NSW Ambulance has introduced several initiatives over the past decade to better manage the number of unnecessary ambulance responses and transports to hospital emergency departments. However, there is no overall strategy to guide the development of these initiatives nor do NSW Ambulance's data systems properly monitor their impact. As a result, the Audit Office was unable to assess whether NSW Ambulance's approach to managing demand is improving the efficiency of ambulance services.
1. Key findings
1.1 Overview of NSW Ambulance
NSW Ambulance's main role is providing emergency health care and transport. It also provides care and transport for many patients with less urgent medical conditions. NSW Ambulance categorises calls for assistance into nine priority codes (Exhibit 2).
|1||1A Emergency||Highest priority, life-threatening case||Cardiac or respiratory arrest, unconscious, ineffective breathing||
|1B Emergency||High priority||Unconscious||Emergency response
|1C Emergency||Priority||Breathing problems, chest or neck injury, serious haemorrhage||Emergency response
|2||Urgent||Urgent||Abdominal pain||Urgent response without 'lights and sirens' within specified timeframes|
|3||Time-critical||Time-critical||Medical response requested by medical practitioners||Undelayed response within specified timeframes|
1.2 About the audit
2. Demand for ambulance services
2.1 Trends in demand for ambulance services
2.2 Trends in ambulance efficiency
Triple zero call answering time performance has declined as demand has increased
NSW Ambulance has a key performance indicator to answer 90 per cent of triple zero calls within ten seconds. Performance against this target decreased by more than eleven percentage points from 2012–13 to 2016–17. The number of emergency and urgent incidents increased by nine per cent during this period (Exhibit 5). The reduction in call answering time performance indicates that NSW Ambulance call centres are not able to meet demand consistently. NSW Ambulance does not have reliable data on the number of triple zero calls it receives. We have used data on emergency and urgent incidents (see Exhibit 2) as a proxy in the absence of reliable data for triple zero calls.
In 2015–16, NSW Ambulance was the only Australian ambulance service that did not meet the 90 per cent benchmark. Its performance was more than ten percentage points worse than every other jurisdiction.
Source: Underlying incident data from Bureau of Health Information Healthcare Quarterly April-June 2017 (unpublished).Call answering time performance data from Productivity Commission, ‘Report on Government Services 2017’, Volume E, Chapter 11, Table 11A.15 and from NSW Ambulance.
Changes to the way calls are prioritised have helped maintain priority one response times
NSW Ambulance has made significant changes to the way it prioritises triple zero calls over the last five years. It changed the definition of a priority one call by moving about 50 types of medical issue from the priority one incident category to priority two (Exhibit 6). The changes were based on a comparison with the approaches of ambulance services in comparable jurisdictions in 2013 and were reviewed by a NSW Ambulance clinical safety committee.
There was a 31 per cent reduction in the number of incidents classified as priority one from 2012–13 to 2016–17 (Exhibit 6). This reduction means about 460 fewer ambulance responses per day are required to respond with lights and sirens. Despite the large reduction in the number of incidents classified as priority one over the past five years, NSW Ambulance's median ambulance response time for priority one incidents has only been maintained, rather than improving. It has remained at around 11 minutes for the last five years (Exhibit 7).
NSW Ambulance has made major changes to reduce demand for its services in recent years. Non-emergency patient transport has been almost completely removed from its workload and the number of calls classified as priority one has reduced by almost one third. NSW Ambulance anticipated that these changes would improve its priority one response times but this has not occurred. NSW Ambulance is unlikely to be able to find significant further efficiency improvements in these areas. This indicates that it will need to find additional ways to deal with forecast increases in demand for services in the future.
NSW Ambulance pays significant overtime and penalty payments to paramedics
NSW Ambulance has done extensive planning work in recent years to identify patterns in demand for its services. Despite this, there are signs of inefficiency in NSW Ambulance’s use of resources.
NSW Ambulance has consistently high rates of unplanned overtime payments. In 2016–17, NSW Ambulance paid more than $36 million in overtime to cover unexpected staff absences and extensions of shifts. More than nine out of every ten NSW Ambulance staff received an overtime payment in 2016–17 and six staff were paid more than $100,000 in overtime.
When paramedics miss a scheduled meal break because they are required to remain available to respond to calls, they receive a penalty payment in addition to their annual salary. In 2016–17, NSW Ambulance paid more than $10.5 million to paramedics due to missed meal breaks. This is the equivalent of about 140 full-time first-year paramedic graduate salaries.
The nature of paramedic work means that some unplanned overtime and missed meal breaks are unavoidable. However, the frequency of these issues at NSW Ambulance indicate that staff resources are not being organised as efficiently as possible. In addition to the financial impact, overtime and missed meal breaks can reduce service quality and employee health and safety if employees become fatigued from working too long without adequate breaks. NSW Ambulance has a high sick leave rate. In 2016–17, NSW Ambulance staff took an average of 85 hours of sick leave each. This is the equivalent of more than two standard working weeks and is considerably higher than the NSW Health average of 62 hours.
