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Actions for Internal Controls and Governance 2017

Internal Controls and Governance 2017

Finance
Education
Community Services
Health
Justice
Whole of Government
Asset valuation
Compliance
Cyber security
Information technology
Internal controls and governance
Project management
Risk

Agencies need to do more to address risks posed by information technology (IT).

Effective internal controls and governance systems help agencies to operate efficiently and effectively and comply with relevant laws, standards and policies. We assessed how well agencies are implementing these systems, and highlighted opportunities for improvement.
 

1. Overall trends

New and repeat findings

The number of reported financial and IT control deficiencies has fallen, but many previously reported findings remain unresolved.

High risk findings

Poor systems implementations contributed to the seven high risk internal control deficiencies that could affect agencies.

Common findings

Poor IT controls are the most commonly reported deficiency across agencies, followed by governance issues relating to cyber security, capital projects, continuous disclosure, shared services, ethics and risk management maturity.

2. Information Technology

IT security

Only two-thirds of agencies are complying with their own policies on IT security. Agencies need to tighten user access and password controls.

Cyber security

Agencies do not have a common view on what constitutes a cyber attack, which limits understanding the extent of the cyber security threat.

Other IT systems

Agencies can improve their disaster recovery plans and the change control processes they use when updating IT systems.

3. Asset Management

Capital investment

Agencies report delays delivering against the significant increase in their budgets for capital projects.

Capital projects

Agencies are underspending their capital budgets and some can improve capital project governance.

Asset disposals

Eleven per cent of agencies were required to sell their real property through Property NSW but didn’t. And eight per cent of agencies can improve their asset disposal processes.

4. Governance

Governance arrangements

Sixty-four per cent of agencies’ disclosure policies support communication of key performance information and prompt public reporting of significant issues.

Shared services

Fifty-nine per cent of agencies use shared services, yet 14 per cent do not have service level agreements in place and 20 per cent can strengthen the performance standards they set.

5. Ethics and Conduct

Ethical framework

Agencies can reinforce their ethical frameworks by updating code‑of‑conduct policies and publishing a Statement of Business Ethics.

Conflicts of interest

All agencies we reviewed have a code of conduct, but they can still improve the way they update and manage their codes to reduce the risk of fraud and unethical behaviour.

6. Risk Management 

Risk management maturity

All agencies have implemented risk management frameworks, but with varying levels of maturity.

Risk management elements

Many agencies can improve risk registers and strengthen their risk culture, particularly in the way that they report risks to their lead agency.

This report covers the findings and recommendations from our 2016–17 financial audits related to the internal controls and governance of the 39 largest agencies (refer to Appendix three) in the NSW public sector. These agencies represent about 95 per cent of total expenditure for all NSW agencies and were considered to be a large enough group to identify common issues and insights.

The findings in this report should not be used to draw conclusions on the effectiveness of individual agency control environments and governance arrangements. Specific financial reporting, controls and service delivery comments are included in the individual 2017 cluster financial audit reports tabled in Parliament from October to December 2017.

This new report offers strategic insight on the public sector as a whole

In previous years, we have commented on internal control and governance issues in the volumes we published on each ‘cluster’ or agency sector, generally between October and December. To add further value, we then commented more broadly about the issues identified for the public sector as a whole at the start of the following year.

This year, we have created this report dedicated to internal controls and governance. This will help Parliament to understand broad issues affecting the public sector, and help agencies to compare their own performance against that of their peers.

Without strong control measures and governance systems, agencies face increased risks in their financial management and service delivery. If they do not, for example, properly authorise payments or manage conflicts of interest, they are at greater risk of fraud. If they do not have strong information technology (IT) systems, sensitive and trusted information may be at risk of unauthorised access and misuse.

These problems can in turn reduce the efficiency of agency operations, increase their costs and reduce the quality of the services they deliver.

Our audits do not review every control or governance measure every year. We select a range of measures, and report on those that present the most significant risks that agencies should mitigate. This report divides these into the following six areas:

  1. Overall trends
  2. Information technology
  3. Asset management
  4. Governance
  5. Ethics and conduct
  6. Risk management.

Internal controls are processes, policies and procedures that help agencies to:

  • operate effectively and efficiently
  • produce reliable financial reports
  • comply with laws and regulations.

This chapter outlines the overall trends for agency controls and governance issues, including the number of findings, level of risk and the most common deficiencies we found across agencies. The rest of this volume then illustrates this year’s controls and governance findings in more detail.

Issues

Recommendations

1.1 New and repeat findings

The number of internal control deficiencies reduced over the past three years, but new higher-risk information technology (IT) control deficiencies were reported in 2016–17.

Deficiencies repeated from previous years still make up a sizeable proportion of all internal control deficiencies.

Recommendation

Agencies should focus on emerging IT risks, but also manage new IT risks, reduce existing IT control deficiencies, and address repeat internal control deficiencies on a more timely basis.

1.2 High risk findings

We found seven high risk internal control deficiencies, which might significantly affect agencies.

