Since October 2022, NSW Ambulance response time performance has improved, despite increasing demand

While COVID-19 had a measurable impact on the demand for ambulance services across New South Wales, data published by the Bureau of Health Information indicates that the increase in demand began in January 2019 and continues to the present. New South Wales experiences the highest volume of emergency and urgent incidents nationally, with the number of ambulance responses in New South Wales increasing by 18% between October–December 2018 to October–December 2023. 

Since October 2022, NSW Ambulance response times at the statewide level have improved for Priority 1 and 2 incidents (Priority 1 is defined as a ‘lights and sirens’ emergency response, and Priority 2 is defined as an ‘urgent’ response). A comparison of 2021–22 and 2022–23 response times in the two ambulance zones we examined as part of this audit (Southern NSW and Murrumbidgee) demonstrated a similar improvement.

NSW Ambulance has effective governance arrangements to monitor regional ambulance performance. However, its key performance indicators are focused at the statewide level, and the Ministry of Health does not regularly monitor NSW Ambulance’s regional performance

NSW Ambulance key performance indicators are set out in its Service Agreement with the Secretary of NSW Health. However, these indicators are focused at the statewide level, with only one of 15 indicators directly specific to regional New South Wales. Within NSW Ambulance, performance data is available at the sector, zone, and station level. NSW Ambulance zone and sector managers are accountable for performance within their respective geographical areas and use this data to improve performance where required. The NSW Ambulance Clinical Governance Framework provides for an escalation pathway from management reporting through to the NSW Ambulance Advisory Board, which reports on key matters to the Secretary of NSW Health.

In addition to the oversight provided by the NSW Ambulance Advisory Board, the Ministry of Health monitors NSW Ambulance statewide performance against the Service Agreement key performance indicators. The Ministry also monitors progress against strategic outcomes, priority areas impacting health service delivery, and is alert to opportunities for the Ministry and NSW Ambulance to collaborate to improve performance.

The Ministry of Health does not routinely consider NSW Ambulance’s performance in regional New South Wales, or performance at the NSW Ambulance zone level, during these meetings. The Ministry of Health advised the audit that it is able to focus on regional or zone performance, should an issue be identified and escalated by NSW Ambulance management or via the NSW Ambulance Advisory Board.

As NSW Health has identified health outcomes in regional New South Wales as a strategic priority, the Ministry of Health could improve its oversight of system performance through routine consideration of regional performance rather than waiting for issues to be escalated.

The key performance indicator used by the Ministry of Health to assess ambulance response times for the most clinically serious calls should be strengthened

The Service Agreement between the Secretary of Health and NSW Ambulance contains one key performance indicator on response time – the median response time for Priority 1A incidents. Priority 1A is reserved for the highest priority incidents, for example where a patient is not breathing, and the Service Agreement target for this indicator is less than ten minutes. The Ministry of Health monitors system performance against this target at the statewide level during its quarterly performance meetings with NSW Ambulance.

The use of a median figure as a performance indicator does not accurately represent system performance, as only the performance of the fastest 50% of responses is reflected in the metric.

For the period October to December 2023, the New South Wales median response time for Priority 1A incidents was eight minutes. For the same period, the 90th per centile response time for Priority 1A incidents was 18 minutes. This means that one in ten Priority 1A responses took almost twice as long to respond to the most clinically critical calls.

Furthermore, the use of a statewide indicator to measure response time performance obscures differences in regional and metropolitan performance. In 2022–23, the median response time for Priority 1A incidents is similar between metropolitan and regional zones (8.27 and 8.64 minutes respectively). When performance is considered at the 85th per centile, metropolitan performance is significantly superior to regional performance (13.58 and 17.88 minutes respectively).

Internally, NSW Ambulance monitors Priority 1A response time at the 50th and 90th per centile by division and sector. Similarly, the Productivity Commission’s Report on Government Service, which provides information on the equity, effectiveness and efficiency of government services in Australia, reports Priority 1A response performance at both the median and 90th per centile at a statewide and capital city level for all Australian states and territories.

The Ministry of Health could improve its system oversight through the use of a more holistic set of key performance indicators.

The Ministry of Health monitors Local Health District transfer of care performance

The Service Agreements between the Secretary of Health and Local Health Districts include a key performance indicator on transfer of care – which is the time taken to transfer a patient from an ambulance to an emergency department. In 2022–23, the target was 90% of patients transferred within 30 minutes. The Ministry of Health monitors Local Health District performance against this indicator and has a performance monitoring framework to identify and manage underperformance. The Ministry of Health has also developed operational processes to escalate transfer of care issues when they arise.

For the period October to December 2023, statewide performance against this target was 79.9%. Performance in regional Local Health Districts is generally higher than the statewide average. During the same period Southern NSW Local Health District reported 95.8% and Murrumbidgee Local Health District reported 87.4%.

At an operational level, NSW Ambulance works effectively with Local Health Districts, communicating regularly with Local Health District staff to facilitate service delivery

The Ministry of Health has developed a Patient Flow Portal, which allows NSW Health staff, including Local Health District staff to track patient journeys through the health system. Tracking of patient journeys starts from anticipated ambulance arrivals through to patient discharge. Because of its ability to display capacity and waiting time information in one place, the Patient Flow Portal allows Local Health District and Ministry of Health staff to monitor and manage performance against key performance indicators, including transfer of care times. Clinical staff working in Local Health Districts reported to this audit that the Patient Flow Portal is a key tool for the management of low-acuity patient transports.

NSW Ambulance and Local Health District staff regularly communicate both formally and informally to share information. Informal information sharing between NSW Ambulance and Local Health District staff includes training and professional learning opportunities, updating one another about staffing and facility availability, and discussing the scheduling of non-emergency patient transport. In addition, both Murrumbidgee and Southern NSW Local Health Districts hold regular formalised forums which include NSW Ambulance to facilitate effective service delivery.

Ministry of Health policy guidance requires Local Health Districts and NSW Ambulance to engage and collaborate when undertaking service planning activities, but this does not always occur

The Ministry of Health has developed its Guide to Service Plans, which instructs NSW Health entities undertaking service planning activities. The Guide highlights the importance of active and inclusive stakeholder engagement and requires NSW Health entities to engage with state-wide health services which are impacted by the services being planned.

The Ministry of Health does not collect data regarding whether NSW Health entities have engaged with other services when undertaking service planning activities. This means it is unable to monitor whether NSW Health entities are consistently engaging with one another during service planning.

The audit identified several instances of service planning at Southern NSW Local Health District not identifying NSW Ambulance as a relevant stakeholder and subsequently not including it in its service planning activities. Additionally, NSW Ambulance did not engage with Local Health Districts when developing its Clinical Services Plan 2024–2029.

NSW Ambulance’s electronic medical record system does not integrate with other NSW Health information systems, is approaching end-of-life, and there are no plans to update or replace it

The current NSW Ambulance electronic medical record system (eMR) is approaching end-of-life and limits clinicians ability to operate effectively. The eMR does not integrate or communicate with other NSW Health systems. This prevents NSW Ambulance clinicians from accessing clinical information such as patients’ medical histories or information regarding previous interactions with the healthcare system. The lack of integration means that tracking patient outcomes for monitoring and evaluation purposes is resource intensive and inefficient.

This also means that paramedics and Local Health District staff are unable to easily share clinically relevant information with one another, including the information allowing paramedics to transfer patients into hospital care after transporting a patient to a hospital emergency department. Under the current system, paramedics are required to print hard copies of patient medical records to complete transfer of care to hospital emergency department staff.

In 2022, eHealth NSW assisted NSW Ambulance in the creation of a business case for a project to update or replace the NSW Ambulance eMR. The business case noted that NSW Ambulance has a ‘limited window to procure, implement and establish a replacement eMR solution to ensure that the same level of care can continue to be provided to the New South Wales community.’ It is unclear whether this business case has been considered for funding, as neither NSW Ambulance, nor eHealth NSW could provide evidence to this effect.

In 2023, NSW Health announced the commencement of a new ‘whole-of-system’ eMR, the Single Digital Patient Record (SDPR). The purpose of the SDPR program is to establish one ‘digital clinical system’ across New South Wales, allowing clinicians to access patient information, record the care they provide, order diagnostic tests and manage medication from any public hospital or community health care facility across the state.

eHealth NSW advised the audit that, while NSW Ambulance is not currently included in the roll-out plan for the SDPR, it intends to include NSW Ambulance in the project. However, this intention is not scoped, planned or funded. Currently, the SDPR does not have the capability to support NSW Ambulance’s specific needs, and the vendor has not committed to expanding its scope or changing its product to meet these needs.

The Ministry of Health is centralising the development of referral pathways for NSW Ambulance across the NSW Health system, but has not developed an evaluation framework for this project

Integrated care activities, which include alternate referral pathways and emergency department diversion services, are system-wide functions which serve to reduce demand on emergency resources while providing patients with the most appropriate form and level of care. Alternate referral pathways are clinical guidelines that paramedics and NSW Ambulance clinicians (such as NSW Ambulance’s Virtual Clinical Care Centre) can use to refer patients who are assessed as not requiring emergency health care at a hospital emergency department.