3. Initiatives to improve demand management
NSW Ambulance uses a telephone referral system to manage triple zero calls from people with medical issues that do not require an ambulance. This has the potential to achieve efficiency improvements but there are weaknesses in NSW Ambulance's use and monitoring of this system. Paramedics are now able to make decisions about whether patients need transport to a hospital emergency department. NSW Ambulance does not routinely measure or monitor the decisions paramedics make, so it does not know whether these decisions are improving efficiency. Extended Care Paramedics who have additional skills in diagnosing and treating patients with less urgent medical issues were introduced in 2007. NSW Ambulance analysis indicates that these paramedics have the potential to improve efficiency, but have not been used as effectively as possible.
Our 2013 audit of NSW Ambulance found that accurate monitoring of activity and performance was not being conducted. More than four years later, this remains the case.
3.1 Using telephone referrals to reduce unnecessary ambulance responses
Correctly identifying the type of response needed to a triple zero call is one of the most important factors in efficient and safe use of ambulance resources. NSW Ambulance refers some triple zero calls that it assesses as non-urgent to the Healthdirect telephone advice service. Healthdirect is a national provider of health services that is jointly funded by the Australian Government and some state governments including the NSW Government. The Healthdirect telephone service is staffed by registered nurses who provide advice to people about less serious medical issues. This includes advice on whether they can care for themselves or should see another health professional such as a general practitioner or dentist. Using this service is intended to make more efficient use of ambulance and health resources, while also providing more appropriate care to people with less urgent medical issues.
Efficiency gains from telephone referral cannot be assessed reliably
NSW Ambulance reports that in 2016–17, approximately 35,000 calls were sent to Healthdirect which is around four per cent of all triple zero calls received. This is an increase from 2011–12 reported figures, when around 27,000 calls were referred to Healthdirect. We were unable to validate these figures because of weaknesses in NSW Ambulance’s data system. This system does not allow accurate routine monitoring of calls referred to Healthdirect. During the audit, we were provided with conflicting information on the use and performance of Healthdirect. This prevented us from assessing its impact on the efficiency of ambulance services.
NSW Ambulance reports that Healthdirect returns about 60 per cent of calls that NSW Ambulance has transferred. We were also unable to verify this figure from the data provided. The large number of returned calls increases the double-handling at ambulance telephone control centres. NSW Ambulance reports that almost one quarter of the calls that are returned from Healthdirect are automatically escalated to an emergency priority one response. This occurs because NSW Ambulance has decided this is the appropriate risk management approach for returned calls, even though not all callers require this level of response. More than half of the calls returned are for patients who do not have an emergency medical issue but are unable to transport themselves to a hospital.
NSW Ambulance staff advised that it pays Healthdirect about $27 for each call transferred, regardless of whether Healthdirect resolves the patient's medical issue or returns the call for an ambulance response. NSW Ambulance could not provide documentation to verify this figure. NSW Ambulance has not completed detailed analysis of the reasons that calls are returned or whether the call return process is triggering an unnecessary number of emergency responses. Our ability to analyse this in more detail was hampered by the late provision of data relating to Healthdirect by NSW Ambulance.
Systems for monitoring patient outcomes are not comprehensive
NSW Ambulance considers a referral to Healthdirect that is not returned for an ambulance response as a successful referral. However, NSW Ambulance does not know what the health outcomes are for people it refers to Healthdirect. It does not know whether their issue was resolved on the telephone, referred to another health provider, or if the caller later called triple zero again.
A steering committee meets every second month to discuss operational issues including complaints and safety incidents. The committee includes representatives from Healthdirect, NSW Ambulance and other Australian ambulance services that use Healthdirect. NSW Ambulance and Healthdirect review a sample of 50 calls per month that were referred to Healthdirect. This review assesses whether the calls referred were appropriate for transfer to Healthdirect and whether Healthdirect handled the call correctly.
Complaints are one of the main sources NSW Ambulance uses to identify problems with use of Healthdirect. However, complaints about Healthdirect cannot be reliably identified within NSW Ambulance's complaints management system due to inconsistent data entry practices and limitations with the system itself. This means NSW Ambulance does not have a comprehensive way of tracking or reporting on trends in complaints about Healthdirect.
A small number of calls referred by NSW Ambulance to Healthdirect are returned because the Healthdirect nurse assesses the patient as having a life-threatening medical condition. NSW Ambulance advised that it investigates each of these cases individually, but it does not have a system to monitor these incidents. It could not provide us with the number of times this had happened in New South Wales since it started using Healthdirect in 2012.
