s capacity to fulfil its role. There are multiple factors impacting the mandate of DoHA
including the political context, pressures in other aspects of the health system and something of a
loss of corporate focus on public health investments.

Jurisdictions
All jurisdictions have taken seriously their public health and operational responsibilities for
management of the Program. The accreditation performance against the measure of the NAS is
the most powerful indicator of the adequacy of the overall performance as well as a jurisdiction
by jurisdiction signal. The NAS are rigorous in design and peer based leading to well informed
analysis of performance through the site visit processes. The fact that most services have sustained
quality performance is impressive.




           BreastScreen Australia Evaluation – Governance & Management Project January 2009             55
               Jurisdictions have evolved several distinctive governance models partly as a result of
               deliberate decisions and partly because of jurisdictional circumstances. Each jurisdiction has
               both Coordination Unit functions including quality assurance, strategic planning and policy
               development; and screening and assessment service functions which implement the screening
               pathway. In broad terms there are 3 models. They are:
               a)      Integrated line management (WA, SA, TAS and ACT) – each jurisdiction operates a
                       single screening and assessment service with direct line management from the Health
                       Department through to service. The Manager of the screening and assessment service is
                       also the Manager of the coordination unit functions and the two aspects of the role are
                       viewed as synonymous.
               b)      Central control and contracted service delivery
                       i.       Through an independent and separate entity (Vic) – a separate entity with an
                                independent Board of Directors is accountable for State-wide delivery and Coordination
                                Unit functions and outsources service provision to a number of centres, including both
                                public sector and private sector providers, on a contractual basis.
                       ii.      Through a statutory body (NSW) – a statutory body which is accountable for State-
                                wide delivery and Coordination Unit functions through the Area Health Services which
                                manage the public health service delivered screening and assessment service functions
                                across the State
               c)      Central co-ordination and devolved operational management at the service level
                       (Queensland) – the State has a central management unit (State Co-ordination Unit) within
                       the Department of Health which provides an overarching management and monitoring
                       function for the State, with operational management devolved to a number of service
                       centres (Screening and Assessment Units) managed through area health structures.
               Specific acknowledgement of the issues confronted by the Northern Territory is also important.
               This jurisdiction faces numerous structural challenges. Fully 45% of the population23 is located
               in remote or very remote areas, often only accessible by unsealed road or water. The Indigenous
               communities make up 31.6% of the population and while breast education is an integral part
               of Indigenous community health initiatives, many women from these communities do not see
               their own health as a priority and place a low value on investing time on preventative and early
               detection health actions, especially when they need to travel long distances (sometimes a day)
               away from their family to access services. Even without competing health funding priorities,
               fully achieving participation objectives would require some significant funding to secure a local
               workforce, a shift in technology to increase accessibility to remote communities and deep shifts
               in mindset.




     23   Australian Bureau of Statistics, 4713.7.55.001 - Population Characteristics, Aboriginal and Torres Strait Islander Australians, Northern Territory,
          2006. Released 27/03/2008



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There were three questions considered in this evaluation project with regard to jurisdictional
performance. They are:
1.   Have jurisdictions taken appropriate action to address systemic and major
     operational issues and failures?
     Through the course of this evaluation numerous examples of problems and issues occurring
     at jurisdictional level have been identified – many of these issues are presented in relation to
     the achievement of Program Objectives in Chapter 6. Undoubtedly there are others that were
     not identified through this process. There is however evidence that in all jurisdictions actions
     have been taken to address important issues. Although it is also clear that in some cases
     jurisdiction level problems have been allowed to persist considerably longer than desirable
     and some problems, such as capacity issues and ensuring equity of participation among
     population sub groups, remain unresolved.
     The governance structures have contributed to these issues in part. Some jurisdictions have
     faced significant issues due to the devolved structure of their governance models. Such
     matters have been difficult to address quickly because of the dispersed responsibilities that
     are a necessary part of models with multiple sites of management. Yet single direct line
     management models also face potential risks and thus it is not possible to advocate for any
     specific, universal governance model. For example, persistent management weaknesses in
     direct line models might have systemic consequences across an entire jurisdiction, rather
     than be confined to a specific place or function.
     Managing emerging issues and operational problems is an inevitable and important aspect
     of running complex human services. To a very great degree the obligation to do so and
     to have mechanisms in place to identify these issues rests directly on line and Program
     Managers. There are, however, things that can be done nationally through joint-jurisdictional
     collaboration to support this work. In the case of the BreastScreen Australia Program,
     the National Accreditation Standards are a critical important contribution. Additional
     contributions which would assist are:
     •     Improved information and knowledge sharing mechanisms
     •     National data collection and feedback that allow comparative performance assessment
           and benchmarking to be done on a broad range of functions, including sharing NAS
           performance information and best practice case studies.




           BreastScreen Australia Evaluation – Governance & Management Project January 2009             57
     2.   Have national arrangements supported and resourced operational
          development at the jurisdictional level adequately?
          It is clear that in the early development phase there were substantial and well regarded
          efforts to provide national mechanisms and processes to support jurisdictional development.
          Through the maturation and the declining momentum phases this has been less evident.
          The most important and instructive example of this erosion is the processes by which digital
          mammography is being introduced at jurisdictional level. Other examples include:
          •    not resolving some areas of policy (such as family history and symptomatic women)
          •    failure to develop timely performance data systems which enable comparative analysis
          •    the limited support for a national communication strategy – notwithstanding the earlier
               commentary regarding the appropriateness of winding back high profile campaigns
          •    an underinvestment in the research capacity of the Program.
          We note that for national leadership on such issues to be effective there needs to be
          cooperation and some concession from jurisdictions to reach agreement. It appears that
          there has been limited willingness to build the consensus required. The reasons for this are
          complex and can relate to jurisdictional issues outside the Program as well as the inadequacy
          of the internal decision making arrangements. Given the position of the Screening
          Subcommittee regarding its role, it is likely that many issues have not had a legitimate forum
          for debate. This is likely to have contributed to the sense of disconnection between Program
          Managers, their representatives on the Screening Subcommittee and DoHA.
          Specific discussions on this issue that give weight to these conclusions include Functions
          (Chapter 7.2), Funding, Financing and Risk (Chapter 8) and Digital Mammography
          (Chapter 9.1).
     3.   Are there structural issues resulting from the differing jurisdictional models
          which should be addressed to improve overall Program performance?
          This is an important and complex question not able to be fully addressed through this
          evaluation. The processes of this evaluation did not enable sufficiently detailed engagement
          at the individual jurisdictional level to enable authoritative comment to be made. Much
          of the diversity which is evident may be sensible responses to jurisdictional differences or
          unimportant local variation.
          It does however appear likely that some jurisdictional models are broadly applicable. Further
          comment is made on this issue in Chapter 10 as a starting point for discussions about the
          future construct, approach and program model.




58
     This evaluation has not enabled a robust evaluation of the performance of individual State
     and Territory services and has found that there are important strengths in the operations.
     There are however numerous issues effecting the performance and efficiency of the Program
     which could be addressed (for examples, see Objectives discussion Chapter 6 and Functions
     discussion Chapter 7.2). It may be appropriate to conduct a systemic review of the operations
     when the results of the evaluation are agreed by Governments in order to ensure that any
     agreed refinements or reforms are implemented to best effect.

Program Managers meetings
While not formally part of the governance and management structure of the Program,
the managers responsible for day-to-day operations in each jurisdiction meet regularly. A
representative from DoHA attends these meetings as well. These meetings have made an
important contribution to maintaining Program operations but have no formal role in national
decision making. The degree to which they can influence the SSC and higher level committees
depends on the ability of the group to present compelling arguments within their report to the SSC
and to brief effectively through jurisdictions. The latter mechanism is somewhat restricted as the
content of SSC meetings is confidential and in some jurisdictions the SSC members and Program
Managers have limited contact.
The fact that these meetings have continued makes them de facto part of the governance and
management machinery. They have made important contributions to knowledge sharing and to
tackling emerging issues.




           BreastScreen Australia Evaluation – Governance & Management Project January 2009          59
     7.2   FUNCTIONS
           All public programs can be said to have a set of generic functions that are necessary to deliver on
           the expectations of citizens, communities and governments. Although all functions are essential
           components of program design, from a governance and management perspective not all functions
           are ‘national’ in design or execution – some functions are local area or State issues and thus the
           desired national effort will be relatively low.
           In this Report we have assessed the level of performance being achieved. We have also provided
           an assessment of the desirable effort from the national-level BreastScreen Australia Program. In
           many of the interviews and workshops conducted the list of functions was explicitly considered
           both to seek participants’ views and perspectives and to identify additional functions which might
           be included. The ‘ratings’ included in the following tables are subjective and indicative. They are
           based on the evaluators’ judgement informed by input from stakeholders, document review and
           our own analysis.
           In Chapter 10.4 of the Report, we explore a number of future program design options for
           consideration. For the options presented for discussion, we outline how the functions below could
           be best delivered under a change in program model.
           Goals and objectives   Description               Setting specific shared outcomes or outputs to be achieved, typically
                                                            with a long-term focus.
                                  Current performance

                                  Desired national effort

                                  Rationale                 The 12 main objectives of the Program and the more specific objectives
                                                            contained within the National Accreditation Standards have provided
                                                            clear, achievable goals that are applicable across different State/
                                                            Territory populations, geographies and can accommodate a variety of
                                                            service delivery approaches.

                                                            As has been identified earlier, review of the relevance and achievability
                                                            of key goals has not happened as proactively as we judge appropriate
                                                            but this does not undermine the quality of the goals and objectives and
                                                            their clarity and application through the Program. The comprehensive
                                                            evaluation of the BreastScreen Australia Program represents an
                                                            opportunity to review the goals and objectives in light of a revised
                                                            evidence base and projections of capacity.




60
Policy formulation       Description                     Articulating and renewing the scope of service provision including
and maintenance                                          expectations of quality, quantity, frequency and degree of discretion
                                                         to be applied.
                         Current performance

                         Desired national effort

                         Rationale                       Policy maintenance has not kept up with the rate of change of Program
                                                         expectation. Services have developed their own policies on issues
                                                         such as family history, invitations outside the target age range and
                                                         women with a personal history of breast cancer leading to inconsistent
                                                         service delivery and subsequent confusion by some women.i It is
                                                         understood that many of the policy issues in question raise capacity
                                                         issues either financial, workforce or both. This means that resolutions
                                                         other than affirming current policy have costs and affirming current
                                                         policy explicitly may increase the level of advocacy for change. The
                                                         uncertainty and sometimes ad hoc decision making which is filling the
                                                         gap appears to be having diverse consequences which will contribute
                                                         to increasing problems in future.




Strategic planning       Description                     Developing a roadmap of the key initiatives and core business that
                                                         needs to be achieved in order to deliver on the goals and objectives,
                                                         including setting milestones and key performance indicators
                         Current performance

                         Desired national effort

                         Rationale                       The national mechanism to respond to and plan for strategic initiatives
                                                         has been eroded over time as DoHA is not resourced or empowered to
                                                         lead on behalf of the jurisdictions and the role of the SSC has evolved
                                                         to one of advisory status. Although the SSC and it predecessors
                                                         have defined a workplan of prioritised projects, these have taken
                                                         the form of short or medium term initiatives. There is no evidence of
                                                         coordinated longer term planning that addresses key strategic issues of
                                                         sustainability and positioning within the broader health context.

                                                         It is highly likely that post evaluation reforms of various kinds will be
                                                         required and a national strategic planning process will be important.

                                                         This provides an important but not time consuming opportunity to
                                                         define a high level national strategic plan. This should not be an
                                                         extensive or onerous process given that much of the detailed strategic
                                                         planning required needs to happen at State and Territory levels.
i    Evaluation of BreastScreen Australia: Policy Analysis Project, Draft Final Report, 23 June 2008, HDG Consulting Group. Pg iii.




            BreastScreen Australia Evaluation – Governance & Management Project January 2009                                          61
     Community                Description                    Providing timely and appropriate information to stakeholders to
     education and                                           increase their awareness and understanding of the Program.
     information              Current performance

                              Desired national effort

                              Rationale                      Community awareness about the benefits of breast screening is high
                                                             among target women and the community in general although it is clear
                                                             that there are continuing needs to both improve the depth and breadth
                                                             of community knowledge and preparedness to participate.ii

                                                             The reduction in national effort which is evident has been largely
                                                             appropriate in the resource constrained environment in which the
                                                             Program operates. There are risks that differing communication
                                                             strategies adopted in jurisdictions will be hard to draw back under one
                                                             umbrella retrospectively.

                                                             Any future expansion of effort should be undertaken:
                                                             • Through collaborative means
                                                             • When resources are available to respond to the increased demand
                                                               consequent upon effective social marketing and information
                                                               dissemination
                                                             • When key workforce issues are better addressed.




     Information and          Description                    Maintaining formal and informal networks and forums to share best
     knowledge sharing                                       practice and insights that can improve the delivery of services and
                                                             maximise the use of resources.
                              Current performance

                              Desired national effort

                              Rationale                      Public health benefits and efficiency gains are both, in part, dependent
                                                             upon widespread take up of best practice across the Program. At the
                                                             current time there are no active governance and management systems
                                                             which support these kinds of activity although it is noted that:
                                                             • Program Manager meetings continue although they have no formal
                                                               status within the Program
                                                             • The accreditation process allows approved assessors the
                                                               opportunity to visit Programs in other States and by observation to
                                                               identify policies and practices with application to their own setting
                                                             • Emerging issues, such as digital mammography, will especially
                                                               benefit from structured knowledge sharing and the Program
                                                               has missed significant opportunities in terms of lessons learned,
                                                               consistency of format and possibly cost efficiencies by not
                                                               coordinating on this issue (see Chapter 9.1 for further discussion).

     ii   Evaluation of BreastScreen Australia Policy Analysis Project, Draft Final Report, 23 June 2008, HDG Consulting Group Pg 7




62
Workforce planning         Description                     Ensuring that there is a stable, committed and consistent pool of
                                                           resources to fulfil key functions.
                           Current performance

                           Desired national effort

                           Rationale                       There are clear limitations in what a single program can or should
                                                           do regarding health workforce issues where those issues span the
                                                           sector. Major issues must be dealt with on a functional rather than
                                                           Program basis. The key issue which needs to be assessed is whether
                                                           jurisdictional Managers, SSC and APHDPC, having identified the major
                                                           issues for the Program in recruiting radiographers and radiologists,
                                                           have raised this with sufficient vigour with a view to having sufficient
                                                           priority given to these professional groups by the Health Workforce
                                                           Taskforce which has been established.

                                                           It is our assessment that more could have been done both on a
                                                           national and local level, including:
                                                           • Formal succession planning for senior surgeons, radiologists and
                                                             radiographers who are close to retirement or already partially retired
                                                           • Working with professional associations and universities to ensure
                                                             adequate places and facilitate early connections with the Program
                                                             through formal placement programsiii
                                                           • Reviewing international experiences in workforce diversity and
                                                             development of tiered technical workforceiv

iii   This is occurring in a few services, driven mainly by individuals working within those services with the strong support of
      service management, but not in a coordinated way across the Program.
iv    For example, the four tiers of radiographer accreditation in the NHS




             BreastScreen Australia Evaluation – Governance & Management Project January 2009                                         63
     Data and                  Description                     Collection, management and storage of data in a format that can
     Information                                               be accessed by authorised persons and shared under a common
     management                                                framework of definition.
                               Current performance

                               Desired national effort

                               Rationale                       Considerable and important work has been done on national data
                                                               issues. This includes:
                                                               • The Data Dictionary was designed to create reporting consistency
                                                                 although it should be noted that this has not been fully achieved.
                                                                 Some jurisdictions have not implemented the Dictionary in full due
                                                                 to system constraints or are unable or under-resourced to collect the
                                                                 information in the method required.
                                                               • The data processes to support the NAS represent important data
                                                                 resources.
                                                               • The annual BreastScreen Australia Monitoring Reports produced
                                                                 by the Australian Institute for Health and Welfare (AIHW) in
                                                                 collaboration with the Screening Subcommittee, jurisdictions and
                                                                 the Screening Section of DoHA. This report presents statistics on
                                                                 Program activity, outcomes and trends for the Program.