Recommendation

Agencies should rectify high risk internal control deficiencies as a priority

1.3 Common findings

The most common internal control deficiencies related to poor or absent IT controls.

We found some common governance deficiencies across multiple agencies.

Recommendation

Agencies should coordinate actions and resources to help rectify common IT control and governance deficiencies.

Information technology (IT) has become increasingly important for government agencies’ financial reporting and to deliver their services efficiently and effectively. Our audits reviewed whether agencies have effective controls in place over their IT systems. We found that IT security remains the source of many control weakness in agencies.

Issues Recommendations

2.1 IT security

User access administration

While 95 per cent of agencies have policies about user access, about two-thirds were compliant with these policies. Agencies can improve how they grant, change and end user access to their systems.

Recommendation

Agencies should strengthen user access administration to prevent inappropriate access to sensitive systems. Agencies should:

  • establish and enforce clear policies and procedures
  • review user access regularly
  • remove user access for terminated staff promptly
  • change user access for transferred staff promptly.

Privileged access

Sixty-eight per cent of agencies do not adequately manage who can access their information systems, and many do not sufficiently monitor or restrict privileged access.

Recommendation

Agencies should tighten privileged user access to protect their information systems and reduce the risks of data misuse and fraud. Agencies should ensure they:

  • only grant privileged access in line with the responsibilities of a position
  • review the level of access regularly
  • limit privileged access to necessary functions and data
  • monitor privileged user account activity on a regular basis.

Password controls

Forty-one per cent of agencies did not meet either their own standards or minimum standards for password controls.

Recommendation

Agencies should review and enforce password controls to strengthen security over sensitive systems. As a minimum, password parameters should include:

  • minimum password lengths and complexity requirements
  • limits on the number of failed log-in attempts
  • password history (such as the number of passwords remembered)
  • maximum and minimum password ages.

2.2 Cyber Security

Cyber security framework

Agencies do not have a common view on what constitutes a cyber attack, which limits understanding the extent of the cyber security threat.

Recommendation

The Department of Finance, Services and Innovation should revisit its existing framework to develop a shared cyber security terminology and strengthen the current reporting requirements for cyber incidents.

Cyber security strategies

While 82 per cent of agencies have dedicated resources to address cyber security, they can strengthen their strategies, expertise and staff awareness.

Recommendations

The Department of Finance, Services and Innovation should:

  • mandate minimum standards and require agencies to regularly assess and report on how well they mitigate cyber security risks against these standards
  • develop a framework that provides for cyber security training.

Agencies should ensure they adequately resource staff dedicated to cyber security.

2.3 Other IT systems

Change control processes

Some agencies need to improve change control processes to avoid unauthorised or inaccurate system changes.

Recommendation

Agencies should consistently perform user acceptance testing before system upgrades and changes. They should also properly approve and document changes to IT systems.

Disaster recovery planning

Agencies can do more to adequately assess critical business systems to enforce effective disaster recovery plans. This includes reviewing and testing their plans on a timely basis.

Recommendation

Agencies should complete business impact analyses to strengthen disaster recovery plans, then regularly test and update their plans.

Agency service delivery relies on developing and renewing infrastructure assets such as schools, hospitals, roads, or public housing. Agencies are currently investing significantly in new assets. Agencies need to manage the scale and volume of current capital projects in order to deliver new infrastructure on time, on budget and realise the intended benefits. We found agencies can improve how they:

  • manage their major capital projects
  • dispose of existing assets.
Issues Recommendations or conclusions

3.1 Capital investment

Capital asset investment ratios

Most agencies report high capital investment ratios, but one-third of agencies’ capital investment ratios are less than one.

Recommendation

Agencies with high capital asset investment ratios should ensure their project management and delivery functions have the capacity to deliver their current and forward work programs.

Volume of capital spending

Most agencies have significant forward spending commitments for capital projects. However, agencies’ actual capital expenditure has been below budget for the last three years.

Conclusion

The significant increase in capital budget underspends warrant investigation, particularly where this has resulted from slower than expected delivery of projects from previous years.

3.2 Capital projects

Major capital projects

Agencies’ major capital projects were underspent by 13 percent against their budgets.

Conclusion

The causes of agency budget underspends warrant investigation to ensure the NSW Government’s infrastructure commitment is delivered on time.

Capital project governance

Agencies do not consistently prepare business cases or use project steering committees to oversee major capital projects.

Conclusion

Agencies that have project management processes that include robust business cases and regular updates to their steering committees (or equivalent) are better able to provide those projects with strategic direction and oversight.

3.3. Asset disposals

Asset disposal procedures

Agencies need to strengthen their asset disposal procedures.

Recommendations

Agencies should have formal processes for disposing of surplus properties.

Agencies should use Property NSW to manage real property sales unless, as in the case for State owned corporations, they have been granted an exemption.

Governance refers to the high-level frameworks, processes and behaviours that help an organisation to achieve its objectives, comply with legal and other requirements, and meet a high standard of probity, accountability and transparency.