Other jurisdictions achieve higher referral rates than New South Wales
Several other comparable jurisdictions operate telephone referral systems that have better reported performance than NSW Ambulance's use of Healthdirect. In 2015–16, Ambulance Victoria referred nine per cent of triple zero calls to its telephone referral service. In England, around ten per cent of calls to ambulance services in England are resolved by telephone advice. St Johns Ambulance in Auckland reports referring 19 per cent of emergency calls to its telephone advice system. Each of these jurisdictions uses telephone referral services staffed by paramedics and registered nurses that are employed directly by the ambulance service. In Western Australia, where Healthdirect is used, 13 per cent of triple zero calls for ambulances were referred to Healthdirect in 2015.
Prior to using the Healthdirect service, NSW Ambulance operated an internal referral service for calls from people with less urgent medical issues. Our audit of NSW Ambulance in 2013 found over 50,000 calls were referred to this system in 2010–11, which is around 15,000 more than the reported number of calls referred to Healthdirect in 2016–17. NSW Ambulance did not consider the previous system to be effective, but could not provide any evidence that it evaluated it or considered alternative options to Healthdirect before signing its current contract. NSW Ambulance has a four-year contract with Healthdirect to provide this service until 30 June 2018.
3.2 Avoiding unnecessary transport to hospital emergency departments
Transporting a patient to a hospital emergency department in an ambulance is the most expensive way to respond to a triple zero call due to the time and resources used. It is also expensive for the health system because the estimated cost of treating a patient in an emergency department is higher than treatment by other health providers such as general practitioners.
NSW Ambulance has introduced options for paramedics to avoid transporting a patient to hospital if they do not need emergency medical treatment. These include referral to other health providers such as a general practitioner, treating patients at the scene, or giving patients advice on how to care for themselves if they have a minor health issue. The average time spent on a response where the patient is not transported to hospital is around 35 to 40 minutes less than the time taken in cases where the patient is transported to hospital.
NSW Ambulance reports that it now transports a smaller proportion of patients to hospital emergency departments
NSW Ambulance reports that the proportion of ambulance patients who were treated at the scene rather than being transported to hospital increased from 14 per cent in 2011–12 to 20 per cent in 2015–16. We were unable to validate these figures because of weaknesses in NSW Ambulance’s data system. This system does not allow the routine monitoring of the non-transport rate and changes made to this system over time mean comparisons across years are not reliable.
NSW Ambulance's targets for reducing unnecessary transport to hospital are not clear. Our 2013 audit noted that NSW Ambulance had a goal of reducing unnecessary transports by 125,000 per year, but was not measuring the use of non-transport options by paramedics. NSW Ambulance has still not developed a reliable way of measuring its non-transport rate.
Most paramedics support the use of non-emergency department options, but many lack confidence in using them
Responses from paramedics to our survey indicate that there is support for and understanding of the use of non-emergency department options for suitable patients. Around two thirds of paramedics who responded to our survey agreed that they consider less urgent care to be a part of their role as paramedics, and that they understand the goals of these pathways (Exhibit 8).
Source: NSW Audit Office survey of NSW Ambulance paramedics, July 2017. Total responses = 440.
However, fewer than half of respondents said they were confident using alternatives to emergency department transport, or that they used these pathways regularly (Exhibit 9). Over one third of respondents indicated they do not feel confident in using non-emergency department options for potentially suitable patients.
Source: NSW Audit Office survey of NSW Ambulance paramedics, July 2017.
Paramedics report multiple barriers to using non-emergency department options
Making assessment and referral decisions requires significantly more judgement on the part of paramedics compared to transporting all patients to hospital emergency departments. NSW Ambulance gives paramedics guidelines which they must use to decide whether to transport a patient to a hospital emergency department.
Training courses for using these guidelines to assess patients and make referral decisions were provided to paramedics. NSW Ambulance operational managers told us that paramedics do not have consistent on the job training or structured opportunities for feedback about using non-emergency department options. NSW Ambulance operates a clinical advice line that paramedics can call for advice on decision making, but this is rarely used.
Many paramedics who responded to our survey indicated they did not have adequate support to use non-emergency department options. Less than a quarter agreed that they had received enough training or could easily refer patients to services other than hospital emergency departments. Only 26 per cent agreed that their manager would support their decisions when using non-emergency department options for patients (Exhibit 10).
The most commonly cited examples that would help paramedics to make better use of non-emergency department options were more training and information or resources about referral options. This was raised by over 40 per cent of the paramedics who responded to our survey. The next most common area for improvement identified by paramedics was better support by managers for the decisions made by staff.
These findings are consistent with similar surveys conducted by NSW Ambulance in 2013 and 2016. NSW Ambulance has made some effort to address these issues, including changing the wording of some guidance documents and circulating more information about the use of non‑emergency department options. Responses to our survey indicate more comprehensive strategies are required to change paramedic attitudes to using non-emergency department options.