These pathways often, but not always, involve the establishment of ‘entry points’ into the health system for patients (such as direct referral to urgent care clinics, or virtual assessment and management by mental health clinicians). Up until recently, in regional New South Wales, the process to establish these pathways has taken place locally, with NSW Ambulance working with Local Health District staff to identify and develop pathways into local services.

The Ministry of Health developed the Pathways for NSW Ambulance Referrals Project to centralise and standardise the process to develop alternate referral pathways. The project also includes a plan to create a governance monitoring plan for all alternate referral pathways in use across the state. However, there is currently no agreed performance monitoring framework in place for the oversight of alternate referral pathways used by NSW Ambulance across the NSW Health system.

As a frontline service, NSW Ambulance has limited resources to participate in non-operational (or strategic) activities. While NSW Ambulance is currently developing a five-year roadmap to implement its Clinical Services Plan, it is unclear how NSW Ambulance intends to implement and resource these objectives in a timeframe that complements similar work across NSW Health.

As NSW Health agencies increase their focus on coordinated clinical redesign and the delivery of new service models to address challenges such as increases in emergency department presentations and ambulance call outs, there is a risk that NSW Ambulance will not be included in all these activities. This exposes the risk that efficiencies in joint service planning are not realised, leading to duplication of effort or inefficient and ineffective resource allocation.

NSW Health prioritised reducing the reliance on the NSW Ambulance fleet for non-emergency patient transport in regional New South Wales, however the roles and responsibilities for doing so are not clear in all Local Health Districts

In 2022–23, NSW Ambulance provided 13,627 patient transports, almost 80% of which took place in regional New South Wales. NSW Health’s overarching strategy, Future Health 2022–2032, and the NSW Health Regional Health Strategic Plan 2022–2032 have prioritised reduction in the use of NSW Ambulance resources for the provision of non-emergency patient transport.

To support its Regional Health Strategic Plan, the Ministry of Health developed a Priority Framework, which includes an initiative where HealthShare NSW’s Patient Transport Service will provide transport for people who require transport to, or from, a health facility such as a hospital, but do not need a time-critical emergency response. Currently, HealthShare NSW’s Patient Transport Service does not operate across all of New South Wales, and the framework does not include provisions or plans to expand its scope.

While HealthShare NSW is exploring the possibility of expanding Patient Transport Services to all Local Health Districts, it advises that it has not yet received official endorsement from key stakeholders to formally commence such an expansion.

HealthShare NSW’s 2023–24 Statement of Service sets out HealthShare NSW’s service and performance expectations for the provision of patient transport. Included in the performance measures is a performance target for the number of patient transport jobs given to NSW Ambulance each month. The Statement of Service sets a target of less than 150 jobs per month as ‘performing’ and defines ‘non-performing’ as greater than 250 jobs per month. HealthShare NSW does not publicly report regular performance data against its targets and the data for 2023–24 is not yet available, so the audit is unable to determine whether the target is being achieved.

NSW Health does not have a strategy to guide the provision and access of transport for patients accessing health services in New South Wales

NSW Health developed a ‘Transport for Health’ strategy in 2006 to meet the transport needs of patients with a system-wide framework to support, simplify, and improve patient access to health services. The Transport for Health strategy expired in 2011 and NSW Health did not start the development of a new strategy until 2023.

This means that for over a decade NSW Health has not had a cohesive state-wide policy to address well known transport needs affecting health outcomes and service delivery in regional and rural New South Wales.

NSW Ambulance’s workforce planning activities are evidence-based

NSW Ambulance’s service planning methodology contains detailed analysis of station and location demand projections, the staffing levels required to meet demand, models of care, specialty resources and infrastructure requirements. Ambulance station resources (including the number of paramedics and ambulances, as well as the types of rosters in use at a station) are allocated under this methodology. NSW Ambulance uses a continuous review strategy to ensure its service planning methodology is accurate and current.

In addition to the demand and activity-based evidence sources NSW Ambulance uses to inform its service planning, NSW Ambulance includes evidence-based analysis in its business cases to support NSW Government funding requests, which contain thorough descriptions of how the funding will be allocated.

Recent investments in the regional paramedic workforce have allowed NSW Ambulance to reduce its use of on-call rostering to improve the working conditions of regional paramedics

NSW Ambulance rostering practices allow for some stations to utilise on-call resources, which can cause fatigue among paramedics rostered on shift following an on-call period. In the 2018–19 New South Wales Budget, the NSW Government announced funding for the recruitment of an additional 750 full-time equivalent (FTE) paramedic and call-centre staff across New South Wales over four years commencing in 2018–19. The Statewide Workforce Enhancement Program (SWEP) was designed by NSW Ambulance to enable improvements in efficiency, coverage, quality, safety and performance across New South Wales and achieve response performance targets.

SWEP resulted in an additional 376 FTE positions across ambulance stations in regional New South Wales, and allowed NSW Ambulance to reduce on-call rostering through the following actions:

• 22 regional/rural locations were converted to a 24/7 operating model removing overnight on-call
• removal of on-call at four locations that were previously operating on a 24/7 roster with overnight on-call
• reduction in on-call at eight locations.

In August 2022, as part of an internal review of the SWEP program, NSW Ambulance found that the program reduced the number of on-call shifts worked by paramedics which improved the working conditions of regional paramedics.

NSW Ambulance station management staff report that incident reports are not always submitted in a timely manner, which limits their ability to actively manage and respond to risks relating to staff welfare

NSW Ambulance zone and sector managers are responsible for multiple stations, often spread across large geographical areas and they cannot be physically present at each station they are responsible for overseeing. In this context, access to information which can assist management to identify risks to staff wellbeing, health and safety, becomes particularly important.

The NSW Ambulance Incident Management System (IMS+) is a tool station managers use to monitor and manage staff wellbeing. NSW Ambulance staff use this system to report work health and safety related incidents. This includes workplace injury and attending traumatic incidents. Our 2020 performance audit report, ‘Managing the health, safety and wellbeing of nurses and junior doctors in high demand hospital environments’, found that NSW Health’s incident management system was not designed for rapid reporting.

NSW Ambulance station management staff reported to this audit that paramedics are not always submitting incident reports to the IMS+ or are not submitting incident reports in a timely manner. Incomplete information limits management’s ability to respond, escalate, and/or monitor risks relating to staff wellbeing and welfare.

By June 2025, the Ministry of Health, eHealth NSW and NSW Ambulance should:

1. implement a new NSW Ambulance electronic medical record system that facilitates information sharing between NSW Ambulance and Local Health Districts to improve clinical decision making and improve the assessment of patient outcomes.

By June 2025, the Ministry of Health and NSW Ambulance should:

2. improve system oversight of ambulance response times through the development and implementation of new performance indicators aimed at the regional level.

By June 2025, the Ministry of Health should:

3. work with relevant agencies to finalise its Transport for Health strategy, including undertaking a review of all non-emergency patient transport operators in place across New South Wales, and determining an approach to provide patient transport services across the state

4. collect and monitor performance data on patient transport services in all Local Health Districts, including the number of non-emergency patient transports provided by NSW Ambulance in each Local Health District

5. ensure that performance on statewide indicators is regularly considered, and publicly reported, at the regional and metropolitan level.

By June 2025, NSW Ambulance should:

6. improve strategic engagement with NSW Health entities (including Local Health Districts and HealthShare NSW) by:

a) ensuring Local Health Districts and HealthShare NSW are included in local, as well as organisation-wide ambulance service planning activities

b) finalising its five-year roadmap for the implementation of the NSW Ambulance Clinical Services Plan 2024–29.

By June 2025, Local Health Districts should:

7. improve strategic engagement with NSW Ambulance by ensuring NSW Ambulance is included in service planning activities and the development of key initiatives.

Multiple NSW Health entities have a role in the delivery of effective and efficient ambulance services

NSW Ambulance is a front line health service provider, delivering emergency and non-emergency medical services and transport to patients in New South Wales. It provides of medical help to patients experiencing life-threatening injuries, illness, and trauma, and connects patients who do not need an emergency medical response with the most appropriate health provider.

NSW Ambulance operates as part of a broader network of public health services, where the performance of one part of the system can have impacts on other parts of the system. For example, for NSW Ambulance to efficiently transfer patients to hospitals, hospitals need to have sufficient capacity to accept new patients. In regional contexts, the distance to the closest hospital with the required clinical capability is another important factor in the effective delivery of ambulance services.

Similarly, access to primary health services (such as general practice and community health services) helps reduce demand on ambulance services. In areas where these services do not exist at levels sufficient to meet demand, NSW Ambulance can experience higher demand for ambulance services, which can impact its ability to deliver services effectively and efficiently.