                                                               Key issues relate to the inadequate attention paid to:
                                                               • Development of compatible information systems and databases so
                                                                 that records of women moving between jurisdictions can be easily
                                                                 transferred.
                                                               • The ease and timeliness that information can be extracted – some
                                                                 jurisdictions can generate reliable reports in hours; others require
                                                                 months to cleanse and prepare the data.v
                                                               • Dissemination and use of data both for Program improvement and
                                                                 broader research purposes, including use of the rich quantitative
                                                                 and qualitative data collected through the accreditation process.vi




     Quality and clinical      Description                     Providing incentives, standards and frameworks for the delivery of
     risk management                                           clinical services, monitoring adherence and ensuring action is taken to
                                                               address any elements not being met.
                               Current performance

                               Desired national effort

                               Rationale                       The commitment and rigour of the quality and clinical risk management
                                                               standards and accreditation process is a clear example of successful
                                                               national coordination and leadership.

                                                               One area that could be improved on is expert support for jurisdictional
                                                               Programs that struggle to meet standards and to develop strategies
                                                               to address issues. See commentary on Objective 5 (above) for further
                                                               analysis.
     v     Comparison based on interviews undertaken across jurisdictions when asked how long is required to generate a report on
           current performance on key indicators.
     vi    A number of staff across jurisdictions have stated that the informal discussions with the accreditation assessment teams
           during the formal process are the most value aspect for developing revised practices to better meet standards in the future.
           Whether this occurs at all as a way of promoting best practice seems to depend on individuals within the assessment teams,
           rather than the design of the assessment process.




64
Emerging issues          Description                    Capability and capacity to identify, evaluate and act upon emerging
                                                        issues in a timely manner.
                         Current performance

                         Desired national effort

                         Rationale                      Although issues of national concern (workforce shortages, family
                                                        history policy etc) have been raised at the NAC, ASAC and SSC
                                                        meetings, we have not seen evidence of specific actions to address
                                                        these issues.

                                                        The lack of coordinated responsiveness to digital mammography
                                                        provides a recent case study of the underperformance in this area (see
                                                        Chapter 9.1). It is highly likely that equally important issues will emerge
                                                        post evaluation and that service quality and efficiency benefits will be
                                                        derived as a result of more proactive assessment of emerging issues.




Research                 Description                    Planning for the systematic collection of knowledge and data in order
                                                        to create a robust measurable framework for analysis and conclusions
                                                        that have the potential to improve clinical or service delivery.
                         Current performance

                         Desired national effort

                         Rationale                      There have been missed opportunities to utilise the national Program
                                                        as a platform for research and to promote its achievements, although
                                                        some individuals have been undertaking research and publishing
                                                        jurisdictionally-based findings.vii

vii   Comparison based on interviews undertaken across jurisdictions when asked how long is required to generate a report on
      current performance on key indicators.




             BreastScreen Australia Evaluation – Governance & Management Project January 2009                                         65
     8. FUNDING, FINANCING AND RISK

     8.1        FUNDING
                The Program was initially funded by Specific Purpose Payments (SPPs) between the
                Commonwealth Government and each of the jurisdictions. The SPPs were predicated on a number
                of principles:
                •       equal State/commonwealth funding of the screening and assessment services and State
                        coordination unit costs
                •       funding should be quarantined at State/Territory level
                •       increased unit cost funding for women in rural and remote areas
                •       flexible service delivery arrangements, including provision to contract and sub contract24.
                The Commonwealth responsibilities under the SPP agreement describe a much broader
                contribution than currently occurs including lead responsibility for national recruitment and
                information strategies, serving as an information clearing house within the Program and a greater
                role in developing and funding training.
                In 1997 the Program funding arrangements changed from being a SPP to a broad-banded
                agreement. BreastScreen Australia funding was linked with several other public health programs
                and became part of Public Health Outcome Funding Agreements (PHOFA). PHOFAs were
                negotiated between DoHA and each State and Territory.
                The shift from SPPs to PHOFAs was motivated by a number of factors including changes in
                Federal-State relations, the growing evidence base that outcome measures lead to better overall
                outcomes in program delivery and a move to introduce broad-banding across portfolios to enable
                more flexible management at State level.25
                As noted earlier, the Program has faced ongoing capacity reductions as a result of failures to
                provide sufficient funding in the face of population growth in the relevant age group. The SPP
                agreements were indexed based on a costing formula subject to ‘continuing review’. The PHOFAs
                include an indexation provision which is outlined in Figure 10 – a Victorian example, however all
                jurisdictions utilise the same indexation provision.




     24     Based on a review of a draft SPP between the Commonwealth of Australia and Queensland (1994)
     25     Joint Committee of Public Accounts, The administration of Specific Purpose Payments: A focus on outcomes (1995) Australian Government
           Publishing Service; Canberra



66
Figure 10     Example PHOFA formula from the Victorian agreement

 1.       The formula for detemining the amount paid under clause 3.2 is:
          (B-1+FPP-1+VCS)*WCI 1
 where:
 B-1      is the broadbanded base funding provided for the previous financial year
          and in respect of the 2004–05 payment year $28,724,000;
 FPP-1 is equal to the Family Planning Payments for nine months of the prevous
       year, and in respect of the 2004–05 payment year is $1,917.810;
 VCS-1 is funding providing for the Victorian Cytology Service in the previous year,
       and in respect of the 2004–05 payment is $5,212,000; and
 WCI      is he Commonwealth’s Wage Cost Index 1.

 2.       The formula for detemining the amount paid under clause 3.3 is:
          POP*[(0.6*CGC)+(0.2*SES)+(0.15*SDR)+(0.05*IND)]*POOL+FF
 where:
 POP      is Victoria’s proportion of Australia’s population as provided by the
          Australian Bureau of Statistics;
 CGC is an index equal to the Commonwealth Grants Commission assessment of
     needs for population health funding in the Population and Preventative
     Health category;
 SES      is a measure of Victoria’s relative disadvantage in
          socio-economic status as derived from Census variables;
 SDR      is a measure of Victoria’s relative disadvantage in morality as represented
          in standardised death rates;
 IND      is a measure of Victoria’s relative disadvantage in providing public health
          services to the Indigenous population;
 POOL is the total pool of boradbanded funding available for all the States in the
      relevant year (including estimatedWCI 1 indexation) minus flagfalls; and
 FF       is a flagfall of $1.0 million for the three smaller States (Tasmania,
          Australian Capital Territory and Northern Territory) in recognition of the
          minimum infrastructure costs required to provide public health services.




            BreastScreen Australia Evaluation – Governance & Management Project January 2009   67
               There are clear public administration benefits which derive from broad-banded funding
               arrangements and reviews of the PHOFA demonstrate this.26 A high level summary of key findings
               is provided below:
               Table 7           Summary of the Joint Review of second round PHOFAs27

                • All Governments were strongly in favour of the Agreements as a mechanism for the coordination of selected public health
                  outcomes of national priority
                • PHOFAs were administratively efficient although some individual program’s governance structures could be improved
                • The Agreements relied too much on historically funded programs that were not necessarily the result of a priority
                  setting exercise
                • The potential to reallocate resources between programs is limited by the nature of the performance indicators that, in effect,
                  support continuation of historical levels of funding for each program. The indicators create barriers that restrict refocussing of
                  effort across existing programs and within existing identified priorities, making it hard to make improvements to services and
                  outcomes in non-reporting areas
                • Considerable disagreement on some performance indicators
                • More should be done to create some structures that could help set new PHOFA priorities.


               The generalised indexation arrangement outlined above however embeds risks for a program
               designed to achieve a specified level of population coverage. The consequences of the introduction
               of the formula above are to impose an increasing cost burden on States and territories or erode the
               capacity of the Program.


     8.2       FINANCING
               The PHOFA also appears to lack a mechanism for dealing with capital cost issues other than
               through the rolled up amount provided to each jurisdiction. As the discussion on digital
               mammography (see Chapter 9.1) demonstrates, this is a problem in service development and a
               cost to States and territories. Data available to this project does not clearly identify what was
               included in the ‘broad banded’ base on which the new arrangements commenced or to assess
               the adequacy of that base for the current operational cost structures both capital and recurrent.
               Assessing the current adequacy of the base and making a current risk assessment regarding future
               erosion is likely to be an important post evaluation task.




     26   Joint Government Review (2003) of the second round PHOFAs 
     27   From S Schlette, K Blum, R Busse (eds.): Health Policy Developments. Issue 9. Focus on Mental Health, New Role for Hospitals, Search for the
          Right Funding Mix. To be published in summer 2008. Accessed from http://www.hpm.org/en/Surveys/CHERE/09/Funding_Public_Health_in_
          Australia.html on 1 September 2008.



68
8.3   RISK
      There are a number of categories of risk in delivering the BreastScreen Australia Program,
      including:
      •      Clinical risk
      •      Legal risk
      •      Financial and budgetary risk
      •      Workforce capacity and capability risk.
      Effective management and mitigation of risks is a core component of ensuring successful program
      performance. With the exception of clinical risk through the contributions of the NQMC and NAS,
      risk management has been largely devolved to the States and territories over time. This appears
      to be appropriate given that most of the issues occur at the local service level; however, a more
      coordinated approach to managing the funding risk may have ensured that Program capacity was
      able to increase with population demand.




                   BreastScreen Australia Evaluation – Governance & Management Project January 2009       69
     9. OTHER MATTERS
                This chapter examines two other issues relevant to governance and management: a case study on
                digital mammography; and Program alignment and interfaces, covering connections with other
                screening programs and connections with other treatment services.


     9.1        TECHNOLOGY – DIGITAL MAMMOGRAPHY CASE STUDY
                The decision making and related processes supporting the introduction of digital mammography
                across Australia is a useful case study in understanding the strengths and weaknesses of the
                current governance and management machinery. Changing and evolving technology is a key
                feature of health care provision. It is essential that the Program is able to recognise which
                emerging technologies are significant, evaluate their impact on the Program and successfully
                absorb any necessary changes into Program objectives, operations and practices.
                Technology generally and digital mammography specifically are important examples of the need to
                have responsive capabilities in Program governance.
                All jurisdictions, with the exception of the Northern Territory, have implemented, are implementing
                or have undertaken analysis on the costs and benefits of moving to a digital environment. From
                our analysis there appears to be four main reasons cited for shifting to digital mammography,
                although not necessarily all were articulated by each jurisdiction:
                1.      Technology lifecycle – Analogue technology is fast becoming redundant and, as such,
                        the costs involved in maintaining ageing equipment and obtaining vendor support are
                        increasing. The main analogue market is now second hand.
                2.      More effective health outcomes – Research indicates that digital mammography is
                        more effective for women under 50yrs with denser breasts, pre-menopausal or those with
                        implants.28
                3.      Better service provision – This includes assumptions about increases in Program
                        screening capacity/productivity and cost efficiencies. For example, the difficulty of obtaining
                        radiologists in situ may be lessened (dependent on workflow and systems). Immediate
                        availability of images will reduce the number of women who are recalled for a second
                        mammogram due to technical problems with the first, thereby reducing anxiety and travel
                        costs for women.
                4.      Market acceptance – Internationally there is a move towards interoperable health
                        information systems supporting the creation and maintenance of e-health records. Private
                        providers are also converting to digital and insisting upon sending digital images.




     28    For example, see Pisano E, Gatsonis C, et al (2005b) Diagnostic performance of digital versus film mammography for breast screening. N Engl J
           Med 353(17), 1773-1783.



70
Digital Mammography was recognised as an emerging issue for BreastScreen Australia in 2000.
A timeline charting the processes and timelines for considering, piloting and introducing digital
technology follows (Figure 11). Discussions continued noting the issue and proposing various
courses of action at national meetings and informally across jurisdictions until April 2007, when
the need for consistency across States and territories was formally recognised. International
comparators suggest that this was a long delay. The delay could be in part because of Australia’s
commitment to establishing the efficacy and cost benefits of investments in new technology, but
appears problematic as a national response given the fact that jurisdictions were already investing
on their own authority.
The decision at a national level to endorse digital mammography is a complex issue. A full
consideration requires bringing together clinical, technical, financial and service delivery
information to evaluate the necessity or otherwise of shifting the technology base. With the
benefit of hindsight and the lessons learned overseas and within Australia, it is now clear that the
shift was all but inevitable for the four reasons described above.




           BreastScreen Australia Evaluation – Governance & Management Project January 2009            71
72
     Figure 11               Timeline of digital mammography rollout in Australia



                                          DM in use in                     MSAC prepares a                   Release of        Commencement of DM                           Ireland completes first full DM
                                          the Scottish                  horizon scanning Report            EU guidelines       implementation in NZ                          implementation in the world
                                        Breast Screening               on DM providing summary               for quality
                                            Program                       of current evidence               assurance in                   APHDPC endorses the cost                           MSAC Report on DM




      External
                                                                                                          breast screening               effectiveness & recurrent costs                   Recommendations endorsed
                                                                                                            include DM                      of DM as priority for SSC                     by Minister of Health & Ageing

                      NAC                                      ASAC                          SSC

                      Digital Mammography identified                           DM not deemed best               Change to NAS requested                                       Changes to NAS to
                            as an emerging issue                              practice for screening            by NQMC denied due to                                      include DM endorsed




        SSC
                                                                                                                    lack of evidence                                           and completed




     NAC/ASAC/
                                                                                                              QIWWG agreed to establish DMAS working group                 DMAS Working Group
                                                                                                              with a view to develop NAS for DM by end of 2006                Stands down




      QIWWG
                                             Project to monitor DM developments identified as
                                            seperate project on ASAC work plan, but work to be
                                           carried out as part of the Screening Framework Project             Assessment of DM for screening referred to MSAC         Draft Screening Framework document
                                                                                                                                                                          delivered (no reference to DM)

                                                                                                          Request change to NAS to incorporate DM




      NQMC PRNTWG
        NSW                                   Business Case      P               Implementation                                  BC          P           Implementation                          Ongoing
           VIC                                                Business Case           P                                               Implementation                                    BC               P       Implementation
          TAS                                                                 BC       P        I
         QLD                                                                                                             Business Case               P             Implementation
          ACT                                                                                                                                      Business Case                          P              I
                                                                                                                                                                                          BC                 I
          WA                                                                                                                                                                                BC                     Ongoing
            SA                                                                                                                                               Business Case
              Jan                       Jan                           Jan                               Jan                        Jan                              Jan                            Jan        Jan  Jan
             2000                      2004                          2005                              2006                       2007                             2008                           2009       2010 2011

                    Pilot    Planned                                                 I = Implementation DM = Digital Mammography              QIWWG = Quality improvement Workforce Working Group
                                       Northern Territory not yet gained or          BC = Business Case PRNTWG = Policy Review and New        MSAC = Medical Services Advisory Committee
                    Full       NT                                                    P = Procurement               Technologies Working Group DMASWG = Digital Mammography Accrediation Standard’s WG
                                       sought approval to move to digital
          A number of lines of enquiry have been explored to understand the contribution to what can now
          be viewed as a delay in national response with a number of consequences:
          •       Did the Program consider available evidence in decision making?
                  Coordinated trials of digital mammography commenced in the United States in 2000, and
                  the technology shift was identified around this time as an emerging issue for the Program.29
                  While the United States often leads in technological developments it seems problematic
                  that they were at the point of coordinated trials at the same time that Australia’s policy
                  mechanisms were giving the issue preliminary consideration.
                  In December 2005, ASAC having examined the evidence available, including the Health
                  Policy Advisory Committee on Technologies (a sub-committee of MSAC) horizon scanning
                  report on digital mammography, determined that Digital Mammography was not best
                  practice for screening at this stage.30
                  Evidence continued to accumulate overseas and jurisdictions within Australia continued to
                  formulate their own views, apparently not satisfied that the ASAC conclusions were the
                  end of the discussion. In May 2006, the assessment of whether digital mammography is
                  equivalent or better than film screen mammography, in terms of safety and effectiveness for
                  use in BreastScreen Australia was referred to MSAC. In parallel, the Quality Improvement
                  Workforce Working Group of ASAC agreed to the establishment of a working group to
                  consider and develop Digital Mammography Accreditation Standards (DMAS).
                  The commissioning of these two projects was important in establishing a sufficient evidence
                  base and led to the endorsement of the issue by APHDPC as one of the top priorities of the
                  Screening Subcommittee in January 2007.31, and ultimately to its current resolution with the
                  changes to the NAS.
                  Although the digital mammography issue went through the remit of a large number of
                  committees and working groups, as detailed in this section, there appears to be appropriate
                  consideration of the available evidence and referral of information between advisory bodies.
                  The next question for evaluation is whether the timing of that consideration was appropriate.