This chapter sets out the governance lighthouse model the Audit Office developed to help agencies reach best practice. It then focuses on two key areas: continuous disclosure and shared services arrangements. The following two chapters look at findings related to ethics and risk management.

Issues Recommendations or conclusions

4.1 Governance arrangements

Continuous disclosure

Continuous disclosure promotes improved performance and public trust and aides better decision-making. Continuous disclosure is only mandatory for NSW Government Businesses such as State owned corporations.

Conclusion

Some agencies promote transparency and accountability by publishing on their websites a continuous disclosure policy that provides for, and encourages:

  • regular public disclosure of key performance information
  • disclosure of both positive and negative information
  • prompt reporting of significant issues.

4.2 Shared services

Service level agreements

Some agencies do not have service level agreements for their shared service arrangements.

Many of the agreements that do exist do not adequately specify controls, performance or reporting requirements. This reduces the effectiveness of shared services arrangements.

Conclusion

Agencies are better able to manage the quality and timeliness of shared service arrangements where they have a service level agreement in place. Ideally, the terms of service should be agreed before services are transferred to the service provider and:

  • specify the controls a provider must maintain
  • specify key performance targets
  • include penalties for non-compliance.

Shared service performance

Some agencies do not set performance standards for their shared service providers or regularly review performance results.

Conclusion

Agencies can achieve better results from shared service arrangements when they regularly monitor the performance of shared service providers using key measures for the benefits realised, costs saved and quality of services received.

Before agencies extend or renegotiate a contract, they should comprehensively assess the services received and test the market to maximise value for money.

All government sector employees must demonstrate the highest levels of ethical conduct, in line with standards set by The Code of Ethics and Conduct for NSW government sector employees.

This chapter looks at how well agencies are managing these requirements, and where they can improve their policies and processes.

We found that agencies mostly have the appropriate codes, frameworks and policies in place. But we have highlighted opportunities to improve the way they manage those systems to reduce the risks of unethical conduct.

Issues Recommendations or conclusions

5.1 Ethical framework

Code of conduct

All agencies we reviewed have a code of conduct, but they can still improve the way they update and manage their codes to reduce the risk of fraud and unethical behaviour.

Recommendation

Agencies should regularly review their code-of-conduct policies and ensure they keep their codes of conduct up-to-date.

Statement of business ethics

Most agencies maintain an ethical framework, but some can enhance their related processes, particularly when dealing with external clients, customers, suppliers and contractors.

Conclusion

Agencies can enhance their ethical frameworks by publishing a Statement of Business Ethics, which communicates their values and culture.

5.2 Potential conflicts of interest

Conflicts of interest

All agencies have a conflicts-of-interest policy, but most can improve how they identify, manage and avoid conflicts of interest.

Recommendation

Agencies should improve the way they manage conflicts of interest, particularly by:

  • requiring senior executives to make a conflict-of-interest declaration at least annually
  • implementing processes to identify and address outstanding declarations
  • providing annual training to staff
  • maintaining current registers of conflicts of interest.

Gifts and benefits

While all agencies already have a formal gifts-and-benefits policy, we found gaps in the management of gifts and benefits by some that increase the risk of unethical conduct.

Recommendation

Agencies should improve the way they manage gifts and benefits by promptly updating registers and providing annual training to staff.

Risk management is an integral part of effective corporate governance. It helps agencies to identify, assess and prioritise the risks they face and in turn minimise, monitor and control the impact of unforeseen events. It also means agencies can respond to opportunities that may emerge and improve their services and activities.

This year we looked at the overall maturity of the risk management frameworks that agencies use, along with two important risk management elements: risk culture and risk registers.

Issues Recommendations or conclusions

6.1 Risk management maturity

All agencies have implemented risk management frameworks, but with varying levels of maturity in their application.

Agencies’ averaged a score of 3.1 out of five across five critical assessment criteria for risk management. While strategy and governance fared best, the areas that most need to improve are risk culture, and systems and intelligence.

Conclusion

Agencies have introduced risk management frameworks and practices as required by the Treasury’s:

  • 'Risk Management Toolkit for the NSW Public Sector'
  • 'Internal Audit and Risk Management Policy for the NSW Public Sector'.

However, more can be done to progress risk management maturity and embed risk management in agency culture.

6.2 Risk management elements

Risk culture

Most agencies have started to embed risk management into the culture of their organisation. But only some have successfully done so, and most agencies can improve their risk culture.

 

 

Conclusion

Agencies can improve their risk culture by:

  • setting an appropriate tone from the top
  • training all staff in effective risk management
  • ensuring desired risk behaviours and culture are supported, monitored, and reinforced through business plans, or the equivalent and employees' performance assessments.

Risk registers and reporting

Some agencies do not report their significant risks to their lead agency, which may impair the way resources are allocated in their cluster. Some agencies do not integrate risk registers at a divisional and whole-of-enterprise level.