The emergency and non-emergency medical services and transport that NSW Ambulance provides to patients in New South Wales are defined in its Service Agreement with the Secretary of Health, which is updated annually. These services include:

• Emergency services: including emergency out of hospital care; delivery of high-quality clinical care, and coordination of referral, transport and retrieval services for emergency and time-sensitive patients; emergency management services and multi-agency operations; and receipt and triaging of triple zero calls for residents of New South Wales and dispatch of ambulance and specialist resources to emergency incidents.
• Trauma services: including Aeromedical and Medical Retrieval consisting of the aeromedical control centre, medical retrieval services, fixed and rotary wing and road transport services. The Aeromedical and Medical Retrieval service manages all requests for aeromedical transport and adult medical retrieval.
• Demand management: including delivery of integrated care programs that are focused on improving the integration and patient connectedness through support of new and already established low acuity pathways in and across Local Health District boundaries; and development of community health promotion programs.
• Emergency management: including emergency management services and multi-agency operations.
• Support services: including health related transport services (including secondary aeromedical); health related transport: booking, scheduling and dispatch; and Clinical Emergency Response Assistance (CERS Assist).

Because ambulance services in New South Wales are delivered as part of the broader NSW Health system, other NSW Health entities hold responsibility for functions that affect the delivery of ambulance services in regional New South Wales. These entities and their responsibilities are:

• Ministry of Health: The Ministry of Health sets the policy and strategic direction for the New South Wales public health system and is responsible for the overall performance of NSW Health entities across the state, as well as supporting and overseeing the planning activities of NSW Health entities.
• HealthShare NSW: HealthShare NSW administers the Patient Transport Service, which provides non-emergency patient transport services and operates across Metropolitan Sydney and the Hunter New England Local Health District.
• Local Health Districts: Local Health Districts are responsible for managing public hospitals and health institutions. Hospital emergency department staff receive patients whose care is transferred to them by paramedics and non-emergency patient transport providers. Local Health Districts also operate non-emergency patient transport services. Local Health District health services can also accept patients for care through alternative referral pathways used by NSW Ambulance clinicians.
• eHealth NSW: eHealth NSW provides ICT services to NSW Health entities. To that end, eHealth supports the Computer Aided Dispatch (CAD) and Electronic Medical Record (eMR) systems in use by NSW Ambulance and Local Health Districts. eHealth NSW is administering the NSW Health Single Digital Patient Record (SDPR) program currently underway, which has been designed to integrate eMR systems in use by NSW Health entities (except NSW Ambulance), and is due to be completed in 2030.

NSW Ambulance operates within Ambulance Zones – defined geographical areas of New South Wales, split into ten regional and ten metropolitan Zones. See Appendix three for further information regarding NSW Ambulance regional ambulance zones.

NSW Health operates within Local Health Districts, which manage public hospitals and health facilities, providing health care services within defined geographical areas of New South Wales. There are 15 Local Health Districts in New South Wales, six across the Sydney Metropolitan region, and nine across rural and regional New South Wales.

According to the NSW Health Regional Health Strategic Plan 2022–2032, regional New South Wales encompasses all regional, rural and remote areas of New South Wales, including some areas within metropolitan Local Health Districts.

NSW Ambulance has applied a ‘peri-urban’ classification to locations across 11 NSW Ambulance Zones within Greater Sydney, Northern Illawarra, Central Coast, and Inner Hunter regions. NSW Ambulance reports its performance for some key performance indicators at the peri-urban and rural level, to highlight its performance in those parts of the state. Where this data is available, the audit has considered performance as defined by both sets of classifications – metropolitan/regional and peri-urban/rural.

This audit focuses on the effectiveness and efficiency of ambulance services in two regional New South Wales Ambulance Zones/Local Health Districts: Murrumbidgee Zone/Murrumbidgee Local Health District and Southern NSW Zone/Southern NSW Local Health District.

Approximately 45% of NSW Ambulance’s activity takes place in regional New South Wales. Appendix two contains information on NSW Ambulance activity (in terms of responses, incidents and numbers of transports) for year 2022–23.

A 2022 NSW Parliamentary inquiry found that residents of regional New South Wales had poorer health outcomes and poorer access to health services

The 2022 NSW Parliamentary inquiry report titled ‘Health outcomes and access to health and hospital services in rural, regional and remote New South Wales’ describes the context and circumstances surrounding access and demand for health services in regional, rural, and remote New South Wales. The inquiry found that, ‘overall, residents of rural, regional, and remote New South Wales have poorer health outcomes and inferior access to health and hospital services, and face significant financial challenges in accessing these services, compared to their metropolitan counterparts.’

The inquiry noted increasing demand for ambulance services across New South Wales, stating calls for ambulances are 2.5 times higher in remote communities when compared with metropolitan or inner regional areas.

With respect to demand for ambulance services, recent data from NSW Health’s Bureau of Health Information shows that almost all regional areas have higher incident rates (calculated as number of incidents per 10,000 people) than the New South Wales average.

The inquiry noted general practitioner shortages are occurring across rural, regional, and remote New South Wales, and that more towns had been identified as being at risk of not having a general practitioner within the next ten years. When regional, rural and remote communities do not have access to a local general practitioner, patients must travel to access this care. The inquiry noted these circumstances often lead to services in nearby towns becoming overwhelmed, resulting in these services closing their books to new patients.

Another issue explored by the Parliamentary inquiry relates to challenges accessing transport in rural and regional areas. In many regional towns, there are limited public transport options available, and where these options exist, they are often irregular, and/or can result in long journeys. The inquiry report noted that when patients do not have access to a private vehicle, patients are often ‘wholly reliant on the generosity of friends, family and neighbours’, and that the distances to be travelled, and related costs (such as fuel) can be a disincentive to individuals following through with, or seeking, treatment.

In regional New South Wales, ambulances often have to travel greater distances, and provide more non-emergency patient transport services

In regional New South Wales, health services are often provided in a ‘hub and spoke’ model, where smaller regional facilities provide integrated health and aged care services to regional, rural, and remote communities. These smaller regional facilities, such as NSW Health Multi-Purpose Services, receive support from larger facilities in regional centres or metropolitan Sydney. Hub and spoke models rely on the ability to transport complex and seriously unwell patients to larger facilities as needs arise.

These arrangements are reflected in NSW Ambulance’s 2022–23 activity data, which demonstrate that 73% of inter-hospital transports undertaken by NSW Ambulance take place in regional New South Wales (63% take place in rural areas).

NSW Ambulance also provides non-emergency patient transport services in regional New South Wales. In 2022–23, NSW Ambulance provided 13,627 patient transports, almost 80% of which took place in regional New South Wales.

The issue of paramedics responding to patients not requiring emergency care and providing non-emergency patient transport services in rural, regional and remote New South Wales was explored in the 2022 Parliamentary inquiry. The inquiry found that paramedics in rural and regional areas are called out to undertake long distance transfers at night, which diverts ‘limited emergency resources to low-acuity cases for which they are not required.’ This leads to the flow-on effect that off-duty paramedics are called out in place of the rostered crews undertaking patient transport. The report states these circumstances are compounded by staffing levels, with staff increasingly experiencing excessive workloads.

The inquiry made a finding specific to the provision of ambulance services in regional and rural New South Wales:

The Parliamentary inquiry recommended that NSW Ambulance and NSW Health:

Addressing increasing demand on health services in New South Wales is a strategic priority for NSW Health

The Ministry of Health has developed broad strategies which guide and inform the activities of the health system. The strategies describe the current landscape, including current challenges, as well as the intended priorities, actions, and investment required to achieve the Ministry’s proposed future state. NSW Health’s Future Health 2022–2032 is NSW Health’s overarching strategy, which outlines how the Ministry of Health intends to meet the needs of its patients, the community, and its workforce over the next decade.

With respect to the current context and challenges across the report period related to the provision of health care services in regional and rural New South Wales, the Future Health report notes that demand for health services in New South Wales is rising at rates which are beyond what can be attributed to population growth, with changing demographics (such as the growing ageing population) and growing complexity accounting for increased activity and demand. The Future Health report states that:

Since 2019, demand for ambulance services has increased significantly. While COVID-19 had a measurable impact on the demand for ambulance services, recent Bureau of Health Information data indicates that the increase in demand continues. Exhibit 1 demonstrates an 18% increase in the number of ambulance responses in New South Wales between October-December 2018 to October-December 2023.

The NSW Government increased funding to NSW Ambulance in recent budgets

In its 2018–19 Budget, the NSW Government allocated $700m in workforce enhancement for NSW Ambulance, which included funding for 700 additional paramedics and 50 control centre employees across four years. To support the funding, NSW Ambulance designed the Statewide Workforce Enhancement Program (SWEP) to enable improvements in efficiency, coverage, quality, safety and performance across New South Wales and achieve response performance targets.

In June 2022, the NSW Government announced the Strategic Workforce InFrastructure Team (SWIFT) program, a $1.76b investment in NSW Ambulance over a four-year period to fund 210 ambulance support staff, 1,878 new paramedics, 52 nurses, eight doctors, and build 30 ambulance stations.