29  National Advisory Committee to BreastScreen Australia Minutes (November 2000) – Agenda item 5. It is unclear why national committees
   considered the evidence in parallel with jurisdictions and concluded differently that digital mammography was not best practice for Australia.
30 Health Policy Advisory Committee on Technology Minutes (December 2005)
31 APHDPC Screening Subcommittee Meeting (January 2007) Agenda Item 4.



                          BreastScreen Australia Evaluation – Governance & Management Project January 2009                                          73
               •       Did the decision making occur in a timely way, given the known
                       external context?
                       As discussed above, although the Program committees took an evidence-based approach
                       to the assessment of digital mammography, at the time that ASAC determined it was not
                       best practice (December 2005), two States had already implemented digital mammography
                       and another was at the business case stage.32 At this point, no strategy proposed at ASAC
                       to resolve the fact that three States were now in conflict with the NAS33. Jurisdictions had
                       already taken action to resolve this in parallel with national discussions, including through
                       the NSW-convened National Accreditation Standard for Digital Mammography Workshop in
                       August 2005.
                       Possibly initiated by a combination of events including the pilot implementation of digital
                       mammography in Victoria in March 2006 and ongoing MSAC review discussions, the
                       national Program through ASAC implicitly acknowledged in April 2006 that it needed to
                       resolve the NAS issue and agreed to the establishment of a working group to consider and
                       develop accreditation standards for digital mammography. It was proposed, that these
                       standards would be developed by the end of 200634. However, the Digital Mammography
                       Accreditation Standards Working Group met for the first time in December 2006, making it
                       impossible to meet the proposed timeframe for the DMAS to be complete.
                       It took 24 months for this group to complete the NAS review, before the working group
                       was stood down in May 2008. The parallel process of the assessment of evidence for digital
                       mammography that was referred to MSAC in May 2006, took 23 months to be completed
                       and was endorsed by the Commonwealth Minister for Health and Ageing in April 2008.
                       During this 2006-2008 period, when the NAS and the evidence report were being
                       completed, the States/territories had embarked on the following:
                       •       NSW was implementing a State wide system
                       •       Tasmania was business as usual with their State wide system already having moved to
                               digital technology
                       •       Queensland had begun implementation of their full State-wide system
                       •       Victoria was implementing their pilot system
                       •       ACT had embarked on their business case for full rollout.




     32  Information requested from jurisdiction on implementation timelines.
     33  ASAC noted in its December 2005 Minutes – Agenda item 6 that Digital mammography was a high priority for ASAC as:
        (a) a number of State/Territory Programs have/or will be considering purchasing digital mammography equipment (b) States and Territories had to
        provide the Secretariat with an update on the status of digital mammography within their program.
     34 PRNTWG Minutes (April 2006) – Agenda Item 11



74
          A number of reasons were proposed throughout the interviews to account for the delay, including:
          •        uncertainty around the evidence base
          •        underestimation of the speed at which the technology would progress
          •        uncertainty over DMASWG reporting lines
          •        a lack of commonwealth support leading to the issue being blocked from escalation.
          More broadly, what is clear from our analysis is that no single entity took leadership of the issue
          and that the divided contributions of the DMASWG and MSAC (and associated committees)
          were focussed only on specific issues (quality and technology acceptability, respectively) and
          missed the wider sphere of policy and implementation issues. Furthermore, there was a failure
          to acknowledge that, although there was not consistent national support, this issue was of
          transformational proportions and needed to be acted upon much earlier to bring it within the
          scope of the Program.
          •        Was the decision to move to implementation supported to ensure it would
                   be successful?
          The decision making process to date has focussed on amending the NAS. The papers tabled at
          committee meetings35 have also identified a number of other issues:
          •        The need for consistency across States and territories
          •        The expense involved in replacing analogue machines with digital equipment
          •        The licensing costs involved in converting to digital mammography
          •        Workforce issues around the conversion
          •        Strategic planning related to any developments in the National and Patient Electronic
                   Medical Record.
          To date, we see no evidence that these issues have been considered at the national level and thus
          there are likely to be a number of ongoing consequences from the lack of a united and proactive
          national effort to evaluate the impact of digital mammography and coordinate its implementation
          (Table 8)36.




35   APHDPC Screening Subcommittee Minutes , (January 2007) – Agenda Item 4 and (April 2007) – Agenda Item 4
36   The NSW Cancer Institute hosted the BreastScreen Digital Mammography User Group Forum on 22 February 2007. Although this was apparently
     a valuable platform for sharing experiences across jurisdictions, there is no evidence presented that it helped to resolve issues outlined in Table 8.



                           BreastScreen Australia Evaluation – Governance & Management Project January 2009                                                   75
               Table 8              Consequences of delay in moving to digital mammography

                1. System compatibility – it appears likely that jurisdiction-by-jurisdiction choices will lead to compatibility issues, reducing the
                   long term efficiency benefits which can be achieved and possibly disadvantaging women.
                2. Business case efficiencies – jurisdictions have ‘reinvented’ the business case several times, while a national effort might have
                   substantially built the detailed template for customisation.
                3. Proactive policy reform – rather than retrospective. Policy update of the NAS took over a year to be effected since the first
                   machine was installed causing uncertainty across Programs.
                4. Faster realisation of benefits:
                     a)      Logistics which help women (e.g. film movement from remote locations for reading) and minimise unnecessary anxiety
                             where there are issues due to technical quality
                     b)      Image quality for dense breasts
                     c)      Improved timeliness of advising women of a screening result
                     d)      Workforce
                            •      Productivity
                            •      Occupational Health and Safety
                            •      Attraction and retention (ability to trial innovative working patterns – remote and distributed reporting; a quieter
                                   and cleaner working environment)
                            •      Potential to use technology to improve quality and consistency of reading
                     e)      Potential for reduced radiation dose.
                5.        Australian Government contribution to cost – the PHOFA includes a rolled up amount for capital and maintenance of
                          existing equipment, which has decreased relatively over time; however, the cost of introducing digital technology is
                          considerably higher than upgrading the existing technology. It may however be argued that some jurisdictions are expecting
                          long term efficiency benefits of significant order (up to 20%) which will provide a return – albeit one that will most likely be
                          reinvested in throughput.
                6. Public announcement – missed opportunity to promote the quality and commitment to improvement.
                7. Integration with eHealth discussions – building links and finding efficiency dividends in the longer term strategy for the
                   collection, storage and access of electronic health records.
                8. Some potential to leverage better procurement of digital through negotiation with major vendors




     9.2       PROGRAM ALIGNMENT AND INTERFACES

               Connections with other screening programs
               BreastScreen Australia was one of the first organised population based cancer screening Programs
               in Australia37 and has benefited from the formality and distinctiveness of its model, resourcing and
               governance. Other cancer screening programs have very different operational models – different
               screening pathways, population target groups and practice arrangements.




     37    National Cervical Screening Program was introduced around the same time.



76
         There are however arguments for approaches which strengthen the linkages between programs
         particularly at the national level. The rationale for building and maintaining connections include:
         a.      Strategic benefits: common sets of functional, technical and professional expertise needed to
                 shape program direction
         b.      Efficiency benefits: secretariat, work plan management, data collection and analysis,
                 performance monitoring and evaluation
         c.      Structural benefits: all screening programs are likely to require ongoing collaboration
                 between the Commonwealth and State/Territory Governments. 38

         Connections with diagnostic and treatment services
         The Program has clear parameters as a public health and well women’s program that ends at
         the point of diagnosis. Women are recruited on the basis of age alone. Over time, however,
         inconsistent application of criteria between jurisdictions have emerged regarding the eligibility of
         women with a personal history of breast cancer, family history or exhibiting symptoms. In some
         cases, jurisdictions have judged that the specific needs of these women are better served outside
         the Program in the diagnostic and treatment sectors.
         A key issue for the broader evaluation is to understand if the Program parameters are calibrated to
         deliver the best health outcomes for Australian women, with consideration of cost/benefit analysis.
         From a governance and management perspective, this also raises a number of issues including:
         •       Population level and Program impacts. The appropriateness of the Program design
                 was raised in relation to two assumptions.
                 –       The role of the private market: It is commonly asserted that there are significant levels
                         of de facto mammographic screening performed in the diagnostic health care setting
                         through radiology practices and funded by the MBS. Some argue that if this is the case,
                         action should be taken to acknowledge and count this activity for population health
                         monitoring purposes. Another suggestion was for validation of a Medicare-based
                         component of screening, though others interviewed asserted that this would damage
                         the Program and lead to reduced population health outcomes.
                 –       Service model: This issue of Program design is also raised, with some advocating that a
                         different service model that would co-locate diagnostic services with the BreastScreen
                         Australia SASs to facilitate sharing of expertise and equipment, particularly with move to
                         digital technology, should be introduced to enable linkage with breast cancer centres.
         •       Program interface. Program design and scope of service model issues aside, consultation
                 feedback has highlighted the importance of managing the interface with the treatment
                 service system with widespread commitment to the ongoing improvement of processes
                 connecting diagnosed women to appropriate treatment as directly and efficiently as possible.
         •       Knowledge and education. There are numerous issues regarding the performance of the
                 Program in building communities of knowledge beyond service staff – for women, support
                 groups, epidemiologists and medical practitioners, especially GPs.


38   Program alignment issues are also considered in the next chapter in regards to different program constructs, approaches and models.



                         BreastScreen Australia Evaluation – Governance & Management Project January 2009                                  77
     10. THE IMPLICATIONS
         Previous chapters of this report have described and analysed a wide range of governance and
         management factors which have impacted upon the Program. This chapter provides an integrated
         commentary on the implications that emerge. The chapter provides:
         •    A summary assessment of the effects of the performance of national governance and
              management
         •    An assessment of the benefits which could emerge from a new program framework and
              revised governance and management arrangements. A number of different options are
              explored.
         The retrospective and prospective assessments draw upon a simple program construct. This
         construct is a tool which is designed to crystallise a number of factors on which judgement can
         be made.


     10.1 PROGRAM CONSTRUCT
         For the purpose of analysis, it is possible to assess the Program against two orthogonal design
         levers – control and consistency. Together they form a set of axes that set out two independent
         continuums of choice. Decisions about the desirability along each of the axes will shape the
         performance outcomes of the system. Figure 12 below provides a visual example of the proposal.
         Figure 12        Program construct model



                                                  Central
                                                  control




                                  discontinuity              national
                                                            focus
                                                                         Policy and
              Policy
                                                                          practice
              exibility
                                                                        consistency

                                  diversity                  shared
                                                            framework




                                              Decentralised
                                                control




78
    This tool provides a mechanism for assessing the appropriateness of an approach to program
    management for particular programs. It does not provide insights into the effectiveness of the
    structures or processes chosen to achieve the outcomes.
    In principle, each of the polar ends represents a potentially desirable proposition in some ‘universe’
    of specific circumstances. In some situations central control is both necessary and desirable while
    in others decentralisation delivers better outcomes. Consistency is a policy good in some domains
    and flexibility an essential part of a responsive service system.
    Combining these propositions with each other, and in the specific context of the Program,
    generates a range of outcomes which may be either productive, or undesirable and inappropriate.
    The italicised words in each quadrant provide a single word descriptor of the consequences of
    particular combinations.


10.2 RETROSPECTIVE ASSESSMENT
    Figure 13 below provides an assessment of the Program against the program construct
    framework. In general terms the Program sits relatively near the mid point. The grey arrow is
    suggestive of a drift towards diversity which is evident. In simple terms the grey arrow symbolises
    the consequences of the operation of the national governance arrangements rather than the
    intent.
    Feedback and analysis of the Program suggests that the aspiration of national governance and
    management arrangements has been to achieve:
    •     High levels of Program consistency in order that women receive a high quality and
          equitable service
    •     Strong operational devolution to States and territories
    •     ‘Light touch’ national decision making which shapes policy and Program objectives.
    It is not clear that this logic was rationally arrived at by a decision making process or whether it is
    a consequence of decisions taken for broader reasons.
    It is clear that high levels of consistency have been achieved given the potential diversity of service
    in a country of this size and the operational autonomy of the States and territories. The NAS is the
    structural ‘glue’ which has contributed to this achievement although it should also be noted that
    Program leaders have driven this commitment. As senior leaders in the Program change over time
    this shared commitment is at some risk.
    It is also clear that the devolution to States and territories is a powerful and almost certainly
    necessary aspect of Program delivery, given existing health structures and the division of health
    responsibilities between the Australian Government and State and Territory Governments.




                BreastScreen Australia Evaluation – Governance & Management Project January 2009              79
     The identification of light touch as a proposition is a conclusion drawn by the evaluators rather
     than an identified or articulated design principle. It is the conclusion which has emerged from both
     the terms of reference for various aspects of the Program and the input from stakeholders.
     The Nous conclusion regarding ‘light touch’ national governance raises two questions. They are:
     •    Is a light touch approach appropriate?
     •    Has it been implemented effectively?
     The answers to these questions are included in the paragraphs which follow.
     Figure 13        Assessment of current Program using the program construct model


                                                       Central
                                                       control




                                                                        national
                                    discontinuity
                                                                       focus




                                                                                         Policy and
          Policy
                                                                                          practice
          exibility
                                                                                        consistency
                                                                 now




                                    diversity                           shared
                                                                       framework




                                                     Decentralised
                                                       control




80
•   There is significant strength in operational performance.
    While not a primary focus for this evaluation, the data and the insights gathered from
    discussion with managers, staff, consumers and clinicians during visits to every jurisdiction
    indicate that the Program delivers effectively to many women. The key indicators to support
    this claim are:
    •    Relatively consistent implementation of the service model and strong performance
         against the requirements of the National Accreditation Standards. These standards are
         rigorous and extensive and provide relatively high levels of confidence in the workings
         of the Program
    •    Clearly stated ongoing commitment from jurisdictions
    •    Examples of a number of services that have addressed performance following some
         important service failures or weaknesses.
    That said there are also important questions about performance and efficiency facing
    each jurisdiction. The extent and nature of the performance issues differ by jurisdiction.
    As noted earlier there is evidence regarding systemic operational issues and failures which
    have occurred and in some cases remaining inadequately addressed for substantial periods.
    Critically, responses to such issues are required, some urgently, if the robustness of the
    operational strengths is to be maintained and enhanced.
    This commentary confirms that embedding the operational responsibilities in State and
    Territory administrations has, on balance, generated benefits. The operational framework of
    the BreastScreen Australia Program determines some aspects of the Program construction:
    a level of practice inconsistency and policy flexibility is a necessary consequence of this
    operational devolution. A level of diversity is also a consequence of the fact that State and
    Territory governance structures emerged from pilots established to demonstrate different
    things and no national consensus emerged at the beginning of the formal Program regarding
    structure and management.
    This strongly suggests that when post evaluation decisions regarding the Program’s future
    development are clear a national review focussed upon jurisdictional performance would be
    justified. Such a review could:
    •    Assist jurisdictions to address ‘local’ performance weaknesses
    •    Facilitate consistent approaches to policy related operational reform
    •    Assess options for improving the national consistency where appropriate in governance
         and operational processes within the service model.