Conclusion

Agencies not reporting significant risks at the cluster level increases the likelihood that significant risks are not being mitigated appropriately.

Effective risk management can improve agency decision-making, protect reputations and lead to significant efficiencies and cost savings. By embedding risk management directly into their operations, agencies can also derive extra value for their activities and services.

Published

Actions for Managing demand for ambulance services 2017

Managing demand for ambulance services 2017

Health
Information technology
Management and administration
Risk
Service delivery
Shared services and collaboration
Workforce and capability

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.

Demand for ambulance services is increasing. Demographic factors including population growth and ageing have contributed to this and ongoing growth in demand is likely. It is important that NSW Ambulance finds ways to respond to this demand more efficiently, while maintaining patient safety standards and meeting community expectations.

Most triple zero calls to NSW Ambulance do not involve medical issues that require an emergency response. NSW Ambulance has introduced a range of initiatives to change the way it manages these less urgent requests for assistance. Its major demand management initiatives include using a telephone advice line, referring some patients to services other than hospital emergency departments and using specialist paramedics to respond to less urgent cases.

The role of NSW Ambulance has changed in recent years. It is aiming to become a ‘mobile health service’ that identifies the needs of patients and provides or refers them to the most appropriate type of care. This change involves a significant expansion of the clinical decision-making role of paramedics. Considerable strategic and organisational efforts are required to make this work. The successful implementation of demand management initiatives is important to NSW Ambulance's ability to continue to meet demand for its services.

This audit assessed NSW Ambulance's major demand management initiatives that aim to reduce unnecessary demand for ambulance responses and unnecessary transport to hospital emergency departments. It aimed to assess the extent to which these initiatives have improved the efficiency of its services.

Conclusion

NSW Ambulance has introduced several initiatives that aim to manage demand for its services from less urgent cases more efficiently. There is no overall strategy for these initiatives and NSW Ambulance’s data systems do not measure their outputs or outcomes. As a result, we are unable to assess the impact of NSW Ambulance's demand management initiatives on the efficiency of ambulance services. More focus is needed to ensure these initiatives achieve the efficiency improvements necessary to help NSW Ambulance meet future increases in demand.

Increasing demand for ambulance services is a key issue for NSW Ambulance. Demand has increased at a faster rate than population growth in recent years and continued growth is expected. NSW Ambulance has introduced several initiatives that aim to manage demand for its services from people with less urgent medical issues more efficiently and align its approach with the rest of the health system in New South Wales.

These individual initiatives lack a broader strategy to guide their development. NSW Ambulance’s demand management initiatives also lack clear goals and performance targets, with insufficient organisational resources allocated to support their implementation. NSW Ambulance does not have a data system that allows it to conduct accurate routine monitoring of the activity and performance of these initiatives.

More effort is required to make demand management initiatives a core part of NSW Ambulance's work. Key relationships with other health services to support demand management initiatives have only recently been established. NSW Ambulance has not communicated proactively with the public about its demand management initiatives. To ensure paramedics are as well prepared as possible for their expanded roles, they need better professional development and up to date technology.

Demand for ambulance services in New South Wales is increasing steadily. Forecast future increases in demand due to population growth and ageing mean that NSW Ambulance must improve its efficiency to maintain its performance.

Demand for ambulance services is growing at a rate higher than population growth. The increase in demand is likely to continue as the population continues to grow and age. NSW Ambulance has made several recent changes to remove large parts of demand for its services, including moving non-emergency patient transport to a separate government agency and changing the way triple zero calls are categorised.

These changes were expected to improve emergency response time performance, but the anticipated improvements have not been achieved. If demand continues to increase as forecast, NSW Ambulance will need to find more efficient ways to manage demand to maintain its performance.

NSW Ambulance has introduced initiatives to change the way it manages demand from patients who have less urgent medical issues. These have the potential to achieve positive results, but we were unable to fully assess their impact because of weaknesses in data systems and monitoring. More needs to be done to demonstrate progress toward the efficiency improvements required.

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. 

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.

Appendix one - Response from agency

Appendix two - About the audit

Appendix three - Performance auditing

 

Parliamentary reference - Report number #295 - released 13 December 2017

Published

Actions for Health 2017

Health 2017

Health
Asset valuation
Compliance
Financial reporting
Fraud
Information technology
Internal controls and governance
Management and administration
Procurement
Project management

The following report highlights results of the financial audits of entities in the NSW health cluster. The report focuses on key observations and findings from the most recent audits of these entities.

The report also includes a range of findings on service delivery. Overall, NSW Health is achieving most of their targets. Some local health districts are continuing to experience increased demand for their services and are finding it more difficult to meet their targets. For example, three local health districts had not achieved some emergency department response time targets for three consecutive years.

1. Financial reporting and controls

Financial Reporting

All health cluster entities received unqualified audit opinions and the quality of financial reporting remains high across the cluster.

Early close procedures were largely completed and all financial statements were submitted by the deadlines.