In the 2023–24 New South Wales Budget, the NSW Government announced a further investment toward ambulance services of $438.6 million to fund an additional 500 paramedics in rural and regional New South Wales.

In 2017, the Auditor-General published a performance audit on NSW Ambulance’s demand management and assessed the extent to which NSW Ambulance’s demand management initiatives improved the efficiency of its services. The audit found that while NSW Ambulance had introduced several initiatives that aimed to more efficiently manage demand from less urgent cases, it didn’t have an overall strategy for these initiatives and NSW Ambulance’s data systems did not measure outputs or outcomes. As a result, the audit was unable to assess the impact of NSW Ambulance’s demand management initiatives on the efficiency of ambulance services.

The Auditor-General made the following recommendations to NSW Ambulance:

1. Develop a demand management strategy that outlines its approach to managing demand. This strategy should include:

• Clear objectives and key performance indicators for demand management initiatives.
• Input from stakeholders in the health system and a continuing plan for collaboration with stakeholders.
• Planned approaches to communication with the public about demand management initiatives.

2. Determine the data system improvements required to provide accurate oversight of demand management initiatives. This should enable routine monitoring and reporting of the activity and performance of these initiatives

3. Develop a strategy to guide the continued use of Extended Care Paramedics. This should include planning for how they are used and how their performance is measured

4. Evaluate its approach to using telephone referrals for managing less urgent demand for services

5. Ensure paramedics are as well prepared as possible for their contemporary role by:

a) Strengthening staff performance and development practices to help paramedics develop their decision-making and communication skills. This could include introducing formal mentoring programs for paramedics.

b) Determining the mobile technology needs of paramedics to support their expanded decision making and assessment roles.

NSW Ambulance accepted all five recommendations of this performance audit.

In 2020, the Auditor-General published a performance audit report on NSW Health’s management of health and safety risks to nurses and junior doctors in high demand hospital wards from 2016 to August 2020. The audit focussed on emergency departments, mental health wards and aged care wards prior to COVID-19 and expanded to include the new health and safety risks to hospital staff presented by COVID-19. The audit assessed the effectiveness of NSW Health’s:

• systems, forums and workplace cultures to support reporting and generate data about risk
• initiatives to support safe workplaces and effectively respond to health and safety incidents
• actions to continuously improve staff health, safety and wellbeing in hospital environments.

The audit found that NSW Health’s incident management system was effective for recording health and safety incidents in hospital wards where incidents occur infrequently, and staff have time to log incident details during shift hours. However, in high demand wards where incidents and risks are common, staff reported that they were unable to log all incidents due to the frequency of events, and the time required to record incidents in the system.

The audit also found that NSW Health was taking reasonable steps to manage and respond to physical health and safety incidents in New South Wales hospitals, but psychological and wellbeing risks and incidents were not routinely recorded or escalated to managers. Stress debriefing was not consistently available to staff after difficult or traumatic workplace incidents.

To address these findings, the Auditor-General made the following recommendations to NSW Health:

• evaluate the effectiveness of the new incident management system to enable full reporting of health and safety incidents and risks in all hospital wards, including those where incidents and risks are common, and monitor for consistency of reporting over time
• ensure that nurses and junior doctors have regular opportunities to report on risks to their psychological health and wellbeing, and that system managers have access to aggregate data to guide responses to mitigate these risks
• develop and implement an evidence-based guiding framework and strategy to support hospital staff in the aftermath of traumatic or unexpected workplace incidents, and monitor implementation.

NSW Health accepted all of the audit recommendations.

The objective of this audit was to assess the efficiency and effectiveness of ambulance services in regional New South Wales, through the examination of three lines of inquiry:

• Does NSW Health work effectively and efficiently to deliver ambulance services in regional and rural New South Wales?
• Is NSW Health effectively and efficiently planning and allocating ambulance services in regional New South Wales?
• Is the effectiveness of ambulance services in regional and rural New South Wales increasing over time?

The audit focused on ambulance services as defined in the Service Agreement between the Secretary, Health and NSW Ambulance, specifically emergency services, demand management and support services. The audit considered whole-of-system planning and information sharing with a specific focus on two NSW Ambulance zones (Murrumbidgee and Southern NSW).

The Ministry of Health monitors the performance of NSW Ambulance and Local Health Districts against key performance indicators described in Service Agreements

The Ministry of Health monitors NSW Ambulance performance through its NSW Health Performance Framework. The Framework describes the performance expectations and process to monitor the performance of public sector health and support services and is intended to sit alongside Service Agreements between the Secretary of Health and NSW Health entities. As part of this process, the Ministry produces monthly Health System Performance Reports for NSW Ambulance, which include performance data against the key performance indicators, any variation from the targets, and the previous years’ performance.

Under the process set out in the NSW Health Performance Framework, NSW Ambulance is required to submit an annual Safety and Quality Account to the Ministry of Health. Additionally, the Ministry holds quarterly performance meetings with NSW Ambulance, per the Performance Framework, which are chaired by the Deputy Secretary, System Sustainability and Performance Division. The purpose of quarterly performance meetings is to discuss:

• performance against Service Agreement key performance indicators
• progress against Future Health strategic outcomes
• priority areas impacting health service delivery
• performance level
• opportunities for the Ministry and health service to collaborate to improve performance.

The Ministry of Health also informally monitors NSW Ambulance performance through the Ministry of Health/NSW Ambulance Operational Meeting, which was established in 2019 to:

• discuss current and emerging issues related to ambulance and retrieval operations, including the development of solutions
• discuss retrieval and/or surge plans, including cross border issues, planning and transfers in and out of Sydney
• enable information sharing and multidisciplinary strategy development
• provide oversight and action recommendations arising from the Patient Safety Distribution Unit Review
• monitor the operational effectiveness of the System Flow functions.

Similarly, the Ministry of Health monitors the performance of Local Health Districts against their Service Agreements. With respect to ambulance services, all Local Health Districts have a key performance indicator for ‘transfer of care’ (which is the time taken to transfer a patient from an ambulance to an emergency department), where the expectation is that 90% of patients will be transferred from the ambulance to the emergency department within 30 minutes.

NSW Ambulance’s data to measure clinical performance is limited

NSW Ambulance uses data captured by its operational systems to assess performance against key performance indicators to measure and monitor clinical performance. NSW Ambulance collects dispatch data from its Computer Aided Dispatch (CAD) system, and clinical data out of its Electronic Medical Record (eMR).

The CAD system contains information such as:

• information about the allocation of resources to triple zero calls
• time-stamped information relating to when activities are begun and completed (e.g., the time when an ambulance arrives at and departs the scene)
• information about the incident (e.g., the type of incident and the transport protocol applied).

The NSW Ambulance eMR system contains information such as:

• information about the incident (e.g., reason for the call and scene location)
• patient information (e.g., demographics, injury/illness characterisation, vital signs, and assessment results)
• treatment details (e.g., pharmacology and interventions)
• outcomes (e.g., patient transported or not transported, died).

NSW Ambulance reports that both the Computer Aided Dispatch and Electronic Medical Record systems were not designed with performance measurement in mind, and because of this, the NSW Ambulance Key Performance Indicators which are monitored through data collected via these systems take the form of output metrics, rather than outcome metrics. Furthermore, NSW Ambulance notes that because the Electronic Medical Record system is designed for use by clinicians at the bedside of a patient, reliable and reproducible data comes secondary to the provision of care.

The NSW Ambulance Computer Aided Dispatch system is primarily concerned with time measurement metrics (i.e., did the patient get to hospital within a certain timeframe), it focuses less on whether the patient received high-quality clinical care before getting to hospital.

The key performance indicators (and the methods used to determine key performance indicators) used to monitor NSW Ambulance performance are agreed between the Ministry of Health and NSW Ambulance each year through the Service Agreement process. This process includes developing data definitions for how these measures are counted.

In addition, the NSW Ambulance Clinical Governance Committee reviews NSW Ambulance’s performance measures each year from the perspective of appropriateness, accuracy, and fitness for purpose. NSW Ambulance reports that when the Clinical Governance Committee considers the accuracy and fitness for purpose of performance measures, one of its primary considerations is its confidence in the percentages, and not necessarily absolute numbers. This means that for output measures with a relatively low count, the Clinical Governance Committee applies more scrutiny around whether the measure is complete. For output measures with a higher count, the risk of incomplete data reduces, which means less scrutiny is applied.

NSW Ambulance systems are approaching end-of-life, and do not integrate with similar clinical systems in place across the NSW Health system. Our 2017 performance audit report, ‘Managing demand for ambulance services’ noted that better linkage between health data would benefit NSW Ambulance by allowing tracking of the health outcomes of patients treated by paramedics.

NSW Ambulance has been working toward a new eMR solution in partnership with eHealth NSW, but it does not have an agreed new state for its clinical systems, or a timeframe in which a solution will be delivered.