         BreastScreen Australia Evaluation – Governance & Management Project January 2009           81
               •        Important weaknesses are evident in national governance arrangements.
                        National governance mechanisms should provide the specific policy leadership, Program
                        development and system capacities to support the quality and equitable service goals of
                        the Program. They might also be reasonably expected to contribute to the achievement of
                        efficiencies through consolidation or consistent action wherever it is in the interests of the
                        overall Program outcomes.
                        As outlined in this report, the current governance and management arrangements are now
                        providing inadequate leadership and direction to the Program. This is reflected largely in
                        deferred or delayed decision making, limited leadership and direction setting and capacity to
                        deal with emerging issues rather than in bad decisions or inappropriate actions.
                        This analysis should be understood in the context that a complex and sensitive program has
                        been established and operates effectively and this could not have happened in the absence
                        of national leadership and sound program design. There are long term benefits which
                        have resulted from the clear Program service model, largely quantifiable and measurable
                        objectives and the national telephone service that enables women across Australia to make
                        appointments through a single number for the cost of a local call.
                        The work of the National Quality Management Committee and the operation of the National
                        Accreditation Standards are also critically important examples of robust governance and
                        management at the national level. Although, because these measures set and monitor
                        performance across the Program, the time between accreditation assessments (between
                        two and four years) and the absence of robust regular service reporting at jurisdictional level,
                        many services have operated in a relatively unsupported environment39. There is also a risk
                        that some senior staff will become less willing to commit the time and effort involved in the
                        peer assessment processes in future given the pressure of operational issues.
                        It is our judgement that the evident weaknesses are now beginning to diminish Program
                        effectiveness. We also judge that this risk will increase over time in the absence of
                        governance and management reform.
                        With regard to the current structural arrangements key issues include:
                        •       Clarifying the terms of reference of the Screening Subcommittee
                        •       Assessing the capacity of the SSC to fulfil the more proactive, strategic role that might
                                be required. In this context capacity relates to breadth of expertise, time and support
                        •       Identifying appropriate secretariat functions and resources
                        •       Ensuring appropriate alignment with other cancer screening programs
                        •       Putting in place mechanisms in the short term to begin work on implementing any
                                outcomes of the current BreastScreen Australia Evaluation and resolving the ‘backlog
                                of issues’.

     39   Through interview discussions, it was apparent that the extent of under performance of a number of services was not apparent to Coordination
          Units until the accreditation process was undertaken. This was not the case in jurisdictions where there is no formal distinction between the
          Coordination until and service functions where quality incidents and more systemic performance failures were identified and dealt with prior to
          accreditation. With the exception of the Northern Territory, all jurisdictions with integrated Coordination Units have four year accreditation status.



82
                 The way to address these issues may be either direct or indirect. Indirect resolutions may be
                 achieved through wide ranging change rather than reform of existing structures. A series of
                 structural change options, including refinement of the existing model are outlined in the next
                 chapter of this report.
                 The issues outlined are largely structural weaknesses and do not inherently derive from
                 commonwealth/State tensions or difficulties. These well known tensions are a common
                 phenomenon in our federation and undoubtedly have played a role in shaping this Program.
                 They are, however, less important than the structural issues which have been identified.
                 Much of the dissatisfaction expressed regarding the current operation of the Program,
                 and the role of DoHA in particular, results from the weakness of the governance and
                 management structures rather than jurisdictional competition or unwillingness to collaborate.
                 Many of the stakeholders in this Program have been involved for many years and there is
                 a relatively high level of commitment to the Program as a national entity based upon cross
                 jurisdictional collaboration. In the experience of the evaluators this is unusual.
                 Having said that, it is clear that jurisdictions strongly protect their individual interests and
                 can act somewhat capriciously if national policy or strategy is inconsistent with their view or
                 priorities40. This tension, however, would be better managed in a robust national governance
                 structure rather than continuation of current arrangements.
         •       High level risks
                 The summary analysis of the weaknesses of the Program generates a number of high level
                 risks. In broad terms our conclusion is that the risks to Program outcomes will increase over
                 time if existing arrangements are maintained.
                 Two issues justify comment in this report. They are:
                 1.      Program performance could be reduced through erosion of population coverage. Other
                         projects within the BreastScreen Australia Evaluation will shed authoritative light on
                         the issue of population coverage needed to achieve population health benefit and cost
                         effectiveness requirements. It is clear, however, that in the absence of clear decisions
                         regarding policy directions, workforce and resources that coverage will be eroded over
                         time. This is highly likely to reduce public support.
                 2.      Consistent outcomes may decline as a result of local interpretation of policy and
                         practice. The absence of timely policy decision making and active linkage of the
                         standards issues to Program leadership is leading to diversification of Program
                         operations. If this environment continues it will be very difficult to re-establish
                         consistency as stakeholders seek to preserve existing arrangements in particular
                         jurisdictions.




40   The implementation of digital mammography being one example in support of this.

                        BreastScreen Australia Evaluation – Governance & Management Project January 2009            83
     10.3 FUTURE APPROACH TO BREAST CANCER SCREENING
              The analysis of the governance and management structures and processes made throughout this
              document provides a retrospective commentary on the Program. This commentary is useful as a
              reflection on current and past decisions and practices. Its most beneficial use is to inform decisions
              about future arrangements.
              It is not intended that this chapter of the report provides definitive advice as to future
              arrangements. This evaluation provides only one perspective and limited insights into the choices
              for the future. This chapter is designed to assist both the Evaluation Advisory Committee and other
              decision makers to consider a range of alternatives and potential options.
              A number of ‘first principle’ propositions, largely beyond the ambit of this evaluation could be
              considered by decision makers in light of the outcome of the overall evaluation. Propositions which
              precede and inform governance and management decisions are:
              A.      To screen or not – is the intervention required and does it provide enough benefit? The
                      overall evaluation will provide a sound information base for policy makers to make this
                      decision.
              B.      If the answer is ‘yes’ then there are high level choices about the type of model required
                      to achieve the agreed screening outcomes. Selection of any of these options would guide
                      subsequent governance and management choices.
                      a.      A population based program structure.41 This option represents the continuation and
                              possible strengthening of the existing approach. Strengthening of the program would
                              focus upon building capacity to achieve higher levels of population coverage.
                      b.      A market based structure that builds capacity/incentives into the health system.
                              This option would involve embedding the screening process in the existing health
                              infrastructure. This would involve an increased role for general practitioners in
                              encouraging women to participate and expanded use of diagnostic mammography
                              services42.
                      c.      A mixed model – using a combination of public (a.) and private (b.) delivery mechanisms.
                              This option would be a hybrid and involve a core program approach supplemented by
                              private practice, either co-locating screening and diagnostic services or by creating a
                              capacity to monitor the actual level of screening based mammography occurring across
                              the nation.
              C.      If the answer to question A is ‘yes’ then it is also useful to define for the future the interface
                      with cancer services more broadly (see Chapter 9.2). This choice could include:
                      a.      A distinctive public health well women’s program
                      b.      An integrated approach to cancer service provision (options: breast or broader cancer
                              centres; with or without structured involvement by the private sector).




     41  The National Screening Framework endorse this model. See Australian Population Health Development Principal Committee Screening Sub
        Committee (Oct 2008) Population Based Screening Framework, p5
     42 We have not explored this option in detail as the benefits from implementing a model that represents an extreme departure from current
        arrangement is all but impossible to justify when weighing the costs and upheaval required.



84
         The answers to questions B and C are likely to be interdependent.
         D.      On the assumption that a program model – either a straightforward or mixed model
                 approach – is to be adopted there is a further question about the national governance
                 focus which precedes structural options. This relates to whether national governance
                 and management should be program-specific or directly linked to other publicly funded
                 population based cancer screening programs. Two options are identified for consideration.
                 They are:
                 a.       BreastScreen Australia specific – Are there benefits which derive from the maintenance
                          of a distinct and separate national governance and management arrangement for the
                          breast screening program?
                 b.  Cancer screening generally – Would there be benefits to be derived from some level of
                     integration of the national management of all cancer screening programs? 43
         The answers to the questions relate to the extent to which commonality and synergies arise across
         cancer screening programs or conversely the extent to which specialist knowledge and focus is
         important to delivering the outcomes.
         As this evaluation has involved only limited exploration of screening programs other than
         BreastScreen the authors can only reflect that there appears to be synergies and benefits but
         further analysis and greater cross-program knowledge would be required to make an informed
         decision.


10.4 NATIONAL GOVERNANCE ARRANGEMENTS – OPTIONS FOR CONSIDERATION
         The commentary in the earlier parts of this chapter provides a high level context for discussion
         regarding the options for future Program governance and management. This part relates
         specifically to governance and management of a program based approach although it is not
         predicated on any particular service or program model.
         The existing Program has many strengths which should be sustained and reinforced through
         the next phase of development. As outlined in earlier chapters, governance and management
         demands of the future will be substantial and may require a different balance and mix of inputs
         than currently prevail.
         For the purpose of informing discussions regarding possible future governance of breast cancer
         screening in Australia, four options are outlined. The options have been selected in order to
         characterise possible approaches not as a result of detailed program design.
         The analysis which follows assesses each of the four options on their merits and provides comment
         regarding their implications for:
         •       Being implemented as a stand alone or integrated with other cancer screening services. It is
                 important to note that through this evaluation, Nous has gained some knowledge regarding
                 other cancer screening programs. The knowledge is, however, limited and the comments we
                 make should be read in that context.
         •       The positioning of the Program on the program construct model outlined earlier.

43   A number of jurisdictions already co-manage breast and cancer screening, and to a lesser extent bowel cancer screening.



                         BreastScreen Australia Evaluation – Governance & Management Project January 2009                      85
               The four options are:
               1.      Devolved
               This option focuses on the fact that operational responsibility is already substantially held at State
               and Territory level and proposes that the functions which could be held centrally be devolved.
               This option would primarily have application if the Australian Government was prepared to
               vacate this policy domain. BreastScreen Australia is the most stand alone of the cancer screening
               programs with States and Territories administratively self contained with management and
               operational processes within one jurisdiction independent of others44, and therefore the most
               administratively and operationally easy to fully devolve.
               That said, it would be difficult to either justify or explain such a decision were the devolution only
               to apply to BreastScreen Australia. It would make most sense in programmatic and public terms if
               the decision were to be made as part of a broadly based health reform strategy. If this proposition
               is accepted associated difficulties in managing other cancer screening programs, particularly the
               National Bowel Cancer Screening Program which involves direct national administration, would
               have to be addressed.
               This action may also be seen to send a message about the importance of cancer screening as a
               national health issue.
               Were the devolved option to be accepted there are arguments that some level of national
               agreement remains important and impossible. The devolved model could include:
               •       National agreement to maintain the Program and to deliver on a high level set of outcomes
                       with a five yearly review cycle.
               •       Funding provisions which share costs on an agreed basis. The financing agreement would be
                       negotiated in the light of agreements about broader national health financing arrangements,
                       currently the subject of intergovernmental negotiations.
               As noted above, the strength of this option is embedding broader responsibilities for governance
               at the State and Territory level where the operational responsibilities reside. The issues raised by
               delays in national decision making such as policy consistency and digital mammography would
               cease as they would be dealt with at jurisdictional level.




     44    Note that some jurisdictions, such as the Northern Territory, do rely on other jurisdictions for some operational and advisory support but that
          these relationships do not rely on national mechanisms for their existence and are largely contractual.



86
The offsetting weaknesses are:
•     The potential loss of the National Accreditation Standards and the assessment process which
      is a highly regarded component of the national governance infrastructure. This risk could be
      mitigated if this option is pursued by:
      –      Including the NAS in the high level intergovernmental agreement; or
      –      States and territories reaching a multilateral agreement to resource the NAS and find a
             national entity to auspice it.
•     The erosion of national consistency. The intergovernmental agreement proposed above
      would protect the core of the Program; however, current experience demonstrates that there
      are always issues at the margins of the Program on which differing decisions can be taken.
      In some cases the impact of these decisions would be quarantined in individual decisions but
      some would impact into the core Program and may undermine the robustness of the service.
The functions identified as important to a national program would be non-national with the
exception of those identified in italics in the following chart.
Function                    National              Jurisdictional                               Informal
Goals and objectives        Could be agreed at    Either independent decision or detailed
                            high level            elaboration of high level agreement
Policy formulation and                            Agree core policy positions for              Sharing of the impact of
maintenance                                       implementation                               differing State/Territory
                                                                                               policy positions
Strategic planning                                Continued planning on a jurisdictional
                                                  basis
Community education                               Mount jurisdictional and local strategy as   Share strategy and
and information                                   demand and resources allow                   resource materials
Information and                                                                                Maintain Program
knowledge sharing                                                                              Managers meeting as
                                                                                               mechanism
Workforce planning                                Undertake localised workforce and
                                                  succession planning and seek to raise
                                                  national issues through other AHMAC
                                                  structures
Data and Information                              Develop jurisdictional systems as required
management
Quality and clinical risk   Maintain systems      Develop jurisdictional approach or agree a
management                  required for NAS by   national system
                            agreement between
                            jurisdictions
Emerging issues                                   Jurisdictions need to ensure active          Maintain Program
                                                  mechanisms in place                          Managers meeting as
                                                                                               mechanism
Research                                          Capacity to identify research needs
                                                  and seek to have addressed through
                                                  independent research mechanism




             BreastScreen Australia Evaluation – Governance & Management Project January 2009                              87
     There would be important financial implications arising from this option. This would relate to
     mechanisms for maintenance of effort given the shared funding arrangements currently in place.
     It would also raise questions regarding State and Territory capacity to meet ongoing costs in the
     absence of a transfer payment of some kind.
     The devolved option would:
     •    Lead to less equitable outcomes as policy diverges between jurisdictions over time
     •    Risk application of best practice and Program improvement as the NAS may not be sustained
          and existing limited mechanisms for cross jurisdictional sharing are reduced
     •    Focus all accountability in the jurisdiction
     •    Lead to duplication of costs and effort for a less certain health outcome.
     The Nous judgement regarding the national program construct is reflected in the following figure.
     Figure 14        Program construct for the Devolved Option


                                                         Central
                                                         control




                                                                          national
                                       discontinuity
                                                                         focus




                                                                                        Policy and
          Policy
                                                                                         practice
          exibility
                                                                                       consistency
                                                                   now




                                                                          shared
                                                                         framework
                           diversity    devolved




                                                       Decentralised
                                                         control




88
2.    Collaborative
This option broadly represents the maintenance of the status quo. It involves collaborative
governance arrangements based on the pre-existing structures. Informed by the analysis made in
this evaluation refinements to existing arrangements could be considered while still preserving the
current approach.
This option gains traction because it adds no new governance overheads to the Program which
continues to deliver relatively well in an operational sense. Affirmation of this option would be
predicated on an acceptance that, over time, an increasing level of control and policy authority
would move to States and territories.
A number of issues would be clarified were this option to be affirmed as the chosen approach
after cross jurisdictional discussion. There has been something of a hiatus in decision making
partly because the evaluation of which this report is part was being planned and conducted. There
has also been something of a hiatus as some stakeholders expect that more direction, clarity and
leadership might emerge from current arrangements than is possible.
Confirmation of the continuity of this option will in part liberate or require States and territories
to make local level decisions in the knowledge that national decisions in a number of areas a
re unlikely.
Notwithstanding the devolution of some decisions which would result there is still a risk that the
current machinery even if somewhat refined would generate ongoing uncertainties and delays.
There is also a risk that the delays and devolutions could further erode policy consistency and
coherent reforms in cases or issues similar to digital mammography.
This option assumes the continued operation of:
•     The National Quality Management Committee and the infrastructure which supports it and
      implements the NAS subject to any changes which may be agreed after completion of the
      overall evaluation.
•     The Screening Sub Committee continuing to be the primary point of policy formulation and
      leadership. The reporting arrangements through to AHMAC would continue. It is anticipated
      that the Terms of Reference for the Screening Subcommittee would be clarified in the
      sense of articulating the expectations of AHMAC and the Australian Population Health
      Development Principal Committee but would essentially be retained in their current wording.
      The Screening Subcommittee may identify a number of procedural reforms or working group
      structures which would aid decision making.
•     The DoHA Secretariat function of the SSC continuing in the same manner as
      currently applies.