Financial performance

Overall, NSW Health recorded an operating surplus of $407 million in 2016–17. Eleven local health districts/specialty networks recorded operating deficits in 2016–17, four more than 2015–16.

Expenses across NSW Health increased by 4.4 per cent in 2016–17 (6.0 per cent in 2015–16), lower than the expected long term annual expense growth rate.

Excess annual leave Managing excess annual leave is a continual challenge for NSW Health, with thirty–five per cent of the workforce having excess balances.
Overtime payments NSW Health entities are generally managing overtime well; however NSW Ambulance’s overtime payments, $74.6 million in 2016–17, remain significantly higher than other health entities.
Time and leave recording practices Unapproved employee timesheets continue to be a problem for health entities. Weak timesheet approval controls increase the risk of staff claiming and being paid for hours they have not worked. There is also an increased risk of high volumes of roster adjustments, manual pays, salary overpayments and leave not being recorded accurately.

2. Service Delivery

Service Agreements Most of the service agreements between the Secretary of NSW Health and health entities were signed earlier than prior years.
Performance monitoring Five NSW Health entities are not meeting the Ministry of Health’s performance expectations at 30 June 2017.
Emergency department performance Data provided by the Ministry indicates NSW Health, on average, met emergency department triage response time targets across all triage categories for the fourth consecutive year.
Ambulance response times Data provided by the Ministry shows NSW Ambulance response times for imminently life‑threatening incidents of 7.5 minutes in 2016–17 was within the Ministry’s target of 10.0 minutes.

Data provided by the Ministry indicates NSW Ambulance response times for potentially life‑threatening incidents did not improve in 2016–17. The median response time of 11.1 minutes in 2016–17 was similar to 2015–16 (11.0 minutes). This is despite the number of Priority 1 responses reducing by 4.3 per cent.
Unplanned hospital re-admissions Data provided by the Ministry shows eight local health districts achieved the Ministry of Health’s unplanned hospital re‑admissions target in 2016–17. The target is for local health districts to reduce re‑admission rates from the previous financial year.

This report sets out the results of the 30 June 2017 financial statement audits of Health cluster entities.

The report has been structured into two chapters focusing on:

  • Financial reporting and controls
  • Service delivery.

This chapter outlines audit observations, conclusions and recommendations related to financial reporting and internal controls of entities for 2016-17.

Observation Conclusion or recommendation

2.1 Quality of financial reporting

All cluster entities received unqualified audit opinions and misstatements identified in financial statements fell. The quality of financial reporting remains high across the cluster.

2.2 Timeliness of financial reporting

Early close procedures were largely completed and all financial statements were submitted by the deadlines. Health entities controlled by the Ministry of Health continued submitting their financial statements well ahead of the statutory deadlines.

2.4 Financial and sustainability analysis

NSW Health recorded an operating surplus of $407 million in 2016–17.



Eleven local health districts/specialty networks recorded operating deficits in 2016–17, four more than 2015–16.


Expenses across NSW Health increased by 4.4 per cent in 2016–17 (6.0 per cent in
2015–16).

The capital replacement ratio of local health districts/specialty networks ranged from 0.5 to 5.7 in 2016–17. Seven local health districts had capital replacement ratio higher than one.

The statewide operating surplus was $84 million higher than 2015–16. Net surpluses contribute to NSW Health’s ability to invest in new facilities, upgrades and redevelopments.

The 2016–17 financial results were once again impacted by the NSW Government initiative to improve cash management across the sector.

The expense growth rate for NSW Health is 1.6 percentage points lower than the expected long term annual expense growth rate.

Substantial ongoing investment in hospitals and other assets across NSW Health is evidenced by high capital replacement ratios for some health entities in 2016–17.

2.5 Performance against budget
Ten local health districts/specialty networks’ expense budget variance was outside performance expectations agreed with the Ministry at the beginning of 2016–17. The Ministry continues to manage performance across NSW Health to improve the accuracy of budgeting practices.
2.7 Human Resources    

Thirty-five per cent of NSW Health’s workforce have excess annual leave balances.

 

 

 

 

 

 

NSW Ambulance had the highest average sick leave rate in NSW Health of 85.2 hours per FTE in 2016–17 (78.7 hours in 2015–16). This was higher than the statewide average of 62.1 hours (62.0 hours in 2015–16).

NSW Ambulance’s overtime payments in 2016–17 totalled $74.6 million; $2.8 million more than 2015–16 and significantly higher than other health entities

Other NSW Health entities are generally managing overtime well.

 

Unapproved employee timesheets continue to be a problem for health entities. Weak timesheet approval controls increase the risk of staff claiming and being paid for hours they have not worked.

 

Managing excess annual leave is a continual challenge for health entities.

Recommendation: Health entities should further review the approach to managing excess annual leave in 2017–18. They should:

  • monitor current and projected leave balances to the end of the financial year on a monthly basis
  • agree formal leave plans with employees to reduce leave balances over an acceptable timeframe.