The NSW Ambulance service agreement contains only one key performance indicator specific to regional New South Wales

The NSW Ambulance Service Agreement contains key performance indicators used to assess NSW Ambulance’s performance. See Appendix four for the key performance indicators in the NSW Ambulance 2023–24 Service Agreement. Of 15 clinical key performance indicators, only one applies specifically to regional New South Wales:

For metropolitan areas, the comparable performance indicator has a higher target (90%), with a more narrowly defined response (patients can only be transported to a 24/7 Acute Thrombolytic Centre).

Furthermore, the performance indicator for major trauma relates to a protocol which describes different processes depending on whether the response occurs in metropolitan or regional areas. If a patient meets the criteria for major trauma, the protocol allows 60 minutes transport time for metropolitan incidents and 90 minutes for regional incidents.

As only one key performance indicator gives specific regard to patients in regional New South Wales, there is a risk that emerging issues or risks in regional ambulance service delivery are not adequately considered unless performance metrics are disaggregated to the regional level.

The key performance indicator used by the Ministry of Health to assess ambulance response times for the most clinically serious calls should be strengthened

The Service Agreement between the Secretary of Health and NSW Ambulance contains one key performance indicator on response time – the median response time for Priority 1A incidents. Priority 1A is reserved for the highest priority incidents, for example where a patient is not breathing. The Service Agreement target for this indicator is less than ten minutes. The Ministry of Health monitors system performance against this target at the statewide level during its quarterly performance meetings with NSW Ambulance.

The use of a median figure as a performance indicator does not accurately represent system performance, as only the performance of the fastest 50% of responses is reflected in the metric.

For the period January to March 2024, the New South Wales median response time for Priority 1A incidents was eight minutes. For the same period, the 90th per centile response time for Priority 1A incidents was 18 minutes. This means that one in ten Priority 1A responses took almost twice as long to respond to the most clinically critical calls.

Furthermore, the use of a statewide indicator to measure response time performance obscures differences in regional and metropolitan performance. In 2022–23, the median response time for Priority 1A incidents is similar between metropolitan and regional zones (8.27 and 8.64 minutes respectively). When performance is considered at the 85th per centile, metropolitan performance is significantly superior to regional performance (13.58 and 17.88 minutes respectively).

Internally, NSW Ambulance monitors Priority 1A response time at the 50th and 90th per centile by division and sector. Similarly, the Productivity Commission’s Report on Government Service, which provides information on the equity, effectiveness and efficiency of government services in Australia, reports Priority 1A response performance at both the median and 90th per centile at a statewide and capital city level for all Australian states and territories.

Performance data on metrics such as ambulance response time or transport time can be more readily understood when considered as a distribution. Exhibit 4 demonstrates the ‘long tail’ present in NSW Ambulance 2022–23 response time data, where there are a significant number of ‘high response time’ incidents that are not reflected in the median value. Without other information, NSW Ambulance or Ministry of Health decision makers are unable to consider these incidents when monitoring performance. The Ministry of Health could improve its oversight of system performance through the use of a more holistic set of key performance indicators.

Source: NSW Ambulance data (unaudited), Audit Office analysis.

NSW Ambulance monitors staff wellbeing through Service Agreement key performance indicators, internally collected and reported data and Sector Health and Safety Committees

The 2022 Parliamentary inquiry into ‘Health outcomes and access to health and hospital services in rural, regional and remote New South Wales’ found that NSW Ambulance staff were at increased risk of burnout and dissatisfaction due to several factors, including:

• an increased reliance on paramedics to provide primary care in some rural communities due to the lack of healthcare practitioners
• excessive overtime due to insufficient staffing
• overreliance on off-duty colleagues filling staffing gaps.

NSW Ambulance monitors the wellbeing of its workforce through several channels, including Key Performance Indicators included in its Service Agreement with the Secretary of Health. Key Performance Indicators included in the 2023–24 Service Agreement under the heading ‘Our staff are engaged and well-supported’ are described in Appendix four.

NSW Ambulance also collects and reports other wellbeing performance data such as workload figures, excess annual leave, and premium labour expenses such as those relating to the use of staff overtime. This information is presented in a fortnightly report received by NSW Ambulance executive staff members.

At the local level, each NSW Ambulance sector has a Health and Safety Committee. In Southern Sector, which includes the focus NSW Ambulance Zones for this audit – Southern Zone and Murrumbidgee Zone – Health and Safety meeting members include Zone Managers, a Safety Partner and other local NSW Ambulance staff.

NSW Ambulance staff in the Southern Sector have used the Health and Safety Committee to raise issues relating to fatigue such as:

• concerns around staff not following fatigue mitigation protocols
• request for consistent messaging regarding how to use fatigue mitigation protocols
• feedback from staff regarding the NSW Ambulance control centre dispatching jobs to staff while they are utilising fatigue mitigation strategies
• job types leading to increased fatigue amongst paramedics (e.g., patient transfers across large distances)
• stations experiencing increased fatigue levels.

NSW Ambulance station management staff report that incident reports are not always submitted in a timely manner, which limits their ability to actively manage and respond to risks relating to staff welfare

In our 2020 performance audit report, ‘Managing the health, safety and wellbeing of nurses and junior doctors in high demand hospital environments’, we noted the importance of system managers having access to all the information needed to identify risks to staff health and safety, reporting that:

NSW Ambulance zone and sector managers are responsible for multiple stations, often spread across large geographical areas and they cannot be physically present at each station they are responsible for overseeing. In this context, access to information which can assist management to identify risks to staff wellbeing, health and safety becomes particularly important.

The NSW Ambulance Incident Management System (IMS+) is a tool station managers can use to monitor and manage staff wellbeing. Staff use this system to make reports of work health and safety related incidents, such as attending traumatic events and experiencing workplace injury. Our 2020 performance audit report, ‘Managing the health, safety and wellbeing of nurses and junior doctors in high demand hospital environments’, found that NSW Health’s incident management system was not designed for rapid reporting.

NSW Ambulance station management staff reported to this audit that paramedics do not always submit incident reports to the IMS+ or are not submitting incident reports in a timely manner, which limits manager’s ability to respond, escalate, and/or monitor risks relating to staff wellbeing and welfare. Station management staff advised that in many instances, delays in reporting are occurring because the paramedic does not feel they have capacity to take the time to make the report.

NSW Ambulance is updating its suite of fatigue management policy documentation to reduce reliance on paramedic self-assessment of fatigue

NSW Ambulance rostering practices allow for some stations to utilise on-call resources. This practice can cause fatigue among paramedics rostered on shift following an on-call period.

NSW Ambulance developed a Work Related Fatigue Mitigation and Management Operating Procedure (the Procedure) in 2023 to provide guidance to staff about their individual responsibilities in this space. The Operating Procedure includes guidelines for employees to monitor and assess their own fatigue levels, as well as a description of the types of mitigation strategy actions employees can utilise to manage fatigue, and the process to notify managers and the control centre when they are in use.

The Procedure includes an ‘assessment of individual fatigue level’ protocol, which is a tool for paramedics rostered with an on-call component to assess their fatigue level. The tool requires paramedics to input hours of sleep over the past 24 and 48 hours and total waking hours since their last sleep (calculated from the end of the previous shift). The tool provides a score for each of the figures input by staff, with each score added together for a final total. The total score links paramedics to the steps they should take to manage their own fatigue.

NSW Ambulance has developed a new draft Fatigue Risk Management Operating Procedure and Business Requirements document in 2023 aimed at reducing its reliance on individual paramedics calculating and self-assessing fatigue levels. The draft operating procedure includes five levels of controls, which focus on managing:

• work hours (including ensuring workers have adequate opportunity to sleep between shifts and/or periods of work)
• individual fitness for duty
• identifying behavioural symptoms of fatigue
• task-based fatigue management
• fatigue-related incidents.

While the draft procedure still employs the use of a fatigue calculator to assist NSW Ambulance staff to assess their fatigue levels, the process of calculating fatigue levels is now automated. This allows Control Centre Officers and Managers to view individual fatigue data in real time to allow them to proactively manage and support staff experiencing fatigue. At the time of writing this report, NSW Ambulance advises that it is currently consulting with key stakeholders on the proposed new Fatigue Risk Management Operating Procedure.

NSW Ambulance’s electronic medical record system does not integrate with other NSW Health information systems, is approaching end-of-life, and there are no plans to update or replace it

The NSW Ambulance eMR (electronic medical record) system is one of NSW Ambulance’s primary datasets and is used to capture:

• information about the incident (e.g., reason for the call and scene location)
• patient information (e.g., demographics, injury/illness characterisation, vital signs, and assessment results)
• treatment details (e.g., pharmacology and interventions)
• outcomes (e.g., patient transported or not transported, died).

While the NSW Ambulance eMR system captures this specific incident information, it does not integrate with other NSW Health information systems. As a result:

• when transferring patients from ambulance to emergency departments, paramedics need to hard copy print NSW Ambulance referral notes at public hospitals which are then subsequently scanned by hospital administrative staff
• NSW Ambulance staff do not have access to potentially relevant clinical information
• Local Health District clinicians do not have access to potentially relevant clinical information
• tracking patient outcomes for the purposes of monitoring and evaluating integrated care programs that involve NSW Ambulance (such as alternate referral pathways) is resource intensive and inefficient.