            BreastScreen Australia Evaluation – Governance & Management Project January 2009            89
     This option imposes a burden on key stakeholders in a number of ways. Critical success factors for
     this option include:
     •     Proactive collaboration and preparatory work by Screening Subcommittee members who
           would have to continue to lead and deliver much of the policy formulation work required,
           developing specialised working groups as required
     •     Cross jurisdictional work to informally capture learnings and reform opportunities not able to
           be facilitated through the formal structure.
     With regard to the overall program functions identified in Chapter 7.2, the approach which
     emerges in this option would focus upon:
     Function                    National                   Jurisdictional                               Informal
     Goals and objectives        Affirm ongoing goals       Interpret and apply
                                 Agree small set of core Implement core set and decide additional        Sharing of the impact of
     Policy formulation and      policy positions for    policy                                          differing State/Territory
     maintenance                 national implementation                                                 policy positions
                                                            Continued planning on a jurisdictional
     Strategic planning                                     basis
     Community education         Agree high level strategy Mount local strategy as demand and            Share strategy and
     and information             if resources justify      resources allow                               resource materials
                                                                                                         Maintain Program
     Information and                                                                                     Managers meeting as
     knowledge sharing                                                                                   mechanism
                                 Identify key issues        Undertake localised workforce and
                                 and advise AHMAC           succession planning
                                 and other structures
                                 responsible for health
     Workforce planning          workforce development
     Data and Information        Maintain systems           Develop jurisdictional systems as required
     management                  required for NAS
     Quality and clinical risk   Maintain NAS and           Maintain cross-disciplinary and quality
     management                  NQMC                       groups
                                 Coincidental capacity to   Jurisdictions need to ensure active
     Emerging issues             respond                    mechanisms in place
                                 Capacity to identify       Capacity to identify research needs and
                                 research needs and         refer proposals to the national level
                                 limited scope for
     Research                    commissioning




90
This option as the status quo, albeit one in which performance can drift because of the limits of
national leadership would:
•    Slightly reduce equity over time
•    Embed policy inconsistency
•    Maintain but not improve existing best practice and Program improvement arrangements
•    Preserve existing accountability arrangements
This option can continue to be applied to all cancer screening programs as currently applies
through the Screening Subcommittee.
The Nous judgement regarding the national program construct is reflected in the following figure.
Figure 15        Program construct for the Collaborative Option


                                                      Central
                                                      control




                                                                       national
                               discontinuity
                                                                      focus




                                                                                   Policy and
     Policy
                                                                                    practice
     exibility
                                                                                  consistency
                                                                now


                                      collaborative

                               diversity                               shared
                                                                      framework




                                                 Decentralised
                                                   control




             BreastScreen Australia Evaluation – Governance & Management Project January 2009       91
     3.   Enhanced
     This option more actively addresses the weaknesses identified in the existing arrangements than
     would be the case in the collaborative option. It involves:
     1.   The Screening Subcommittee continuing to be the primary point of policy formulation and
          leadership. The reporting arrangements through to AHMAC would continue. It is also
          proposed that:
          •     The Terms of Reference would be refined to make clear that while the committee is
                advisory it has a proactive mandate for Program leadership including active attention to
                implementation issues. The goal of the enhanced option is to more effectively achieve
                the activist aspirations for national leadership and Program development which can be
                read into the existing terms of reference but which have not been fully realised.
          •     The membership would be supplemented to include senior clinical adviser with observer
                status (that is, with rights to contribute to deliberations but not voting rights). This
                is broadly consistent with the existing operating guidelines which envisage these
                contributions only on a time to time rather than ongoing adviser basis. The proposal to
                add an ongoing clinical adviser would provide substantive input and send a symbolic
                and practical message to stakeholders. It is anticipated that the next stage of the
                Program’s development will involve a range of clinically sensitive policy and strategy
                choices.
          •     At least one ongoing working group would be established to undertake detailed
                work on policy and strategic priority development in order to support the Screening
                Subcommittee’s high level deliberations. It is beyond the scope of this evaluation to
                propose more specific working group arrangements. This proposal is made in order to
                reflect the limits of the capacity of the SSC given its broader screening mandate and
                workload and of the need to actively engage informed stakeholders in providing detailed
                advice to the Committee.
     2.   The continued operation of the National Quality Management Committee and the
          infrastructure which supports it and implements the NAS, subject to any changes which may
          be agreed after completion of the overall evaluation. It is anticipated that the NQMC and the
          NAS processes may be refined after completion of the evaluation but that the core functions
          and processes will be retained and possibly strengthen.
     3.   The Secretariat’s capacity would be increased to support the expanded work involved.
          The more proactive approach anticipated in the enhanced option will require increased
          administrative and analytical capacity if it is to achieve the goal. It is beyond the scope of
          this evaluation to comment on the size of the expansion. This should be considered in the
          light of a more detailed business case prepared after the results of the evaluation have been
          considered and of decisions about whether administration is to be distinctively focussed on
          breast cancer screening or more generally applied to cancer screening programs.




92
     Feedback during this project included comment on the risk that DoHA as the host could
     skew the work and outputs to meet Australian Government policy goals. It is important
     to note that line departments are obligated to meet their Minister’s requirements and this
     can build a structural conflict of interest where a national secretariat function involves
     management of the views and priorities of all jurisdictional partners. Options for managing
     this potential risk include:
     •     Developing an agreed Memorandum of Understanding at the APHDPC level about
           the processes and transactional requirements of the Secretariat dealing with State and
           Territory proposed issues or matters of contention between the Australian Government
           and some or all States and territories
     •     Providing some or all of these secretariat functions through a neutral entity.
The strengths of the Enhanced option are that it maintains strong linkage into the AHMAC
structures and processes and thus retains both linkage with and accountability to Ministerial
decision making processes. It also enhances the capacity of the existing machinery to make
strategic decisions and provide appropriate leadership to the Program. These gains are likely to be
made at modest cost by utilising existing platforms and structures.
The key concern would be whether the enhancements are sufficient to deliver worthwhile
improvements in national governance and management. The decision making and implementation
capacity remains embedded in committee structures and thus the time and capacity of committee
members. The Screening Subcommittee has a substantial and diverse brief across cancer and
other forms of screening. Committee members as senior representatives of their jurisdictions also
have heavy workloads which do not, necessarily, provide them with easy access to or detailed
knowledge of breast screening issues.
To the extent that an investment is made in secretariat capacity this mitigates the issues of having
a committee-led national governance model. This would raise funding issues as to whether the
funds come from the Program base or from AHMAC funds.
This option ensures that national policy and strategy regarding breast screening is actively
co-ordinated with other cancer screening programs through the agency of the Screening
Subcommittee. It is also possible that some of the activities in the functions outlined below can
be focussed across cancer screening programs. There is also greater opportunity to link with the
treatment pathway through clinicians and closer relationships with professional associations.




           BreastScreen Australia Evaluation – Governance & Management Project January 2009            93
     With regard to the overall program functions identified in Chapter 7.2, the approach which
     emerges in this option would focus upon:
     Function                 National                                 Jurisdictional                 Informal
     Goals and objectives     Affirm ongoing goals and objectives      Implement
     Policy formulation and   Agree core policy positions for national Implement core set, decide Sharing of the impact of
     maintenance              implementation                           additional local policy    differing State/Territory
                                                                       which is complementary     policy positions
                              Ongoing monitoring of performance
                              and assessment of the need for change Advise SSC of the needs for
                                                                       policy change
     Strategic planning       Prepare a high level 3 year plan         Continued planning on a        Share plans and strategies
                              which communicates the strategy for      jurisdictional basis
                              Program management
     Community education      Agree and support the development of Mount local strategy               Share strategy and
     and information          a high level strategy if resources justify as demand and                resource materials
                              this investment                            resources allow
     Information and          Support targeted mechanisms for cross Proactively share through         Maintain Program
     knowledge sharing        jurisdictional sharing on key issues  network arrangements              Managers meeting
                                                                    established by agreement          as mechanism
                                                                    between jurisdictions
     Workforce planning       Identify key issues and advise AHMAC     Undertake localised
                              and other structures responsible for     workforce and succession
                              health workforce development             planning.
     Data and Information     Maintain systems required for AIHW       Maintain and develop
     management               Monitoring Reports and NAS               jurisdictional systems as
                                                                       required
     Quality and clinical     Maintain NAS and NQMC                    Maintain cross-disciplinary
     risk management                                                   and quality groups
     Emerging issues          Proactive monitoring is possible given   Jurisdictions can manage
                              adequate Secretariat support             emerging issues at their
                                                                       own level and have
                                                                       representative mechanism
                                                                       for raising them at national
                                                                       level
     Research                 The national arrangements could
                              be utilised to identify and support a
                              targeted research program based upon
                              the needs of the Program and the data
                              it generates.




94
This option would:
     •           Make marginal changes in the equity of the Program
     •           Provide increased capacity for ongoing Program improvement and dissemination of best
                 practice evidence
     •           Reinforce existing accountability arrangements.
The Nous judgement regarding the national program construct is reflected in the following figure.
Figure 16         Program construct for the Enhanced Option


                                                   Central
                                                   control




                                                                     national
                              discontinuity
                                                                    focus




                                                                            Enhanced
                                                                                        Policy and
     Policy
                                                                                         practice
     exibility
                                                                                       consistency
                                                              now




                                                                     shared
                              diversity
                                                                    framework




                                                 Decentralised
                                                   control



4.   Integrated
The integrated option requires the establishment of a new entity to lead national governance of
breast cancer screening and conceivably all cancer screening programs. The justification for this
option would be based upon a view that the committee with secretariat options (collaborative
or enhanced – as outlined above) are inadequate or impose too large a burden on committee
members with other roles and responsibilities in both AHMAC and jurisdictional work.
The discussion which follows presumes that the existing arrangements where States and territories
continue to have operational responsibility. This is the core strength of existing arrangements and
the goal would be to more adequately support their operations. The new national mechanism
would, however, need to be both developed through a process of active engagement with States
and territories to align the proposed functions and activities.


             BreastScreen Australia Evaluation – Governance & Management Project January 2009           95
     This option involves the greatest change of all the options. On the issue of governance the goal
     would be to ensure that the entity:
          •     Is accountable to AHMAC in a transparent manner
          •     Has governance mechanisms which enable jurisdictional input and attract support from
                jurisdictions. The entity needs to be seen as delivering for all parties in breast screening
                not representing one party (be that party Commonwealth or the collective interests of
                jurisdictions).
     It would also be important that mechanisms be developed to ensure that these goals are
     achieved on a continuing basis given the risk that the governance body could ‘drift’ away from
     accountability and engagement with jurisdictions and become focussed on its own agenda.
     Options for the proposed entity include:
     a)   Stand alone. This is likely to be the highest cost option within the Integrated Option as it
          involves creation of a new body and meeting all of the overheads, both establishment and
          ongoing, that that involves. As a ‘purpose built’ entity, however, it could be expected to be a
          very robust and strong leader of breast screening or cancer screening.
          As noted above the entity would require a board acceptable to and accountable to all
          jurisdictions. The form of such an entity would require detailed consideration.
     b)   Collocate with another government entity. There are two distinctive possibilities
          within this option. They are:
          •     Cancer Australia. Cancer Australia is a statutory agency responsible to the Minister for
                Health and Ageing. It is responsible for:
                –     providing national leadership in cancer control
                –     guiding improvements to cancer prevention, treatment and care
                –     coordinating and liaise between the wide range of organisations, groups and
                      service providers with an interest in cancer care and support
                –     making recommendations to the Australian Government about cancer policy and
                      priorities
                –     overseeing a dedicated budget for research into cancer, help implement Australian
                      Government policies and programs in cancer control
                –     undertaking other tasks as directed by the Minister for Health and Ageing.
                Cancer Australia provides a potential base for leadership of breast or cancer screening.
                The issues which would require consideration include whether:
                      •     As a body directly accountable to the Australian Minister for Health and
                            Ageing it can attract the support of other jurisdictions
                      •     The leadership of such a large program(s) would disrupt its delivery of the
                            functions and priority activities with which it is currently involved
                      •     The linkage to a ‘cancer’ focussed service unhelpfully risk the well women
                            framework on which the Program has based.




96
      •     A public health entity. Nous understands that consideration is being given to
            the establishment of a new body which could lead, coordinate and provide national
            stewardship for a range of public health issues. This proposal emerges, in part, because
            of the work of the National Preventative Health Taskforce. The details of the role,
            accountability and resources for such a body are still under consideration.
            If such a body was a legitimate options to provide a cost effective governance capacity
            for BreastScreen Australia and other cancer screening programs, a key criterion
            indicating its suitability would relate to whether the governance mechanism provides
            sufficient jurisdictional input to align the operational and policy components of
            screening programs.
            It would also need to be established that adding national leadership for one or more
            programs with large operational roles would not represent a diversion for the entity’s
            other functions and priorities. While the national role in cancer screening is not itself
            operational, there are substantial and practical issues which must be addressed and
            require ongoing engagement.
c)    Contracted to a national non–government body. The most obvious, but not the only
      example of such body, would be the National Breast and Ovarian Cancer Centre (NBOCC).
      NBOCC plays a vital role in the translation of worldwide cancer research into meaningful and
      evidence-based information to guide the work of Australian health professionals, improve
      health service delivery, inform people with breast or ovarian cancer about all aspects of their
      diagnosis and treatment, and raise community awareness about the diseases.
      In some ways the national leadership role links well with NBOCC but it is a significant
      operational function which does not. The relationship of this or any other non-government
      body to the Australian Government and States and territories is also problematic.
If an entity cannot be found which meets the criteria above it is unlikely that this option is worth
pursuing further. Nous is not in a position to comment further on this as it is beyond the scope of
our engagement in this evaluation.
On the issue of cost there are three high level factors which would influence a judgement
regarding the potential benefits to be derived from the Integrated option. They are:
a)    The kind of organisational capacity sought – what the functional mandate is.
b)    The extent of the brief – how extensive the brief is, including a judgement regarding the
      inclusion or exclusion of other cancer screening programs in the option.
c)    The depth of the brief – how much activity is required within each of the programs included to
      provide the leadership required.