NSW Ambulance continues to face significant challenges in managing sick leave.

Recommendation: NSW Ambulance should further implement and monitor targeted human resource strategies to address the high rates of sick leave taken

Recommendation: NSW Ambulance should further review the effectiveness of its rostering practices to identify strategies to reduce excessive overtime payments.

Recommendation: Health entities should conduct a risk‑based review of time and leave recording practices to ensure control weaknesses are identified and fixed.

This chapter outlines our audit observations, conclusions and recommendations relating to service delivery for 2016–17.

Observation Conclusion or recommendation
3.1 Service agreements in NSW Health

Most of the service agreements between the Secretary of NSW Health and health entities were signed earlier than prior years.

Thirteen local health districts/specialty networks signed their service agreements by the 31 July 2017 due date. This is a significant improvement with only seven local health districts/specialty networks meeting the date in 2015–16.

Having service agreements signed as close as possible to the start of each year provides the Ministry and NSW Health entities with clarity around roles, responsibilities, performance measures, budgets, and service volumes and levels.
3.2 Performance of NSW Health entities
Five NSW Health entities were not meeting the Ministry’s performance expectations at 30 June 2017. The Ministry is managing the five entities in accordance with its performance review process.
3.4 Emergency department response times

Data provided by the Ministry indicates NSW Health again, on average, met emergency department triage response time targets across all triage categories for the fourth consecutive year.

The Ministry manages performance across NSW Health to ensure patients presenting at emergency departments receive care in a clinically appropriate timeframe.

Based on the Ministry’s data, local health districts/specialty networks are, on average, meeting triage targets despite increasing emergency department attendances.

The data shows eleven local health districts met all triage targets in 2016–17, compared to eight in
2015–16. 

3.5 Emergency treatment performance

The Ministry manages public patient access to emergency services in public hospitals.

It has an emergency treatment performance target of 81 per cent of patients leaving emergency departments within four hours.

Data provided by the Ministry indicates NSW Health maintained its overall emergency treatment performance in 2016–17, but did not achieve its target. The State average emergency treatment performance was 74.2 per cent (74.2 per cent in 2015–16).

Based on the Ministry’s data, only four local health districts achieved the target in 2016–17, five in
2015–16.

3.6 Ambulance response times
NSW Ambulance has a response time target of 10.0 minutes for imminently life‑threatening incidents in New South Wales. Data provided by the Ministry indicates NSW Ambulance response times for imminently life-threatening incidents of 7.5 minutes in 2016–17 was within the Ministry’s target.
 
3.7 Transfer of care
The Ministry has a target of 90 per cent for the number of ambulance arrivals within a 30 minute ‘transfer of care’ timeframe. Data provided by the Ministry indicates the rate of ambulance arrivals within a 30 minute 'transfer of care' timeframe improved from 87.6 per cent in
2015–16 to 91.7 per cent in 2016–17, exceeding the Ministry’s target.
3.8 Average length of stay in hospital
Based on the Ministry’s 2016–17 data, the average length of stay for acute episodes was 3.0 days. The average length of stay in New South Wales hospitals is lower than the national average of 3.2 days (in 2015–16). The Ministry’s data shows the average length of stay by patients for acute episodes has remained stable in New South Wales hospitals for four years. 
3.9 Elective surgery access performance
Data provided by the Ministry indicates NSW Health continues to manage waiting times for elective surgery in public hospitals. The Ministry’s data shows NSW Health improved on‑time admission of patients for elective surgery in 2016–17 despite a 1.8 per cent increase in admissions. While the result improved, only one of the three targets for elective surgery waiting times was met in 2016–17.
3.10 Unplanned hospital re-admissions

Data provided by the Ministry indicates NSW Health, on average, did not reduce the rate of unplanned hospital re‑admissions in 2016–17. The Ministry has a target of reducing unplanned hospital re‑admissions compared to the previous financial year.

Low re‑admission rates may indicate good patient management practices and post-discharge care.

The Ministry’s data shows eight local health district met the target to reduce the rate of re‑admissions compared to the previous financial year. The statewide average rate increased from 6.3 per cent to 6.4 per cent.
3.11 Post discharge care for acute mental health patients
NSW Health has a goal to increase community-based care to acute mental health patients after they are discharged. Continuity of care in the community can lead to reduced symptom severity, lower re‑admission rates, and improved quality of life. The Ministry’s 2016–17 data shows the statewide average for post discharge follow-up of acute mental health patients within seven days was 70.0 per cent (66.0 per cent in 2015–16). The statewide average improved and met the NSW Health target of 70 per cent. Nine local health districts exceeded the NSW Health target.
3.12 Mental health acute re-admissions
NSW Health has a goal to reduce acute public sector mental health re-admissions. High re‑admission rates may indicate deficiencies in inpatient treatment and follow up care. The Ministry’s data shows twelve local health districts did not achieve the NSW Health target of 13 per cent mental health acute re‑admissions in 2016–17.
3.13 Unplanned and emergency re‑presentations

NSW Health aims to reduce the number of unplanned and emergency re‑presentations to emergency departments.