In November 2022, NSW Ambulance and eHealth NSW developed a business case for the replacement and enhancement of NSW Ambulance’s eMR. The business case noted that the current version of the NSW Ambulance eMR is approaching end-of-life and has limitations which negatively impact clinicians’ ability to operate effectively.

In 2023, NSW Health announced its Single Digital Patient Record (SDPR) program, to be led by eHealth NSW. The SDPR is designed to replace multiple systems across the NSW Health system in use by Local Health Districts, Specialty Health Networks, and other NSW Health organisations, but does not include NSW Ambulance. eHealth anticipates that SDPR will be implemented over the six years from 2023 to 2029/30.

The purpose of the SDPR program is to establish one ‘digital clinical system’ across New South Wales, allowing clinicians to access patient information, record the care they provide, order diagnostic tests and manage medication from any public hospital or community health care facility across the state.

eHealth NSW advised the audit that it has taken effort to help NSW Ambulance address interoperability challenges relating to its eMR system, including:

• upgrading NSW Ambulance’s eMR to a newer version with better integration capabilities
• developing an interface between the NSW Ambulance and hospital eMRs
• developing a business case, in partnership with NSW Ambulance to replace its current eMR with a solution which would have improved integration capabilities.

It is unclear whether this business case has been considered for funding, as at the time of writing this report, neither NSW Ambulance, nor eHealth NSW could provide evidence to this effect.

eHealth NSW has reported to this audit that it intends to include NSW Ambulance in the SDPR, but this intention is not scoped, planned or funded. Additionally, the planned SDPR final product does not have the capability to support the needs of NSW Ambulance, and the vendor in use for the SPDR program has not committed to an expansion of its scope or changes to its product to meet the needs of NSW Ambulance.

NSW Ambulance, Murrumbidgee Local Health District and Southern NSW Local Health District effectively share information to raise risks and opportunities for improvement to service delivery

Local Health District and NSW Ambulance staff use many informal avenues for communication to facilitate information sharing and operational activities at a day-to-day level. Staff in Southern NSW Local Health District report that they regularly met with NSW Ambulance staff during COVID-19 to undertake planning activities, discuss ‘hot and cold zones’, and keep each other updated on changes as they occurred. Southern NSW Local Health District and Murrumbidgee Local Health District regularly inform NSW Ambulance regarding the availability of medical officers in their facilities because of the impact this may have on where paramedics can transfer patients.

The NSW Ambulance Health Relationship Manager position is key to local information sharing and raising or escalation of issues between NSW Ambulance and Local Health District staff. The position description for this role states its primary purpose is to ‘establish and maintain close working relationships with hospital and Local Health District stakeholders to improve the working relationships between NSW Ambulance and the primary health providers’, noting that the promotion of shared NSW Ambulance and NSW Health demand management initiatives, programs and policies is central to the role.

Each NSW Ambulance Zone is allotted one Health Relationship Manager. Staff at Murrumbidgee Local Health District and Southern NSW Local Health District highlighted the importance of the Health Relationship Manager role in facilitating a regular flow of open communication and issues resolution and reported local Health Relationship Managers are the key contact person for hospital staff in all matters involving NSW Ambulance.

Additionally, the Health Relationship Manager and, in some instances the NSW Ambulance Zone Manager, attend regular forums with Southern NSW Local Health District and Murrumbidgee Local Health District.

In the Southern Zone/Southern NSW Local Health District, this includes:

• the Stroke Care Clinical Governance Committee
• the Quarterly Southern NSW LHD & Ambulance Liaison Committee to discuss strategic trends, insights and improvements
• fortnightly Memorandum of Understanding meetings for mental health patients
• the Snowy Mountains Trauma Committee
• seasonal planning forums.

In Murrumbidgee Zone/Murrumbidgee Local Health District, this includes:

• daily (Monday to Friday) Patient Flow Unit meetings
• ambulance liaison meetings
• Memorandum of Understanding meetings for mental health patients.

The Ministry of Health and NSW Ambulance effectively share information to raise risks and facilitate opportunities for improvement to service delivery

Across the NSW Health system, NSW Health entities regularly collect, share and report performance data that extends beyond Key Performance Indicators included in Service Agreements. Key data sources include:

• Ministry of Health Patient Flow data: The Ministry of Health developed a Patient Flow Portal, which allows NSW Health staff, including Local Health District staff to track patient journeys through the health system. The portal has five main functions, which include:
  • Electronic Patient Journey Board: provides information about every patient on a ward that directly relates to coordinating care and managing patient flow.
  • Dashboard: a one-page overview of all current Patient Flow Portal activity. It identifies how many beds are required for that day, displays patients waiting in emergency departments, and identifies pending interhospital transfers.
  • Bed Board: provides an up-to-date view of occupancy by ward, hospital beds and Local Health District. Data includes the Estimated Date of Discharge and average length of stay for each patient. Bed Board records inter ward and inter hospital transfers and shows the status of the transfer (requested, confirmed, allocated, in progress and completed) and allows patient information to be sent to the receiving hospital or ward.
  • Predictive Tool: provides the prediction of hospital demand and capacity up to 14 days and assists in future planning
  • Report Module: provides access to pre-defined patient flow reports.
• NSW Ambulance data: NSW Ambulance collects data on its performance against key performance indicators and other performance metrics. This data is reported in dashboards which allow executive and local station staff to monitor performance. These dashboards can break performance data down to station, zone, sector, regional/metro and state wide levels. Data reported includes:
  • Emergency triple zero calls, and the number of priority incidents
  • Emergency response performance (including response times, scene time turnaround times, transfer of care and other related indicators)
  • Secondary triage performance, including HealthDirect call activity
  • Staff overtime, breaks missed.
• NSW Ambulance also routinely collects and reports data on patient experience, premium labour (overtime), staff experience, clinical incidents and work health and safety data.

Because of its ability to display capacity and waiting time information in one place, the Patient Flow Portal allows Local Health District and Ministry of Health Staff to monitor and manage performance against key performance indicators. Additionally, Local Health District staff report to this audit that the Patient Flow Portal is a key tool for the management of low-acuity patient transports.

Source: NSW Ambulance information and data, Audit Office analysis.

NSW Health entities (including NSW Ambulance and Local Health Districts) operate under roles and responsibilities set out in Service Agreements with the Secretary of Health

NSW Health entities, including NSW Ambulance and Local Health Districts are required to enter into annually updated Service Agreements with the New South Wales Secretary of Health. These Service Agreements include a description of current NSW Health legislation relevant to service delivery, NSW Health strategic priorities, a description or list of the purchased services under the Agreement, and performance measures for the period of the Agreement.

The 2023–24 Service Agreement between NSW Ambulance and the Secretary of Health contains a description of purchased services NSW Ambulance is responsible for delivering, a description of the activities covered under purchased services, as well as key performance indicators and performance deliverables. The current Service Agreement between Local Health Districts and the Secretary of Health contains a description of NSW Health services and networks, purchased volumes and services (including information relating to Activity, State wide dental services, and priority programs), and key performance indicators and performance deliverables.

Under the Service Agreement between NSW Ambulance and the Secretary of Health, NSW Ambulance is responsible for providing of emergency patient transport to local hospital emergency departments, demand management (which includes delivery of integrated care programs), and for working with HealthShare and Local Health Districts to reduce reliance on the emergency fleet for non-emergency patient transport in rural New South Wales.

Service Agreements between the Secretary of Health and Local Health Districts do not explicitly include any patient transport activities. However, Southern NSW Local Health District and Murrumbidgee Local Health District both provide non-emergency patient transport services (including some interhospital transfers) within their Districts.

The Ministry of Health has prioritised a reduction in the use of emergency ambulances for the provision of non-emergency patient transport, and HealthShare NSW tracks performance against this objective

The Ministry of Health has developed broad strategies to guide and inform the activities of the NSW Health system. Two of the key strategies in place for the health system in New South Wales are the Future Health Strategy 2022–2032 and the Regional Health Strategic Plan 2022–2032. Each of these strategies underpin the Service Agreements between NSW Ambulance and the Secretary of Health, and Local Health Districts and the Secretary of Health which states that the delivery of NSW Health strategies and priorities is ‘the responsibility of The Ministry of Health, health services and support organisations.’

The Future Health Strategy 2022–32 contains one strategic outcome and key objectives which relates to the provision of low-acuity patient transport:

• Strategic Outcome Two: Safe care is delivered across all settings. This outcome includes key objectives to strengthen equitable outcomes and access for rural, regional and priority populations and to align infrastructure and service planning around the future care needs.

The NSW Regional Health Strategic Plan 2022–32 contains one priority and four associated strategic objectives which relate to the provision of low-acuity patient transport:

• Priority Two: Enable better access to safe, high quality and timely health services. This priority is to be achieved through the following strategic objectives:
  •  improvement of local transport and access schemes
  •  delivering appropriate services in the community
  • driving and supporting… timely access
  • aligning infrastructure and sustainable service planning.