           BreastScreen Australia Evaluation – Governance & Management Project January 2009             97
     In broad terms the cost of this option is likely to correlate to the depth and extent of engagement
     and with the degree of internal synergies in terms of the functional mandate. An assessment of
     benefits would be contingent upon an assessment of whether:
     •     The entity and the proposed level of activity will improve overall performance compared to
           other options.
     •     The entity has the potential to deliver efficiency gains in Program operation.
     •     There are cross-program synergies which generate both effectiveness and efficiency gains
           not able to be realised without the alignment and effort implied by this option.
     It is also beyond the scope of this evaluation to develop the business case for this option. It does
     appear that if there is support for this option a rigorous business case would be required in order
     to have confidence that the additional investment required would provide both a long term health
     gain and a financial benefit.
     For indicative purposes the following chart provides commentary on the possible functions of
     the integrated entity. Note that they are largely identical to the Enhanced option reflecting that
     considerations are about the power of the governance and management models to support
     outcomes, rather than differences in functionality.
     Function                    National                                   Jurisdictional                  Informal
     Goals and objectives        Affirm goals and objectives                Implement
     Policy formulation and      Agree core policy positions for national   Implement core set, decide      Sharing of the impact
     maintenance                 implementation                             additional local policy which   of differing State/
                                                                            is complementary                Territory policy
                                 Ongoing monitoring of performance and
                                                                                                            positions
                                 assessment of the need for change     Advise SSC of the needs for
                                                                       policy change
     Strategic planning          Prepare a high level 3 year plan which     Continued planning on a         Share plans and
                                 communicates the strategy for Program      jurisdictional basis            strategies
                                 management
     Community education         Agree and support the development of a Mount local strategy as             Share strategy and
     and information             high level strategy if resources justify this demand and resources allow   resource materials
                                 investment
     Information and             Support targeted mechanisms for cross      Proactively share through       Maintain Program
     knowledge sharing           jurisdictional sharing on key issues       network arrangements            Managers meeting as
                                                                            established by agreement        mechanism
                                                                            between jurisdictions
     Workforce planning          Identify key issues and advise AHMAC       Undertake localised
                                 and other structures responsible for       workforce and succession
                                 health workforce development               planning.
     Data and Information        Maintain systems required for AIHW         Maintain and develop
     management                  Monitoring Reports and NAS                 jurisdictional systems as
                                                                            required
     Quality and clinical risk   Maintain NAS and NQMC                      Maintain cross-disciplinary
     management                                                             and quality groups
     Emerging issues             Proactive scanning of the environment
                                 and inclusion in planning processes
     Research                    Could commission research consistent
                                 with the Program’s goals and support
                                 broader research based on Program data

98
This option would:
•    Have potential to improve the equity of service delivery through more consistent
     policy determination
•    Strengthen capacity for Program improvement and dissemination of best practice
     as a result of the increased national capacity
•    Enhance accountability arrangements.
The Nous judgement regarding the national program construct is reflected in the following figure.
Figure 17        Program construct for the Integrated Option


                                                    Central
                                                    control




                                                                      national
                                  discontinuity
                                                                     focus



                                                                          Integrated

                                                                                        Policy and
     Policy
                                                                                         practice
     exibility
                                                                                       consistency
                                                               now




                                                                      shared
                                  diversity
                                                                     framework




                                                  Decentralised
                                                    control




             BreastScreen Australia Evaluation – Governance & Management Project January 2009        99
      10.5 COMMENTARY
          The options outlined above are relevant archetypes. They are intended to promote discussion
          about the extent and nature of national governance and management which will deliver the
          most favourable breast screening outcomes and be consistent with all Governments’ intentions
          regarding administration of health services. Table 8 presents an overview of the different options
          key features.
          There are numerous issues and potential trade offs required in the options. As noted in the
          exploration above, the Devolved option is substantially dependent upon an Australian Government
          decision to step back from active involvement in this health domain. The Collaborative option
          can be sustained provided that jurisdictions adjust expectations regarding what can be achieved
          through national infrastructure and all take action to address current and future issues more
          autonomously.
          The Enhanced option and the Integrated option both represent approaches to improving the
          effectiveness of national governance. The Integrated option possibly offers the greatest chance
          of significant gains, but further work is required outside this Report to understand any cost
          implications. The costs are likely to reduce if synergies can be realised across cancer screening
          programs and/or through scale efficiencies by linkage with another entity. The lack of an obvious
          entity also represents a challenge.
          The effectiveness of the Enhanced option is dependent upon a judgement about the extent
          to which existing structures can be enhanced and more adequately supported by a somewhat
          expanded secretariat and whether further funding is required for its success.




100
Table 9        Spectrum of options – approach to BreastScreen Australia governance and management

Option          Devolved                    Collaborative             Enhanced                      Integrated
Description     The national approach       This approach             This approach would           This approach would involve
                would involve all           would involve the         involve enhancing the         the establishment of a new
                jurisdictions agreeing      maintenance of current    capacity of the existing      entity, authorised by all
                to maintain cancer          arrangements based on     structure to provide          Governments to provide
                screening programs and      the AHMAC committee       leadership and somewhat       ongoing national leadership.
                to share (on some basis)    structure as is.          more timely policy
                                                                                                    It does not presume transfer
                the cost.                                             decisions and support for
                                                                                                    of operational responsibility
                                                                      operational requirements.
                All other functions would                                                           from States and territories but
                be devolved to States                                                               does require independent and
                and Territories.                                                                    sustained national leadership
                                                                                                    within BreastScreen Australia
                                                                                                    alone or across cancer
                                                                                                    screening programs.
Strengths       Enables States and          Avoids the development    Provides a way to address     A competent entity would
                territories to get on       of additional cost        key issues arising from       drive or facilitate national
                with their operational      overheads and if it       existing deficiencies         agreements on key issues and
                responsibilities and        was an agreed option      without requiring a           proactively support ongoing
                to adapt the Program        would enable States       step change in cost and       Program reform. Separation
                as required by local        and territories to make   governance structures.        from AHMAC and inner
                requirements.               ongoing adjustments to                                  budget sector agencies would
                                            their operations.                                       provide greater flexibility.
Weaknesses      Erodes national             Likely to provide         May not provide the level     The costs would need to
                consistency and             ongoing uncertainties     of national leadership,       be investigated further and
                would jeopardise            and delays given the      policy reform and             weighed against anticipated
                quality through the         continuation of an        operational support           Program performance. The
                loss of the national        expectation of national   required to maintain a        greater flexibility arising from
                accreditation system.       consistency.              strong national Program.      separation may also diminish
                                                                                                    accountability.
Commentary The risk of quality              Would require a strong    While it will provide         Cost-benefit analysis
           erosion and/or                   commitment to local       a stronger national           should consider various
           diversification of               leadership across the     direction, this option will   models including if the
           Program delivery is high         network and enhanced      require both informal and     entity had carriage of
           under this option.               informal/formal           formal cooperation and        multiple screening programs.
                                            cooperation to be         engagement with the
                                            more effective.           service delivery network
                                                                      to be effective.




              BreastScreen Australia Evaluation – Governance & Management Project January 2009                                         101
      11. CONCLUSION
        Australia benefits from an effective and robust breast screening program. The nation has crafted
        an effective service model and evolved broadly effective ways to administer the BreastScreen
        Australia Program from a national to local level. This is an important achievement.
        One vignette tells a powerful story. The story, told to one of the evaluators during consultations
        with consumers, involved three generations of this woman’s family.
              The woman’s mother attended an information session around the time of the
              Program’s inception and subsequently attended for screening. Unfortunately
              too late for her and her death from breast cancer followed in the near future.
              The person telling the story became committed to attendance when possible
              and was found to have a malignancy. Surgery has given her a good survival
              outcome. Now one of her daughters has commenced screening and a very
              small, hard to find, lump was identified and early treatment gives her a very
              good prognosis.
        This intergenerational story not only tells of health outcomes but also of Program improvement.
        There are however problems which need to be addressed. Given the focus of this evaluation,
        the primary issues identified are those relating to national governance and management. While
        the overall mechanisms are robust, there are issues at jurisdictional level which require careful
        attention. These issues go to ensuring that governance and management is focussed on client
        outcomes, quality, effectiveness and efficiency.
        A key strength of the national arrangements resides in the National Accreditation Standards and
        peer assessment process which is part of those standards. The National Quality Management
        Committee is a critical component of the Program infrastructure which works very well.
        An important theme throughout this report has been the failure to achieve the stated goal of 70%
        participation and the associated objective of rescreening at two-yearly intervals. The critique in
        this report goes as much to the failure to raise this issue with clarity for Government consideration
        rather than the failure in its own right. The failure is a key issue for the overall evaluation and for
        future design.
        Similarly the delays and discontinuity in reaching agreement on the introduction of digital
        mammography is evidence of governance weakness. The future Program governance mechanisms
        need to be better equipped to deal with the next decade equivalents of these issues.




102
On the basis of the insights from this evaluation consideration should be given to:
a.   Clarifying the mandate for national leadership
b.   Strengthening the capacity of whatever vehicle or mechanism is chosen to provide national
     leadership
c.   Developing cross jurisdictional performance reporting mechanisms which go to issues not
     covered by the NAS to improve the focus on efficiency and cross jurisdictional sharing
d.   Reviewing jurisdictional governance and management to ensure optimal capacity to deliver the
     agreed service model, achieve policy consistency and operational efficiency.
These proposed actions could be acted upon in whichever program approach and governance
model is agreed.
The lens of governance and management provides important but limited perspectives on the
performance of the BreastScreen Australia Program. The weaknesses in national governance
identified in this report are important and deserve analysis and scrutiny. The obligation of
evaluators is to hold a mirror to their subject to aid informed discussion and decision making.
The limited lens of evaluation of one part of one program may miss completely or misjudge the
importance of particular issues.
The benefits of change and improvement need to be considered in the light of Program change
opportunities emerging from other aspects of this evaluation and from knowledge about the
pressures and issues in other parts of the national health administration systems. Opportunities
need to be weighed not only within the Program but across programs.
That said, it is our judgement that no change risks diminishing returns.




           BreastScreen Australia Evaluation – Governance & Management Project January 2009         103
      APPENDIX A
      MAPPING THE PROGRAM LOGIC
      Nous has used program logic mapping as a tool to dissect the elements of the BSA Program
      and develop a picture of how they interrelate. The map has allowed us to draw a number of
      conclusions about the logic of the Program design (Figure 18). We expect that this model will
      not be seen as definitive or comprehensive in the context of the greater evaluation and therefore
      should be considered as a tool for discussion.
      Assumptions in building this model:
      •    The Program logic is the same now as in the initial set up phase (post pilot)
      •    It is a well women’s program; not linked to hospitals/treatment pathway
      •    Policy should be consistent across all locations
      •    Participation for eligible women is without co-payment.




104
                                                                                   Figure 18      BreastScreen Australia Program logic map


                                                                                               A                              B                              C                               D                         E                  Ultimate
                                                                                      Inputs / resources                  Activities                      Outputs               Short - Mid-term outcomes     Long-term outcomes        Social impact


                                                                                                                          Implement                 Possitive particiapnt           Appropriately identi ed                               Decrease in
                                                                                                                           Screening                    experience                     women move into               Decrease              mortality
                                                                                                                            Pathway                                                   treatment pathway            mortality from
                                                                                                                                                                                                                   breast cancer
                                                                                                                                                       Increased early
                                                                                                                                                                                                                                          Increase in
                                                                                                                                                     detection of breast
                                                                                                                                                                                     Increased health and                               socialeconomic
                                                                                                                                                     cancer, particularly
                                                                                                                        Maintain policy                                               wellbeing of women                                   wellbeing
                                                                                                                                                     small and invasive
                                                                                                                                                           cancers                    in program and their
                                                                                                                                                                                        support network          Increased health
                                                                                                                                                                                                                and wellbeing of all      Increase in
                                                                                                                                                    Participation level of                                          women their          quality of life
                                                                                      Funding                          Maintain quality
                                                                                                                                                   70% to be achieved in              Increase in health          support network
                                                                                                                         assurance
                                                                                                                                                     5 years (biannual;                cost (need data)
                                                                                      People
                                                                                                                                                     equitable across
                                                                                                                                                   population sub groups)
                                                                                      Physical
                                                                                      infrastructure                      Undertake                                                  Increased education
                                                                                                                         performance                                                  and awereness, of          Decrease in health
                                                                                      Machines                                                      Capacity to manage                breast cancer and           cost (need data)
                                                                                                                        monitoring and              and drive change &
                                                                                                                          evaluation                                                   cancer generally
                                                                                      Research and                                                      innovation
                                                                                      evidence                                                                                                                                         Contribute to the
                                                                                                                                                                                                                                          health and
                                                                                                                                                   Stable, competent and               Improved clinical
                                                                                                                                                                                                                   More effective        wellbeing of
                                                                                                                            Engage                  connected workforce              knowledge & practice
                                                                                                                                                                                                                  health planning      Australian women
                                                                                                                         stakeholders
                                                                                                                                                    High quality service,            Willingness of target
                                                                                                                                                       measured by                  group women to return
                                                                                                                                                                                                                 Improved clinical
                                                                                                                                                   technical, operational            to the Program after
                                                                                                                                                                                                                    outcome
                                                                                                                          Program                     and public value                  rst screen and/or
                                                                                                                         management                      standards                    move ino treatment


                                                                                    In uencing factors        Attitudes of population sub-groups                             Workforce shortage




BreastScreen Australia Evaluation – Governance & Management Project January 2009
105
      The Program logic map indicates:
      1.   As a program construct, the design is internally coherent
      2.   Program assumptions and consequent design are now legitimately up for reassessment as
           part of this evaluation
      3.   There are a number of questions that are raised by this logic map that are outside the scope
           of the Governance and Management project.
      Each one of these assertions is explored below.
      1.   As a program construct, the design is internally coherent
           A design is judged to be internally coherent where the component elements are rationally
           interconnected. This can be seen in a diagrammatic sense, all levels of design are
           contributing to the next, from left to right (Figure 18).
      2.   Program assumptions and consequent design are now legitimately up for
           reassessment as part of this evaluation
           •     The Program logic is the same now as in the initial set up phase (post pilot)
           Whether a revised Program logic will better deliver on outcomes is a key question to be
           answered in the overall evaluation.
           •     It is a well women’s program; not linked to hospitals/treatment pathway
           Strengthening the interface with the treatment pathway may lead to better outcomes for
           women as they are directed to the most appropriate health professionals more quickly. In
           addition to clinical benefits, being linked to hospitals appears to provide more opportunity to
           leverage operational efficiencies in procurement and facilities services.
           •     Policy should be consistent across all locations
           Policy has not been consistent across all locations. Where there are no definitive national
           policies, State/Territory coordination units and sometimes individual services have developed
           their own policy. Examples can be found in whether initial screening and rescreening
           invitations are extended to women 40 to 49 years and 70+, criteria for annual screening
           including women with a family history of breast cancer and the eligibility of women with
           symptoms. Although this undeniably causes negative responses from some women who
           move across policy jurisdictions, whether consistent application of policy across all locations
           will lead to better outcomes is a hypothesis to be tested as part of this evaluation.