The Ministry’s 2016–17 data shows the State average of emergency department re‑presentations decreased marginally from 5.0 per cent in 2015–16 to 4.9 per cent.

Patients attending rural emergency departments are more likely to re‑present within 48 hours of being discharged than those in regional or metropolitan emergency departments.
3.14 Healthcare associated infection
The national target for the rate of Staphylococcus aureus (golden staph) bloodstream infection is two cases per 10,000 bed days. Data provided by the Ministry indicates the rate of golden staph bloodstream infection in New South Wales hospitals continues to be well below the target and national benchmark at 0.72 cases per 10,000 bed days in 2016–17 (0.75 in 2015–16).
3.15 Patient experience and satisfaction

The Bureau of Health Information analyses and reports on the results of patient surveys.

The Bureau’s survey shows 65 per cent of adult admitted patients rated the care they received in hospital as ‘very good’ and 29 per cent rated it as ‘good’.

NSW Health recognises that patient surveys are an important feedback mechanism on the health care system that can only come from personal experiences.

Published

Actions for Agency compliance with NSW Government travel policies

Agency compliance with NSW Government travel policies

Education
Community Services
Finance
Health
Industry
Justice
Local Government
Planning
Premier and Cabinet
Transport
Treasury
Universities
Whole of Government
Compliance
Internal controls and governance
Procurement

Overall, agencies materially complied with NSW Government travel policies.

However, the Auditor-General found some agencies:

  • did not always book official travel through the approved supplier
  • had weaknesses in their travel approval processes
  • had travel policies that were inconsistent with the NSW Government policy
  • did not adequately manage their travel records.   

Last year the NSW Government spent almost $250 million on travel. The government’s travel policies aim to help agencies make better travel decisions and reduce costs. The Department of Finance, Services and Innovation (DFSI) is responsible for the government’s travel policy and manages the government contract with an approved private sector provider to procure travel services.

This audit assessed how effective agency processes were to ensure compliance with:

  • the ‘Policy on Official Travel within Australia and Overseas’ issued by the Department of Premier and Cabinet in Circular OFS-2014–07 ‘Official Travel in Australia and Overseas’ (the former policy)
  • the ‘NSW Government Travel and Transport Policy’ issued by DFSI (the new policy), effective from 28 September 2016.

We examined 15 agencies from different NSW Government clusters with significant travel expenditure. For a list of participating agencies, refer to the Appendix two.

Conclusion

We found that overall, agencies materially complied with NSW Government travel policies. However, some agencies:

  • did not always book official travel through the approved supplier
  • had weaknesses in their travel approval processes
  • had travel policies that were inconsistent with the government policy
  • did not adequately manage their travel records.

Self-assessments indicate agencies comply with most aspects of the new policy. Agencies also believe more guidance from DFSI about certain aspects of the policy would increase compliance.

We asked the 15 participating agencies to complete a self assessment of the processes they have implemented to comply with the new policy. The key observations are summarised below.

Published

Actions for Central Agencies 2017

Central Agencies 2017

Finance
Premier and Cabinet
Asset valuation
Compliance
Financial reporting
Fraud
Information technology
Internal controls and governance
Project management

This report highlights the results of the financial audits of NSW Government central agencies. The report focuses on key observations and findings from the most recent financial statement audits of agencies in the Treasury, Premier and Cabinet, and Finance, Services and Innovation clusters.

The report includes a range of findings in respect to service delivery. One repeat finding is that while the Government regularly reports on the 12 Premier's priorities, there is no comprehensive reporting on the 18 State priorities. 

1. Financial reporting and controls

Audit Opinions Unqualified audit opinions were issued for all agencies' 30 June 2017 financial statements.
Early close Early close procedures continue to facilitate the timely preparation of financial statements and completion of audits, but agencies can make further improvement.
Deficient user administration access User access administration over financial systems remains an area of weakness. Agencies need to strengthen user access administration to critical systems.
Transitioning to outsourced service providers Transitioning of services to outsourced service providers can be improved. Outsourcing services can lead to better outcomes, which may include lower transaction costs and improved services, but it also introduces new risks.

2. Service delivery

Premier and State Priorities   A comprehensive report of performance against the 18 State Priorities is yet to be published. While some measures are publicly reported through agency annual reports or other sources, a comprehensive report of performance against the 18 State Priorities would ensure all State Priorities are publicly reported, provide a single and easily accessible source of reference and improve transparency.
ICT and digital government The Digital Government Strategy was released in May 2017. Targets will need to be set to assess and monitor progress against the Strategy.
Digital information security Not all agencies are complying with the NSW Government's information security policy. This increases the risk of noncompliance with legislation, information security breaches and difficulty restoring data or maintaining business continuity in the event of a disaster or disruption.
Property and asset utilisation Property NSW's performance reporting would be enhanced by developing and reporting on customer satisfaction, reporting against set targets and benchmarking cost of service to the private sector.

