Volume Eleven 2012 focusing on Health

Ambulance delays at hospitals

“One in three ambulance crews were delayed for longer than 30 minutes at hospital,” said the Auditor-General, Mr Achterstraat. “Over the year these delays totalled 84,680 hours of lost time, up from 78,224 last year and 58,399 the year before, he added.
“The longer ambulance crews are at hospitals the less time they are available to respond to the next emergency,” said Mr Achterstraat.

Of the largest hospitals in the State, Gosford Hospital kept the ambulance crews waiting the longest in 201112. On average, each ambulance crew arriving at Gosford Hospital waited 42 minutes, significantly longer than last year’s 34 minutes. Concord Hospital kept the ambulance crews waiting the least at 25 minutes. The statewide average was 30 minutes.

“There is also a financial impact of having ambulances crews waiting at hospitals,” said Mr Achterstraat. “Lost time cost $6.9 million, up from $6.1 million last year and $4.4 million the year before,” he added.  Demand for ambulances increased by nearly five per cent from last year, while the number of times the ambulance crews took more than 30 minutes to transfer patients and return to their vehicle increased by nearly ten per cent. The Ambulance Service of NSW transported 627,913 patients in 2011-12 up from 598,798 last year. The number of times ambulance crews took more than 30 minutes to transfer patients into hospital care and return to their vehicle was 208,972 in 2011-12, up from 190,704 last year.

Ambulances taking longer to respond

In 2011-12, the median ambulance response time for potentially life threatening cases for New South Wales was 10.9 minutes up from 10.6 minutes last year. Over the past five years response times have been gradually increasing from 9.6 minutes in 2006-07.

Overtime has stabilised, even for the top earners  

Total overtime payments, including call backs in 2011-12 were $389 million, very similar to last year’s $387 million. This represents five per cent of NSW Health’s salaries and wages expense.
“One career medical officer has been paid more than $1 million in overtime including call backs over the last three years. This is in addition to the officer’s base salary,” said the Auditor-General, Mr Achterstraat. “While I appreciate overtime is an important and necessary workforce strategy in delivering 24 hour health care services, I find it astounding one person can consistently earn $325,000 or more a year in overtime and call backs. Excessive overtime, whether it be rostered, unrostered or on call cannot be good for the employees’ health and patient well being,” he added. 

“All health entities should identify the top one per cent overtime, including call backs, earners in 2011-12 and investigate whether excessive reliance on these employees is value for money and whether it compromises patient safety,” said Mr Achterstraat.  Of all the local health districts, the South Western Sydney and Illawarra Shoalhaven districts paid the most overtime including call backs as a percentage of salaries and wages. They paid some six per cent in overtime while the Sydney Children’s Hospitals Network paid the least at 3.6 per cent.

NSW Health testing suppliers’ patience 

At 30 June 2012, NSW Health owed suppliers $702 million or 55 days of supplies. Of this amount, $46.0 million was on hold. “Despite recent improvements in procurement and payment processes, it is disappointing that the value of invoices on hold has grown from $33.4 million at 30 June 2011 to $46.0 million this year,” said the Auditor-General, Mr Achterstraat. “I am particularly concerned that nearly half of the 46,591 invoices on hold were only awaiting approval from the health entities to pay,” he added. The reasons for invoices being on hold include:

  •  invoices awaiting approval

  •  invoices not agreeing with the price or quantity receipted by health entities

  •  health entities not raising purchase orders, or

  •  the supplier not quoting the correct purchase order on the invoices.

Of the total invoices on hold, $15.4 million ($6.8 million in 2011) was more than six months old. The health entites with the highest invoices on hold at 30 June 2012 were Sydney Local Health District with $11.1 million, Western Sydney Local Health District with $6.4 million and South Western Sydney Local Health District at $6.1 million.  “NSW Health needs to do more to reduce invoices on hold. Paying suppliers six months after they provide their goods or services cannot be good for the NSW Health’s reputation for paying suppliers on time,” said Mr Achterstraat.

Payments to small business improve 

“In the first quarter in 2012-13, NSW Health paid 91 per cent of all eligible small business invoices within 30 days, significantly better than 78 per cent in the six months ended 30 June 2012,” said Mr Achterstraat. “This is a pleasing turnaround,” he added. Starting 1 January 2012, NSW Treasury requires government agencies to pay all registered small business suppliers within 30 days of receiving a correctly rendered invoice.

Finding a bed remains a challenge 

Despite a two per cent increase in attendances, the State average of patients triaged within the clinical timeframes in emergency departments was the same or better than last year. However, moving patients from emergency to a ward bed remains a challenge.

“For the seventh consecutive year, NSW Health has failed to meet its own targets for moving patients from the emergency department to a hospital bed,” said the Auditor-General, Mr Achterstraat. 
The Ministry of Health’s target for local health districts and the Sydney Children’s Hospitals Network is to admit 80 per cent of emergency department patients who need to be admitted as an inpatient into a hospital bed within eight hours of arriving or receiving triage in the emergency department.

“Timely patient flow within the hospital is important as it gives emergency departments more capacity to deal with the next emergency and it helps get ambulance crews back on the road”, he added.

The Southern NSW and Far West Local Health Districts were the only districts which met the Ministry’s 80 per cent target in 2011-12. They too were the only ones that met the target last year. Local health districts have implemented many strategies to improve the flow of patients through the system and make more beds available for admissions. This includes early review and transfer of patients to home or other levels of care, greater use of ‘Hospital in the Home’ and community care packages.
As part of the national health reform, the Australian Government introduced a new measure of emergency admission performance, the ‘National Emergency Access Target’. This measures the percentage of patients
admitted, transferred or discharged within four hours of presenting to the emergency department. From 1 January 2015, the Australian Government has set a target of 90 per cent. The Ministry advises this is very ambitious given growing demand at emergency departments.

The journey to improve asset management practices has commenced 

“I welcome the steps NSW Health is taking to improve its asset management practices. They are investing in a single state-wide asset management system which will give health managers and decision makers’ more complete information to help better manage and maintain these vital assets,” said Auditor-General, Mr Achterstraat. 
“NSW Health needs to have the right assets at the right place at the right time, and functioning properly, to maintain and improve its delivery of health services,” he added. 
Effective asset management for NSW Health is critical given the size and age of its asset base and increasing demand for health services. The gross replacement cost of its property, plant and equipment portfolio exceeds $19 billion at 30 June 2012. 

The full extent of backlog maintenance in NSW Health is unknown

“To fully understand the extent of backlog maintenance, I recommend all local health districts complete a condition based assessment of their buildings by 30 June 2013,” said the AuditorGeneral Mr Achterstraat. “Knowing what the backlog maintenance is, its location and how much it will cost to fix, will result in better use of very limited resources,” he added. 
As part of its 2012-13 asset planning process, the local health districts identified $96.0 million of ‘high priority maintenance’, which they need to complete in the next four years. High priority maintenance is defined as maintenance exceeding $250,000 and largely connected with ensuring legislative compliance or minimising disruption to clinical services. Given this assessment only includes high priority maintenance, the Ministry of Health believes the backlog will be significantly higher when all maintenance is included in the assessment.

Further information

Barry Underwood, Executive Officer, on 9275 7220 or 0403 073 664, barry.underwood@audit.nsw.gov.au.