Source: NSW Audit Office survey of NSW Ambulance paramedics, July 2017. Total responses = 434.
Paramedics do not always have access to suitable referral options for patients
A 2016 NSW Ambulance evaluation found that of those patients who were not transported to hospital, around 85 per cent received self-care advice with no further medical services required. The remaining 15 per cent were referred to other service providers, such as general practitioners or a community health service.
In our survey, paramedics noted the limited availability of after-hours services. This is evident in data from NSW Ambulance showing a decline in the number of referrals to other services outside business hours. Despite formal agreements in place with after-hours general practice services, the most recent NSW Ambulance analysis has shown that these services are rarely used, averaging one referral per day in 2015.
Several local projects are exploring ways to reduce unnecessary transport to hospital
Over the past five years, NSW Ambulance regions have trialled new approaches to provide paramedics with alternatives to unnecessary transport to hospital emergency departments, including transporting or referring patients to other facilities. Transport to other facilities (such as a general practitioner or specialist practitioner) represent less than one per cent of patients assessed as not requiring transport to an emergency department.
These initiatives largely focus on demographic groups where demand is expected to increase, such as mental health and aged care. Some trial projects have shown promising early results, but evidence on their effectiveness is limited and most have not been rolled out beyond a small local area (Exhibit 11).
|Frequent Users Management program||This program aims to reduce the number of unnecessary triple zero calls from frequent users of NSW Ambulance services. Internal evaluation of the program estimated a reduction in the number of calls from program participants. This program stopped accepting new participants in 2017 due to lack of capacity.|
|Integrated Paramedic Screening and Streaming||This project involves patients being transported to one of two Urgent Care Centres instead of the Emergency Department at their local public hospital. Internal evaluation found some positive effects for reducing the number of transports to the emergency department, also showing benefits for reducing the total time spent per patient. The project has not been rolled out in other areas.|
|Mental Health Acute Assessment Team||This project targets patients experiencing an acute mental health crisis. Internal evaluation reported a small increase in the number of patients bypassing the emergency department. However, the crew allocated to this program was only utilised about 50 per cent of the time.|
|Police and Ambulance Early Access to Mental Health Assessment via Telehealth||This project recently commenced in the Hunter New England region, led by the Hunter New England Local Health District. This project provides paramedics with tablet devices to access resources and telehealth specialist support for managing patients in acute mental health crisis.|
|Authorised Care Plans||NSW Ambulance has introduced general authorised care plans as well as palliative care plans. These plans assist paramedics in supporting patients’ wishes and general practitioner instructions for managing chronic or terminal conditions, and avoiding unnecessary transport to emergency departments. Over 3,000 plans have now been registered across the state.|
|Aged Care initiatives||NSW Ambulance is working with Local Health Districts and Primary Health Networks to establish a range of local aged care initiatives such as referral pathways to geriatric outreach services, and building capability within residential aged care facilities to reduce transports to hospital.|
3.3 Using specialist paramedics to avoid unnecessary transport to hospital emergency departments
4. Implementation of demand management initiatives
NSW Ambulance has recognised the need to change the way it manages demand and has developed initiatives that have the potential to improve efficiency. However, there are significant weaknesses in the strategy for and implementation of its demand management initiatives.
NSW Ambulance has identified the goal of moving from an emergency transport provider to a mobile health service and developed several initiatives to support this. Its demand management initiatives have the potential to contribute to the broader policy directions for the health system in New South Wales. However, there is no clear overall strategy guiding these initiatives and their implementation has been poor.
NSW Ambulance's reasons for changing its approach to demand management have not been communicated proactively to the community. Demand management initiatives that have been operating for over a decade still do not have clear performance measures or targets. Project management of new initiatives has been inadequate, with insufficient organisational resources to oversee them and inadequate engagement with other healthcare providers.
NSW Ambulance uses an in-house Vocational Education and Training course to recruit some paramedics, as well as recruiting paramedics who have completed a university degree. No other Australian ambulance services continue to provide their own Vocational Education and Training qualifications. Paramedics will need more support in several key areas to be able to fulfil their expanded roles in providing a mobile health service. Performance and development systems for paramedics are not used effectively. Up to date technology would help paramedics make better decisions and improve NSW Ambulance's ability to monitor demand management activity.
There are gaps in NSW Ambulance's oversight of the risks of some of the initiatives it has introduced, particularly its lack of information on the outcomes for patients who are not transported to hospital. Weaknesses in the way NSW Ambulance uses its data limit its ability to properly assess the risks of the demand management initiatives it has introduced.
4.1 Prioritising demand management initiatives
4.2 Providing resources for demand management initiatives
4.3 Managing the risks of new demand management initiatives
Parliamentary reference - Report number #295 - released 13 December 2017