To support its Regional Health Strategic Plan, the Ministry of Health has also developed a Priority Framework, which sets out investment and initiatives, targets to reach by 2026, and strategic objectives for each of the priorities included under the plan. An initiative included in the Framework under Priority 2 is to reduce ambulance use in non-emergency patient transports through HealthShare NSW’s Patient Transport Service. However, Patient Transport Service does not operate throughout all of New South Wales, and the framework does not include provisions or plans to expand its scope. Of the three targets included under Priority 2, none relate to this initiative.

Under the Service Agreement between NSW Ambulance and the Secretary of Health, NSW Ambulance has responsibility to work with HealthShare and Local Health Districts to reduce reliance on the emergency fleet for non-emergency patient transport in rural New South Wales. The Service Agreement does not include any accompanying performance indicators or measures for this activity.
HealthShare NSW’s 2023–24 Statement of Service sets out HealthShare NSW’s service and performance expectations for the provision of patient transport. Included in the performance measures is a performance target for the number of patient transport jobs given to NSW Ambulance each month. The Statement of Service sets out a target of less than 150 jobs as ‘performing’ and defines ‘non-performing’ as greater than 250 jobs per month.

In 2022–23, NSW Ambulance provided 13,627 patient transports. This figure excludes interhospital transports, also known as P4 transports. Almost 80% of which took place in regional New South Wales. HealthShare NSW does not publicly report regular performance data against its targets and the data for 2023–24 is not yet available, so the audit is unable to determine whether the target is being achieved.

Rural and regional transport of patients under the Mental Health Act 2007 presents a significant resourcing challenge for regional ambulance services

The Mental Health Act 2007 mandates a 72-hour period under which people can be held for the purposes of conducting an assessment. After that time, all people held involuntarily under the Act must be treated within a declared mental health assessment and inpatient unit. In regional and rural New South Wales, this requires transporting patients to a smaller number of sites than is available in metropolitan areas, which are often long distances away from the health facility where they were initially assessed.

In the financial year 2022–23, Murrumbidgee Ambulance Zone reported 113 ambulance scheduled psychiatric transfers, with a median transport time of 84 minutes. In the same financial year, Southern NSW Ambulance Zone reported 155 scheduled psychiatric transfers, with a median transport time of 68 minutes. Refer to Appendix six for more data on this topic. On average, this represents more than two transfers per week in each Ambulance Zone. Furthermore, transport time only reflects the time taken to transport from the first location to an inpatient unit, and does not include transport to the first location, transfer of care, or the return travel time back to base.

NSW Ambulance and Local Health District staff advised the audit that these transfers can be resource intensive for significant periods of time and limit NSW Ambulance’s ability to respond to other emergencies. The audit also heard that when patients are transported long distances (for example from Jerilderie to Wagga Wagga), there is a reluctance from Local Health District staff to accompany patients due to concerns regarding understaffing and challenges in arranging transport back to the home facility. Local Health District staff report to this audit that it is challenging for Local Health Districts to provide staff to accompany patients, due to the risk of leaving facilities without the necessary level of staffing.

Source: Murrumbidgee Local Health District and NSW Ambulance, Audit Office analysis.

There is no single source of truth for non-emergency patient transport activity across New South Wales

NSW Ambulance and HealthShare NSW have developed non-emergency patient transport business rules, which outlines the process for transferring non-emergency patient transport requests between NSW Ambulance and HealthShare NSW Patient Transport Services. However, the process laid out in this document does not include provisions for, or consideration of, non-emergency patient transport carried out by Local Health Districts, except to note that existing agreements with Local Health Districts continue. The business rules also do not include any accompanying performance indicators or measures.

In addition to the business rules, NSW Health also developed its service specifications for non-emergency transport providers policy directive, which sets out expectations for non-emergency transport providers, including:

• transport and vehicle specifications
• transport staff service specifications
• classes of transport (describing the types of care required for each class and whether it is in or out of scope for non-emergency transport providers)
• clinical governance specifications
• record keeping specifications for individual transfers.

Although the service specifications policy directive includes record keeping directions for non-emergency transport providers, it does not include any accompanying performance indicators or measures against which non-emergency transport providers are required to report performance.

Local Health District staff report to this audit that outside of communications to NSW Ambulance requesting the provision of non-emergency patient transport, they do not share information with NSW Ambulance regarding the number of non-emergency transports undertaken by the Local Health Districts. While HealthShare NSW captures information recorded in the Patient Transport Service booking system for all Local Health Districts, except Far West Local Health District, it is not clear how state wide activity and performance data for non-emergency patient transport undertaken by Local Health Districts is reported to the Ministry of Health.

HealthShare NSW is exploring the possibility of expanding Patient Transport Services in regional Local Health Districts, but there are no current plans in place to expand its services

In May 2022, the NSW Parliament tabled the report for its inquiry into health outcomes and access to health and hospital services in rural, regional and remote New South Wales. The inquiry recommended that NSW Health review the use of ambulance vehicles for patient transfers and, in partnership with rural and regional Local Health Districts, explore extending the hours of operation of patient transfer vehicles to minimise the number of low-acuity jobs that paramedics attend to. The NSW Government supported this recommendation. NSW Health made HealthShare NSW responsible for the expansion of Patient Transport Services into regional and remote New South Wales and the use of private market providers to provide support in this area.

As at June 2023, NSW Health had not determined a delivery due date for these responsibilities and while HealthShare NSW has trialled an expansion of its Patient Transport Services into Hunter New England Local Health District since 2015, HealthShare NSW does not provide patient transport in six (of nine) rural and regional Local Health Districts. However rural and regional Local Health Districts, including the focus Local Health Districts for this audit – Murrumbidgee Local Health District and Southern NSW Local Health District – deliver non-emergency patient transport services within their districts. HealthShare NSW reports to this audit it has developed a proposed expansion of Patient Transport Service in regional and rural Local Health Districts, which has not yet received the official endorsement from key stakeholders required for the proposal to commence.

At an operational level relevant entities coordinate with each other to manage the use of non-emergency patient transport services

Under the Service Agreement between NSW Ambulance and the Secretary of Health, NSW Ambulance is responsible for providing emergency patient transport to local hospital Emergency Departments, as well as working with HealthShare and Local Health Districts to reduce reliance on the emergency fleet for non-emergency patient transport in rural New South Wales.

In addition to non-emergency patient transport, NSW Ambulance has Service Level Agreements with each Local Health District for to provide interhospital patient transport , which is defined as the provision of ambulance services to patients from a public hospital to another public hospital. Under these Service Level Agreements, NSW Ambulance is responsible for the provision of interhospital transports. Staff in Southern NSW Local Health District and Murrumbidgee Local Health District reported to this audit that their patient transport units also undertake interhospital patient transports.

In Metropolitan Sydney, Hunter New England, Nepean Blue Mountains, Central Coast and Illawarra Local Health Districts, HealthShare operates Patient Transport Service, which provides low-acuity patient transports for patients not requiring emergency ambulance transport. In Southern NSW Local Health District and Murrumbidgee Local Health District, the regional and rural New South Wales Local Health Districts this audit focused on, non-emergency patient transports are coordinated and provided in the first instance through Local Health Districts. Local Health Districts in these regions use a mixed approach of Local Health District-owned fleets and private and community operators, with NSW Ambulance providing coverage for transports Local Health Districts cannot complete.

Murrumbidgee and Southern NSW Local Health Districts operate non-emergency patient transports through a Patient Flow Unit and Patient Transport Unit respectively. These units:

• process requests for patient transports (including processing clinically relevant patient information, such as urgency or timeframe for transports to occur)
• manage patient transport vehicle fleets and drivers
• schedule transports
• send patient transport requests their staff are unable to complete to NSW Ambulance
• regularly liaise and coordinate with NSW Ambulance to coordinate and schedule non-emergency patient transport.

Murrumbidgee and Southern NSW Local Health District staff report they do not have enough resources available to complete all low-acuity patient transports within their districts, which requires them to rely on NSW Ambulance to fulfil those transports. NSW Ambulance uses different methods for triage and does not operate under the same access key performance indicators as Local Health District and hospital staff, which specify timeframes patients must be moved within. This means that when NSW Ambulance is required to complete low-acuity patient transports, it does so in a timeframe which does not always align with Local Health District requirements due to NSW Ambulance’s competing priorities to attend to emergency cases prior to providing non-emergency transport.

Community organisations across New South Wales also provide patient transport services but these are difficult to factor into planning

Patients in rural and regional New South Wales have fewer transportation options available to them when they require health care services. Across New South Wales, community transport providers sometimes provide non-emergency patient transport services, for example assisting patients to attend medical appointments.

Non-emergency patient transport services provided by community organisations can help to reduce demand on emergency ambulances, while also supporting the needs of patients without access to private vehicles and/or the financial means to pay for other private transport options.