106
                 •        Participation for eligible women is without co-payment
                 This assumption should be considered as part of the larger discussion about whether current
                 and future funding levels will be sufficient to achieve Program outcomes. In addition it
                 should be noted that there is a subset of target-age women who choose to access screening
                 services in the private sector, in part due to a perception that private providers provide a
                 higher quality service, including ultrasounds and a same day results. Some women were also
                 confused about whether they had attended BreastScreen Australia or a private service.45
         3.      There are a number of questions that are raised by this logic map that are
                 outside the scope of the Governance and Management project
                 Some important questions flow from this logic map that other evaluation projects will
                 contribute to, including:
                 •        Does the commitment to quality translate into better clinical outcomes?
                 •        To what degree have participation targets influenced the achievement of breast cancer
                          detection outcomes and mortality reduction?
                 •        Have breast screening health costs increased and are overall health costs likely to
                          decrease based on current assumptions?




45   Based on Nous interviews and BreastScreen Australia Qualitative participation report (pp 118 - 120)



                         BreastScreen Australia Evaluation – Governance & Management Project January 2009         107
               APPENDIX B
               INTERNATIONAL COMPARISON
               To provide a broader perspective on the Australian Program, breast cancer screening
               programs were examined in five other countries – Canada, England, New Zealand, Sweden
               and The Netherlands. Four broad issues were examined: governance and management; the
               participation objective; structures and processes; and funding. The following discussion draws
               on interviews with country experts (detailed at the end of Appendix D)46 and published material
               on the country programs.47


               CANADA
               Governance and management
               In Canada, the delivery of all health services, including breast screen services, is the responsibility
               of the individual Provinces and territories. As such, the governance and management of breast
               screen programs is determined by each Province/Territory government.
               At the federal level, the Public Health Agency (PHA) of Canada provides a mechanism for the
               Provinces and territories to communicate with each other. Lacking the ability to mandate changes,
               the PHA necessarily places a high emphasis on building consensus. For example, in the lead up to
               the establishment of organised programs in the early 1990s, the predecessor to the PHA played
               an important role in establishing the collaborative Canadian Breast Cancer Screening Initiative
               (CBCSI). The initiative set priorities and directions for research; prevention; screening; surveillance
               and monitoring; treatment; community capacity; and public and professional education.48 In more
               recent times, the PHA has played a role in facilitating discussions and brokering consensus around
               issues of ongoing enhancement of screening programs, monitoring and evaluation, and also
               research regarding into adapting to new technologies.
               The key collaborative body at the national level is the National Committee for the CBCSI. The
               Committee is drawn from the federal and provincial and territorial governments, health care
               professionals, breast cancer survivors and support groups. The Committee’s broad responsibility
               covers the review, discussion and action on issues related to breast screening. Its activities focus
               on: public education, health promotion, and program awareness; and program development,
               evaluation, and information sharing. A number of sub-committees report to the National
               Committee, covering issues such as quality and data reporting.




      46   The following people were consulted: Canada – Dr Kay Onysko, Manager, Screening and Early Detection, Chronic Disease Management Division,
           Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada (17 October) Netherlands – Dr Jacques Fracheboud,
           Department of Public Health, Erasmus MC, University Medical Center Rotterdam (14 October) New Zealand – Dr Madeleine Wall, Clinical
           Leader, National Screening Unit, BreastScreen Aotearoa (13 October) Sweden – Associated Professor Gunilla Svane, Mammography Department,
           Department of Surgery, Karolinska University Hospital (16 October) United Kingdom – Ms Julietta Patnick CBE, Director, NHS Cancer Screening
           Programmes (forthcoming on 31 October).
      47   Only very rudimentary information exists in English for the Dutch and Swedish programs.
      48   See: http://www.hc-sc.gc.ca/hl-vs/iyh-vsv/diseases-maladies/breast-sein-eng.php



108
         Participation objective49
         At the national level the participation target is 70 per cent for women aged 50 to 69. Meeting
         the target has proved challenging. The most recent detailed examination of performance across
         Canada indicated that in 2003 and 2004 just 36.5 per cent of the target population received a
         screening mammogram through an organised program. Population health surveys suggest an
         overall screening rate close to 62 per cent for the target group, taking into account screening
         outside the organised program.50
         Outside the core 50-69 age group, approaches vary across Provinces and territories. Nine of the
         12 Provinces/territories screen women in the 40-49 age group and one of these screens women
         aged 35-39. All Provinces and territories provide opportunities for women aged over 70 years to
         receive screening, with one allowing women above 80 years of age to be screened. However, a
         number of Provinces and territories do not provide such women with the same formal invitations
         as women in the core target group.51
         The Provinces achieving higher participation rates tend to be performing well in some common
         areas, such as: effective promotion; careful integration of program components, especially
         screening and diagnostic services; and a strong focus on the woman’s experience of the program.
         Yet a number of factors that affect performance are outside the control of the Provinces, such
         as the population’s cultural and ethnic diversity and also age distribution. The PHA is looking at
         developing statistics to be able to present more meaningful comparisons across Provinces to take
         account of some of these differences.
         Structures and processes
         The screening services provided by organised screening programs are publicly provided in all
         Provinces and territories, while the provision of services in the non-organised sector varies across
         Provinces. In New Brunswick, for example, the nature of the funding system for health services
         means that the Province can co-opt into the organised program all radiographers who want to
         get paid for completing a mammogram. Other Provinces are trying to integrate private practice
         into organised programs, citing the benefits of: a constant stream of clients; the need to ensure
         participation is handled by another organisation; and the kudos from participating in the same
         accreditation process as public facilities.
         Most Provinces and territories rely on sending letters to women to encourage participation,
         although some rely on public promotion. The database that generates the letters varies across
         jurisdictions. In some cases, invitations are only sent to those registered with the Province or
         Territory health system, while other Provinces send letters through the drivers licence registration
         system.




49 The broader performance measures for organised screening program are available at in Public Health Agency of Canada (2008) Organized Breast
   Screening Programs Review – Report on Program Performance in 2003 and 2004, p. 10.
50 Public Health Agency of Canada (2008) Organized Breast Screening Programs Review – Report on Program Performance in 2003 and 2004,
   pp.1, 12
51 For a list of the relevant provinces see Public Health Agency of Canada (2008) Organized Breast Screening Programs Review – Report on
   Program Performance in 2003 and 2004, p.14.



                         BreastScreen Australia Evaluation – Governance & Management Project January 2009                                        109
                Funding
                The federal government does not provide any dedicated funding to Provinces to provide screening
                services. On an ad hoc basis certain special grants and contributions are made from the federal
                level. In recent years, for example, Provinces and territories were provided with support to
                undertake technological improvements to their breast screen services. Services are provided free
                of charge.


                ENGLAND52
                Governance and management
                The National Health Service Breast Screening Programme was established in 1988 and national
                coverage was achieved by the mid 1990s.53 A National Coordination Office sets national standards
                which are monitored through a national quality assurance network. Services are provided by
                around 80 breast screening units around England.
                The Programme is nationally coordinated. National standards are monitored through a national
                quality assurance network. Each NHS region (of which there are ten in England) has a quality
                assurance director for breast screening, supported by an assurance team, and a quality assurance
                reference centre (QARC). The director meets regularly with colleagues in the regions to review
                performance and outcomes and encourage continued improvements. There are also regular quality
                assurance visits to screening units. The QARC is responsible for the collection and collation of data
                about the performance and outcomes of the Programme in a given region.
                National guidance on good practice, and standards and targets for Programme staff and
                the technical performance of equipment are set by national coordinating committees.54 The
                membership of these committees covers the regional quality assurance directors and professional
                coordinators and also professional organisations (such as the Royal Colleges). The committees
                are also responsible for the published national standards and targets for the performance and
                outcomes of the Programme.
                The key advisory body in England is the Advisory Committee on Breast Cancer Screening. The
                Committee advises the Minister and the Department of Health on the development of the
                Programme, monitoring the effectiveness of the Programme and advising on research. As a
                ministerial committee the members are appointed by the Secretary of State, with membership
                drawn from the full range of professionals working within the Programme (such as surgeons,
                pathologists, radiologists, radiographers, management etc).55 The Cancer Policy Team at the
                Department of Health provides a secretariat for the committee and members of the NHS Breast
                Screen Programme National Team attend as ex officio members. In recent years, the committee
                has also included a lay member of the public to provide a public/patient perspective. The



      52    England was chosen over the United Kingdom due to differences in program structure across the four countries within the UK.
      53    http://www.cancerscreening.nhs.uk/breastscreen/index.html
      54    Five training centres provide specialist training for staff working in the programme.
      55    Some professionals attend as members of professional associations and in such circumstances their membership is endorsed by the appropriate
           professional body.



110
         Committee maintains a close relationship with the screening units. For example, following the
         recent decision to expand the eligible age range (see below), there were close discussions between
         the screening units and the Committee about the necessary changes to put this into practice.
         At the UK level, the key advisory group is the National Screening Committee which advises the
         Minister and the NHS on all aspects of screening policy and supports the implementation of the
         Programme. Its membership is predominantly public health officials. The NSC has no jurisdiction
         over the English Programme, but does act as the executive for the English non-cancer screening
         programmes.
         Participation objective
         The Programme aims to invite all women aged 50–70 years for screening once every three years,
         with such women receiving routine invitations for screening, including an actual appointment time.
         In September 2007, the Prime Minister announced that the eligible age range will be expanded to
         47-73.56
         The most recent figures, for 31 March 2007, indicate that 76 per cent of women aged 53-64
         had been screened at least once in the previous three years. For women aged 65-70 participation
         is 67.7 per cent, up 8.7 percentage points from March 2006, as the Programme continues to
         be rolled out.57 In recent times participation rates have been falling, driven by less interest from
         women towards the end of their time in the Programme and also lower rates for women around
         50 years of age. There is also a concern that women are not being screened on time every
         three years.
         Participation tends to be higher in rural areas than the cities and towns. Various reasons have
         been suggested for this, including a greater sense of community and greater appreciation for the
         services being provided in less accessible areas.
         Structures and processes
         Screening takes places at around 80 screening units across England which are run by the local
         hospital trust. The location of the screening units varies, with some based in hospitals or other
         convenient locations such as shopping centres. There are also a number of mobile units. Examining
         new ways of working to boost efficiency and increase the capacity of screening units receives
         ongoing attention, and evening and weekend screening has often been made available. As part
         of managing workforce shortages, non-State register radiographers are responsible for taking
         mammograms, with experienced and advanced radiographers responsible for analysing the
         screens with medical staff. Clinics also have the flexibility to use their facilities for dual purposes.
         For example, in many clinics screening takes places in the morning, while in the afternoon the staff
         and the facility are used for diagnostic services.
         All screening units were provided by public facilities until 2006, when following a competitive
         tendering process a contract was awarded to the independent sector for the East Devon region.
         Only limited screening occurs in the private sector, as private insurers will not pay for screening
         (and NHS services are provided free of charge).

56   http://www.cancerscreening.nhs.uk/breastscreen/index.html
57   http://www.ic.nhs.uk/statistics-and-data-collections/screening/breast-cancer/breast-screening-programme-england-2006-07-ns



                        BreastScreen Australia Evaluation – Governance & Management Project January 2009                          111
               A routine call and recall system issues invites to well women, with details drawn from a
               national database of all women registered with a GP. Women less than 50 years of age are
               able to ask their GP for a referral to a hospital breast clinic if they have are concerned about
               a specific breast problem.
               Individual screening units are responsible for compiling participation figures. These figures are
               then validated by regional Quality Assurance teams. UK wide figures are compiled by the Cancer
               Screening Evaluation Unit at the Institute of Cancer Research in London.
               Funding
               The Programme is funded by the English Government. Services are provided free or charge.


               NEW ZEALAND
               Governance and management
               The New Zealand program, Breastscreen Aotearoa (BSA) commenced in 1999. The lead body
               for the program is the National Screening Unit (NSU), an autonomous unit which sits within the
               National Services Directorate of the Ministry of Health. The NSU funds and contracts with eight
               lead providers who are responsible for the entire screening pathway, which includes: health
               promotion; invitation; screening assessment; referral to treatment; and quality assurance.
               The NSU has a number of core functions which cover: national co-ordination, leadership and
               advising government; research and development, including evaluation of new evidence and
               evidence-based appraisal of technological advances in screening; and developing frameworks,
               standards and policy.58 In addition to its responsibilities for BSA, the NSU is also responsible for
               cervical cancer screening and a number of non-cancer screening programs (newborn metabolic,
               antenatal HIV and universal newborn hearing). Further development here is possible, with ongoing
               discussions on whether cancer screening should sit in a screening unit or a cancer control unit.
               The national program is monitored by a university based epidemiological unit, currently the
               University of Queensland, which is contracted to produce a quantitative report. A monitoring
               agency outside the BSA was appointed as the BSA did not believe it could fund, and also
               independently monitor, the programs. More recently, the development of a single software
               system has allowed for a daily uploading of data from the lead providers, meaning that the NSU
               can prepare regular national reports and lead providers can prepare their own online reports to
               consider trends in their performance – comparisons across providers are only available in the
               published national report. The audit process has also been contracted out to an accredited audit
               organisation, which involves professionals who work in the screening program.
               The monitoring report feeds into the NSU’s internal processes. Its results are considered alongside
               each lead provider’s performance in meeting its last audit report (and the recommendations
               therein) and monthly report. Such information is used as part of the NSUs six monthly site visits to
               the lead providers.59


      58   A full list is available in the National Screening Unit (2003) Strategic Plan 2003-08, p. 11.
      59   The frequency of visits is varied in line with performance.



112
         Two key advisory groups are the National Screening Advisory Committee (NSAC) and the multi-
         disciplinary Breastscreen Aotearoa Advisory Group (BSAAG). NSAC provides advice to the Director-
         General of Health on screening policy and practice, including reviewing feasibility and effectiveness
         and providing guidance on quality assurance. BSAAG’s roles include providing independent
         advice on the policy and strategic direction of BSA and considering research and development
         opportunities for BSA.60 Sitting under BSAAG are ten uni-disciplinary groups which are responsible
         for the initial development of operational policy, amongst other things.
         Participation objective61
         The program is focussed on well women, across an age range of 45 to 69 years. (The initial age
         range was 50 to 69 years.) The program targets a 70 per cent screening rate for eligible women in
         the 50 to 69 year old age group.
         The program is currently well short of meeting its participation target, with the most recent data
         indicating that coverage for the period July 2005 to June 2007 was 61.2 per cent.62 Performance
         differs significantly across regions (with BS South Limited achieving 77.8 per cent participation)
         and also across different ethnic groups (with participation for Maori and Pacific populations, 43.5
         and 43.8 per cent respectively, significantly lower than other ethnic groups, 63.1 per cent).
         Structures and processes
         The eight lead providers are responsible for the delivery of services in their geographical area,
         with services provided in both fixed and mobile sites (with 11 mobile vans across New Zealand).
         The providers cover both public and private sector organisations, with two lead providers
         completely private. Alongside the lead providers are nine independent service providers in defined
         geographical areas who provide specific health promotion for Maori and Pacific Islander women.63
         New Zealand does not have a population register from which to invite women to participate which
         places a greater emphasis on promotion activities and referrals from GPs. The most successful lead
         provider, BreastScreen South – a private partnership of GPs and radiologists, has overcome this
         challenge by identifying and inviting women ‘through GP registers provided to BreastScreen South
         for an administration fee’.64 Processes and engagement, in addition to the fee, are considered
         crucial to maximising participation.
         Funding
         The eight lead providers and nine independent service providers are fully funded by the Ministry of
         Health. Services are provided free of charge.