The Local Health Districts included in this audit reported they frequently communicate with the community transport providers operating in their districts. However, as community services are often funded by multiple government agencies across jurisdictions, it is not clear to what extent NSW Health entities interact with, or oversee, non-emergency patient transport services provided by these organisations.

It is not clear whether NSW Health is progressing a plan to update its policy to guide health related transport provision, despite a Parliamentary inquiry and its own key strategy highlighting significant need in this space

Patients across New South Wales, but especially in regional and rural New South Wales, experience many transport related barriers which can hinder or block their ability to access health services for diagnosis, treatment, and care. These barriers include, but are not limited to:

• lack of access to private vehicles
• no or limited public transport availability
• no or limited private transport availability (e.g., taxis, community transport)
• lack of locally situated health care providers
• long distances travelled to reach health care services.

In 2006, NSW Health released its Transport for Health policy to assist NSW Health in simplifying and improving patient access to health services. Transport for Health was intended to integrate all non-emergency health-related transport provision into one program. The Isolated Patients Travel and Accommodation Assistance Scheme (IPTAAS), which provides financial assistance for travel to patients traveling more than 100km for medical treatment, was included under the umbrella of Transport for Health and is still in operation today.

The Transport for Health policy expired in 2011, and has not been replaced by NSW Health, with NSW Health acknowledging in internal documents from 2023 that previous attempts to update it were impacted by ‘the availability of resources, parallel reform processes and competing priorities.’

In November 2023, NSW Health developed a draft Transport for Health project plan as part of its plan to refresh the Transport for Health policy. This move came out of an agreement between the NSW Health Regional Health Division, Social Policy Branch, and HealthShare NSW to revise NSW Health’s approach to non-emergency transport which utilises a system-wide approach, but has a specific focus on regional, remote, and rural communities. The project plan notes:

The intended long term outcome of the project to update the Transport for Health strategy is to develop a refreshed approach to transport for Health which is reflective of current priorities and effectively facilitates access to care for all New South Wales residents. The project has been split into three phases and is expected to result in a report which includes:

• a detailed description of the current state of non-emergency patient transport
• identified gaps and barriers in the current state
• studies of exemplary New South Wales non-emergency patient transport programs
• high-level principles to support implementation of a seamless and connected approach to non-emergency patient transport
• informed recommendations for a refreshed approach based on key stakeholder insights
• identifies opportunities and strategies to improve access to care through transport for disadvantaged groups, including (but not limited to):
  • regional communities
  • Aboriginal communities
  • socioeconomic disadvantaged groups
  • renal dialysis patients.

The first phase of the project is a review of the current state of non-emergency patient transport across New South Wales, which includes non-emergency ambulance, non-emergency patient transport (including that provided by Patient Transport Service and Local Health Districts), the Isolated Patient Access and Accommodation Scheme, ride share, community transport, and active and public transport. This phase has been approved by the NSW Health Secretary, but it is not clear whether work has commenced.

Per the draft project plan, the project was planned to commence in December 2023, with each phase due as follows:

• Phase 1 – Review – March 2024
• Phase 2 – Analyse – April-May 2024
• Phase 3 – Report – June 2024.

It is not clear whether the project has commenced as planned, which means that currently, all health-related non-emergency transport in New South Wales is not guided by a central NSW Health policy position.

NSW Ambulance and Local Health Districts work to reduce demand on ambulance services and have implemented alternate referral pathways to reduce demand on emergency services

Under the Service Agreement between NSW Ambulance and the Secretary for Health, NSW Ambulance is responsible for demand management. This includes the delivery of integrated care initiatives and programs intended to improve integration across the health system and improve the patient experience through pathways for lower acuity patients. Integrated care initiatives can also include health promotion programs.

Our 2017 performance audit report, ‘Managing demand for ambulance services’ noted that links between NSW Ambulance and the broader health system were underdeveloped. In particular, the report noted relatively little evidence of collaboration on demand management initiatives. To support this finding, the audit recommended NSW Ambulance:

NSW Ambulance accepted the recommendation and finalised a Demand Management Strategy in 2018.

Alternate referral pathways are clinical guidelines that paramedics and NSW Ambulance clinicians (such as NSW Ambulance’s Virtual Clinical Care Centre) can use to refer patients assessed as not requiring emergency health care at a hospital Emergency Department. The aim of these pathways is to reduce avoidable transfers by ambulance to Emergency Departments, improve patient experience of care, and improve wait and transfer times for high-acuity triple zero calls. A patient may be eligible for an alternate referral pathway if, upon calling triple zero for an ambulance, or once assessed by a paramedic, triaging activities determine the patient requires lower-acuity care which can be provided through other health services outside of an Emergency Department.

NSW Ambulance partners with the Ministry of Health Local Health Districts and other health services to identify, develop, and implement alternate referral pathways to reduce unnecessary emergency department presentations.

These pathways often, but not always, involve the establishment of ‘entry points’ into the health system for patients (such as direct referral to urgent care clinics, or virtual assessment and management by mental health clinicians). Until recently, in regional New South Wales, the process to establish these pathways has taken place locally, with NSW Ambulance working with Local Health District staff to identify and develop pathways into local services.

Some of the types of services for which NSW Ambulance has alternate referral pathways in place in the areas visited for this audit include:

• Southern NSW Local Health District/Southern Zone:
  • hospital clinic: the Rapid Assessment Unit at the Canberra Hospital
  • virtual care: virtual enhanced community care
  • mental health: PACER.
• Murrumbidgee Local Health District/Murrumbidgee Zone:
  • hospital clinic: the Rapid Access Clinic at Wagga Wagga
  • urgent care: Wodonga Priority Patient Care
  • mental health: PACER.

The ability of NSW Ambulance to establish and implement alternate referral pathways is limited by the availability of healthcare services and medical officers in regional New South Wales. This means, in the absence of a viable alternative, patients may be transported to hospital emergency departments.

NSW Ambulance and the Ministry of Health are in the process of centralising the procedure to develop alternate referral pathways, through the establishment of a principle-based approach

Currently, many of the alternate referral pathways used by NSW Ambulance staff are Local Health District specific. Between Local Health Districts, pathways with similar purposes and approaches (such as PACER) have different operating hours, exclusion/inclusion criteria and governance. NSW Ambulance staff interviewed as part of this audit have expressed a desire to move towards a ‘standardised’ set of alternate referral pathways.

The Ministry of Health and NSW Ambulance are centralising the process to develop alternate referral pathways, through the establishment of a principle-based approach. NSW Ambulance has developed internal documentation to support the project, which would see NSW Ambulance implement a formalised co-governance structure to establish alternate referral pathways, in partnership with health service providers, with each pathway overseen by an advisory committee.

There is a risk that this approach may result in the loss of localised knowledge, including opportunities to leverage local relationships to develop locally specific alternate pathways. For example, NSW Ambulance paramedics have reported to this audit they can sometimes refer patients directly to local GPs because of their relationships with local providers. It is important that as the Ministry of Health and NSW Ambulance proceed with the plan to centralise processes to establish alternate referral pathways, local staff can still leverage local knowledge and local relationships to continue reducing demand on emergency services.

There is no central monitoring or evaluation framework for ambulance referral pathways

The Ministry of Health developed the Pathways for NSW Ambulance Referrals Project to centralise and standardise the process to develop alternate referral pathways. The project also includes a plan to create a governance monitoring plan for all alternate referral pathways in use across the state. However, there is currently no agreed performance monitoring framework in place for the oversight of alternate referral pathways in use across the NSW Health system.

Our 2017 performance audit report, ‘Managing demand for ambulance services’ noted:

Specifically, the Auditor-General recommended that NSW Ambulance determine the data system improvements required to provide accurate oversight of demand management initiatives.

In 2019, as part of its inquiry ‘Examination of the Auditor-General’s Performance Audit Reports May 2017 – December 2017’, the Public Accounts Committee requested that NSW Ambulance update the committee on its progress in implementing this recommendation. In response, NSW Ambulance noted that 'new technology was now fully operational, with greater individualised reporting capability. A series of updates to the electronic medical record (eMR) had been released or were in train.' NSW Ambulance further noted that the updates to the eMR had improved the quality of its reporting.

NSW Ambulance reported it completes evaluations of the alternate referral pathways it has established but only provided an evaluation for the Frequent User Management Program, which is a demand management model of care. NSW Ambulance provided evidence of performance monitoring activities it undertakes for some alternate referral pathways, which include:

• a steering committee for Elderly and Frail Connected Pathways
• a presentation of activity and performance for the NSW Ambulance Arrivals Board and Intouch referral service (including numbers of referrals and ED avoidances and analysis of outcomes data)
• documentation for the Mental Health First Responder pathway rollout, including steering committee minutes and agenda, a rollout plan, rollout progress report and other Mental Health First Responder rollout related documentation.

It is not clear whether NSW Ambulance currently uses a uniform approach to referral pathway performance monitoring. NSW Ambulance reports to this audit that, as it does not hold control over the service delivery of referral pathways, referral pathway performance monitoring should be assessed by service delivery partners.