60  For more detail, see http://www.nsu.govt.nz/1614.asp
61  The program’s broader objectives are available in the National Screening Unit (2003) Strategic Plan 2003-08, p. 33.
62  Breastscreen Aotearoa Independent Monitoring Report, January-June 2007, p. 2
63  District Health Boards are separately funded to provide mammography outside of BSA for women of any age who have symptoms or are at high
   risk due to: a previous breast cancer; a high risk family history; or an ‘at risk’ lesion such as ADH diagnosed on a previous breast biopsy.
64 Madeline Wall, Clinical Leader, ‘BreastScreen Aoteraroa’, O&G Magazine, Vol. 9 No. 3, Spring 2007.



                         BreastScreen Australia Evaluation – Governance & Management Project January 2009                                         113
                SWEDEN
                Governance and management
                Sweden has had a national breast screen program since 1997. Responsibility for day-to-day
                operational matters and also evaluation and monitoring lies at the individual county level (there
                are 21 counties). In most counties, key professionals meet at six monthly intervals to discuss
                performance. Counties discuss their individual programs collectively and insights are shared, but
                decentralisation is the dominant theme.
                Sweden’s relatively small size allows means that radiologists are generally familiar with each other,
                which makes it easier to translate learnings around the country during regular meetings. This is
                also true of surgeons and oncologists.
                Quality assurance is undertaken at the county level, although there are on-going discussions
                about developing a national wide quality assurance program. Achieving greater central control
                over quality is an ongoing debate, with counties cautious about relinquishing access to their data
                without guaranteed access to data from other counties. Counties are also responsible for deciding
                whether to publish their results, although contracts signed by each county mean the Social Board
                of Welfare is able to see county results.
                Participation objective
                Most counties screen women from age 40-74, although some limit screening to 50-69. (The
                choice of age range has typically depended on resources available at the county level, and more
                broadly a shortage of radiologists.) The target participation is 70 per cent. The national policy
                dictates screening every 18 months for women from 50 years of age, and every two years for
                women below 50.
                In large cities, such as Stockholm, participation in the organised program tends to be around
                60 per cent, with a further 10 to 15 per cent of women receiving screening in private x-ray
                departments.65 The private sector is important, as there is some tendency for women who receive
                a private screen below the eligible age to remain in the private sector. Participation in rural areas is
                much higher, and has been around 90-95 per cent since the inception of the program. This reflects
                the use of mobile units which only visit rural areas at a specific period on a bi-annual basis.
                Structures and processes
                In each county screening was initially the responsibility of one hospital radiology department. In
                recent years, private x-ray departments have also started to undertake screening in three counties.
                In such counties, a competitive process determines where the screening takes place.
                County Governments use invitation letters to drive participation. Details for women invited for
                their first screen are drawn from the national population registry, with subsequent invitations
                drawn from the details in a separate screening database (although the national register is used to




      65    Stockholm is broken up into five sections with coverage of the organised program varying from 62-63 per cent (for those parts with significant
           private coverage) to 75 per cent in one part.



114
          find women who moved since the last screening). To boost participation, some counties have used
          follow-up letters, others have tried to send information letters in other languages and/or pass on
          information about the program in other languages in newspapers.
          Funding
          The funding of programs is done on a county basis. County budgets are overwhelmingly funded
          from county council taxes, with some funding from the central government.66 The service was
          initially provided free of charge, though women are now charged a fee, generally around 140-200
          Swedish krona (around AUD$27 to AUD$40).


          THE NETHERLANDS
          Governance and management
          A national screening program commenced in The Netherlands in 1990, following pilot activities in
          three regions in 1988 and 1989. By 1991, screening had commenced in all regions. Responsibility
          for national coordination rests with an Institute directly reporting to the Ministry of Health. Other
          responsibilities at the national level also include evaluation, quality assurance and technical
          assurance and teaching. These activities are undertaken by independent organisations that are
          separate to the Ministry. The actual screening is undertaken by a number of regional bodies. Such
          bodies are administrative units, with no political status and no policy responsibility.
          A national reference centre was set up in Nijmegen and given responsibility for training
          radiographers, radiologists and pathologists and monitoring the physical and technical quality of
          screening. Evaluation of the screening process and effects is undertaken by the National Breast
          Cancer Screening Evaluation Team led by the Department of Public Health at Erasmus University.
          The legislation governing the program mandates that screening units cooperate with the national
          evaluation process.
          Participation objective
          The original target was women aged 50 to 69, and all women in the target group were receiving
          invitations by 1997. From 1998 women up to 75 years of age were invited to participate. In 1990
          around 75 per cent of the target women were reached, with coverage now around 81-82 per cent.
          We were unable to obtain the specific participation objective over the course of the project.
          There are ongoing discussions about expanding the age range. For women at younger ages, the
          official policy was to wait for the result of a UK study, released in 2006. That study showed some
          effect in reducing mortality for women under 50, although the effect was not significant. There
          is also some discussion regarding the upper age limit (prompted, in part, by legal action taken by
          women too old to receive screening). The present expectation is that the age band will be lowered
          to 45 and increased to 79 or 80.




66    County council taxes make up 71 per cent of county budgets and 89 per cent of budgets are spent on health and medical care and dental care
     (see: http://www.sweden.gov.se/sb/d/4114).



                         BreastScreen Australia Evaluation – Governance & Management Project January 2009                                          115
                Structures and processes
                There are presently nine regionally based screening bodies, and a planned consolidation will
                reduce this to five in the coming period. The bodies are a relationship between local health
                agencies and the Comprehensive Cancer Centres. They cooperate with the Municipal Health
                Services in the region to implement the program and have responsibility for breast screening and
                also cervical screening.67 All screening is undertaken by public agencies.
                Invitations for eligible women to participate are generated by the national population register,
                which links to the regional bodies. Screens are only available on the basis of an invitation. The
                screening process stops once women have received their notification letter of their screening
                results (after two weeks). Women requiring further attention are referred to a GP who refers
                women to an out-patient clinic.
                Unlike other countries, the Netherlands maintains a repository of information that shows the path
                from screening through to ultimate outcomes. This is an important to build understanding of the
                impact of different parts of the process on morbidity and mortality.
                Funding
                Since 2006, the program has been directly funded by the Ministry of Health, with regions receiving
                funding in advance based on an expected number of screens at a rate of 51 euros per screening
                examination (which includes all overheads). The program is provided free of charge to women.




      67   A colorectal cancer screening program is presently under development. The expectation is that it will also be undertaken by the five screening
           bodies.



116
APPENDIX C
IMPLEMENTATION OF DIGITAL
MAMMOGRAPHY
Key events contributing to the implementation of digital mammography in Australia and
significant events internationally have been combined in (Table 10) to create an overall storyline.
This information has been used to build (Figure 11).
Table 10       Implementation of digital mammography – storyline of key events

Date                  National                               State/Territory                  International
November 2000         Digital mammography identified as an
                      emerging issue for the Program (NAC)
October 2001                                                                                  The Digital Mammographic
                                                                                              Imaging Screening Trial
                                                                                              (DMIST), involving 49,500
                                                                                              women in the United States
                                                                                              and Canada, compared
                                                                                              digital mammography to
                                                                                              standard film mammography
                                                                                              to determine how this new
                                                                                              technique compares to
                                                                                              the traditional method of
                                                                                              screening for breast cancer.
January 2004                                                 During 2004 NSW developed
                                                             and submitted a business case,
                                                             gained approval and went out
                                                             to public tender for a digital
                                                             mammography pilot.
July 2004                                                                                     Digital mammography in
                                                                                              use in the Scottish Breast
                                                                                              Screening Program.
September 2004        Digital mammography noted as a
                      future challenge for the Program at
                      inaugural meeting of ASAC. (ASAC)
September 2004        A project to monitor digital
                      mammography developments
                      identified as a separate project on
                      ASAC work plan, but the work to be
                      carried out as part of the Screening
                      Framework Project. (ASAC Work Plan
                      2004 – 2009)
November 2004:                                               VIC developed and submitted
                                                             a business case for a digital
                                                             mammography pilot.




            BreastScreen Australia Evaluation – Governance & Management Project January 2009                                 117
      Table 10       Implementation of digital mammography – storyline of key events (continued)
      Date                  National                                 State/Territory                      International
      January 2005                                                   During 2005 NSW implemented
                                                                     a digital mammography pilot
      February 2005                                                  Tasmania developed a business
                                                                     case for the full implementation
                                                                     of digital mammography across
                                                                     the State.
      March 2005                                                     Tasmania submitted business
                                                                     case and got approval for full
                                                                     implementation
      April 2005            The Monitoring digital mammography
                            developments project is identified
                            as one of the top 4 priorities for the
                            PRNT working group: (ASAC)
      May 2005                                                       Tasmania undertakes
                                                                     procurement process for
                                                                     implementation.
      July 2005                                                      Tasmania rollout of full
                                                                     implementation of digital
                                                                     mammography commences.
      August 2005                                                    NSW convened meeting of all
                                                                     Jurisdictions to discuss standards
                                                                     for digital mammography
                                                                     throughout Australia
      August – October                                               Approval for digital
      2005                                                           mammography pilot
                                                                     given to VIC
      December 2005         ASAC Policy Review and New
                            Technologies Working Group
                            (PRNTWG) produced a prioritising
                            summary for digital mammography
                            to be considered by Health Pact a
                            sub-committee of MSAC at its Dec
                            2005 meeting.

                            Digital mammography considered
                            not best practice for screening at
                            this stage.

                            Digital mammography a High priority
                            for ASAC as:

                            (a) a number of State/Territory
                            Programs have/or will be
                            considering purchasing digital
                            mammography equipment.

                            (b) States and Territories had to
                            provide the Secretariat with an update
                            on the status of digital mammography
                            within their Program. (ASAC)




118
Table 10       Implementation of digital mammography – storyline of key events (continued)
Date                  National                                  State/Territory                   International
December 2005         MSAC prepared a horizon
                      scanning report on digital
                      mammography, providing a
                      summary of current evidence.
January 2006                                                    Tasmania full implementation of
                                                                digital mammography complete.
March 2006                                                      Pilot implementation of
                                                                digital mammography in
                                                                VIC commences.
April 2006            The Quality Improvement Workforce                                           The European Union
                      Working Group has agreed to the                                             releases its 4th edition
                      establishment of a working group to                                         of the guidelines for
                      consider and develop accreditation                                          quality assurance in
                      standards for digital mammography.                                          breast screening. Digital
                      Membership of this working group                                            mammography is included for
                      will be drawn from various disciplines                                      the first time.
                      with a view to developing the
                      accreditation standards by the end of
                      2006. (PRNTWG)
May 2006              NQMC requested a change to
                      BreastScreen Australia NAS to include
                      digital mammography. Members
                      agreed that no policy change
                      would occur until there was a clear
                      assessment of the evidence for digital.
                      (ASAC)
May 2006              The assessment of digital
                      mammography and screening was
                      referred to the Medical Services
                      Advisory Committee by DoHA (ASAC)
June 2006                                                       QLD submits Business case for
                                                                full implementation of digital
                                                                mammography
October 2006          Proposed that the DMAS report             NSW started development of
                      directly to the NQMC (SSC)                business case for full digital
                                                                implementation
December 2006         The Digital Mammography                                                     BreastScreen Aotearoa
                      Accreditation Standards Working                                             commences digital
                      Group meets for the first time                                              implementation
                      (DMASWG)
January 2007          The cost-effectiveness and recurrent
                      costs of digital mammography was
                      endorsed by APHDPC as one of
                      the top priorities for the Screening
                      Subcommittee.(SSC)




             BreastScreen Australia Evaluation – Governance & Management Project January 2009                                   119
      Table 10      Implementation of digital mammography – storyline of key events (continued)
      Date                 National                              State/Territory                    International
      February 2007                                              NSW completed business case
                                                                 for full digital implementation.
      March 2007                                                 • ACT developed Business case
                                                                   for full digital mammography
                                                                   implementation
                                                                 • QLD gets approval for
                                                                   business case.
      April 2007           • The need for consistency            The Cancer Institute NSW
                             across States and territories,      hosted the BreastScreen
                             and Australian Government           Digital Mammography User
                             leadership, in purchasing digital   Group Forum.
                             mammography equipment in an
                             attempt to reduce costs
                             was recognised.
                           • The need for endorsement by the
                             APHDPC and AHMAC of the digital
                             mammography standards was
                             recognised. (SSC)
      August 2007                                                SA begins development of
                                                                 a business case for a digital
                                                                 mammography pilot
      December 2007                                                                                 NHS UK release Cancer
                                                                                                    Reform Strategy That extends
                                                                                                    the age range for breast
                                                                                                    screening to provide nine
                                                                                                    screening rounds between
                                                                                                    47 and 73 years. Starting in
                                                                                                    2008 this expansion will be
                                                                                                    completed by 2012. Direct
                                                                                                    digital mammography will
                                                                                                    be introduced over the same
                                                                                                    period to facilitate this.
      February 2008                                                                                 Ireland becomes first
                                                                                                    breast screening program
                                                                                                    in the world to be
                                                                                                    completely digital.
      March 2008           Endorsement of the majority of
                           changes recommended by the
                           DMASWG to the NAS (SSC)




120
Table 10      Implementation of digital mammography – storyline of key events (continued)
Date                 National                                State/Territory                    International
April 2008           MSAC’s report on the safety,            SA submits a business case for a
                     effectiveness and cost effectiveness of digital mammography pilot.
                     digital mammography finds that
                     • digital mammography is as
                       safe and as effective as film
                       mammography. There may be
                       subgroups of patients in whom it is
                       more effective.
                     • Film mammography is
                       being superseded by digital
                       mammography and will lose
                       technical support.
                     • MSAC recommends that public
                       funding for this procedure be
                       supported under the arrangements
                       that currently apply to film
                       mammography.
                     • Report endorsed by Minister of
                       Health and Ageing.
May 2008             • Revisions have been made to the       WA develops business case for
                       BreastScreen Australia National       digital mammography pilot and
                       Accreditation Standards to            in tandem the business case for
                       encompass digital mammography.        full implementation.
                     • Noted that the Digital
                       Mammography Accreditation
                       Standards Working Group will now
                       stand down as required work has
                       now been completed. (SSC)
June 2008                                                    • VIC finish pilot, request
                                                               underway for further funding
                                                               for State wide rollout
                                                             • QLD begin implementation
                                                               of full digital mammography
                                                               across the State.
July 2008            Draft Screening Framework delivered.




             BreastScreen Australia Evaluation – Governance & Management Project January 2009                   121
      APPENDIX D
      PEOPLE CONSULTED DURING THE PROJECT
      A large number of people were consulted with in each jurisdiction. The list of individual and
      groups consulted in each jurisdiction covered:
      •      Program Managers
      •      Senior Program staff
      •      Public officials from State and Territory health departments
      •      Screening and Assessment service managers and staff
      •      Executive staff
      •      State/Territory Advisory Committee members
      •      Consumer reference group members
      •      Clinical leaders
      •      State/Territory Accreditation Committee members
      •      Data and quality unit staff
      •      Round tables with diverse contributors were held at the end of
             jurisdictional consultations
      The international experts consulted with are as follows:
      Name                                 Organisation
      Dr Jay Onysko                        Screening and Early Detection, Chronic Disease Management Division, Centre for
                                           Chronic Disease Prevention and Control, Public Health Agency of Canada
      Dr Jacques Fracheboud                Department of Public Health, Erasmus MC, University Medical Center Rotterdam,
                                           The Netherlands
      Dr Madeleine Wall                    National Screening Unit, BreastScreen Aotearoa, New Zealand
      Associate Professor Gunilla Svane    Mammography Department, Department of Surgery, Karolinska University
                                           Hospital, Sweden
      Professor Julietta Patnick CBE       NHS Cancer Screening Programmes, England




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