3. Government financial services

Prudential oversight
of NSW Government superannuation
funds  
Prudential oversight of SAS Trustee Corporation Pooled Fund and Parliamentary Contributory Superannuation Fund has not been prescribed. Structured and comprehensive prudential oversight of these funds remains important as they operate in a specialised, complex and continuously changing investment market sector, have over 106,000 members and manage investments in excess of $42.4 billion.
Green slip scheme affordability Currently, Green Slips in NSW are the most expensive in Australia. However, CTP reforms are expected to reduce the cost of Green Slips.

This report sets out the results of the 30 June 2017 financial statement audits of NSW Government's central agencies and their cluster agencies.

Central agencies play a key role in ensuring policy coordination, good administrative and people management practices and prudent fiscal management. The central agencies and their key responsibilities are set out below.

Confidence in public sector decision‑making and transparency is enhanced when financial reporting is accurate and timely. Appropriate financial controls help ensure the efficient and effective use of resources and administration of agency policies. This chapter outlines our audit observations, conclusions or recommendations related to financial reporting and controls of agencies for 2016–17.

Observation Conclusion or recommendation
2.1 Quality of financial reporting
Unqualified audit opinions were issued for all agency financial statements. The quality of financial reporting continues to remain strong across the clusters.
2.2 Timeliness of financial reporting
Most agencies complied with the statutory timeframes for completion of early close procedures and preparation and audit of financial statements. Early close procedures continue to facilitate the timely preparation of financial statements and completion of audits, but agencies can make further improvement.
2.3 Financial performance and sustainability
We assessed the performance of agencies listed in Appendix six against some key financial sustainability indicators. This highlighted two agencies with negative operating margins of more than ten per cent and one agency with a liquidity ratio of less than 0.5. These agencies have strategies in place to remain financially sustainability and manage their liquidity. Our analysis found that, overall, the agencies are not at high risk of sustainability concerns.
2.4 Internal Controls

User access administration over financial systems remains an area of weakness. Sixteen moderate risk and ten low risk issues related to user access administration across eight agencies were identified. 

Recommendation: Agencies should review user access administration to critical systems to ensure:

  • policies for user access creation, modification and deactivation are documented
  • approval is being obtained to establish, modify or delete user accounts
  • regular user access reviews are performed and highly privileged user account activity is logged and monitored
  • evidence of review is maintained.

Transitioning of services to outsourced service providers can be improved. Our 2016–17 audits identified one high risk issue relating to Property NSW's outsourcing of property and facility management services to the private sector.

While a high risk issue was identified in 2015–16 from the Department of Finance, Services and Innovation's outsourcing of transactional and information technology services to GovConnect there has been an improvement in GovConnect's internal control environment throughout
2016–17.

Outsourcing services can lead to better outcomes, which may include lower transaction costs and improved services, but it also introduces new risks. The transition needs to be carefully managed and requires thorough planning and effective project governance. This should be supported by oversight and direction from senior management and independent project assurance.
2.5 Human Resources    
The percentage of full‑time equivalent staff with annual leave greater than 30 days in the Finance, Services and Innovation, Premier and Cabinet and the Treasury clusters is 7.9 per cent, 17.1 per cent and 18.4 per cent respectively. Agencies have strategies in place to reduce annual leave balances that are greater than 30 days. The effectiveness of these strategies will need to be monitored to ensure they are helping to achieve the desired outcome.

This chapter outlines our audit observations, conclusions and recommendations relating to service delivery for 2016–17. 

Observation Conclusion or recommendation
3.1 Premier and State priorities

The Department of Premier and Cabinet monitors the achievement of targets and the implementation of initiatives to deliver the 12 Premier’s Priorities.

Responsible ministers and agencies manage the 18 State Priorities. A comprehensive report of performance against the 18 State Priorities is yet to be published.

While some measures are publicly reported through agency annual reports or other sources, a comprehensive report of performance against the 18 State Priorities would ensure all State Priorities are publicly reported, provide a single and easily accessible source of reference and improve transparency.
Where possible, independent sources are used to measure performance, however without independent assurance there is an increased risk that the target measures are inaccurate, not relevant or do not fairly represent actual performance.

Performance against the State Priority to make NSW the easiest state to start a business is not currently published.

A key aspect of making NSW the easiest state to start a business is making regulatory obligations easier to understand and implement.

Initiatives, such as easy to do business and red tape reduction are in place to help achieve this priority.

The regulatory policy framework is under review following an October 2016 performance audit on ‘Red tape reduction’ that found the regulatory burden of legislation had increased.
3.2 Financial management
Revenue NSW earned record crown revenue of $30.0 billion in 2016–17 to support the state's finances. Record crown revenue has been driven by the sustained increase in duties revenue, which has increased by 93.7 per cent over the last five years. This is a consequence of the continued strength in the property market over this time and large one off NSW Government business asset sales and leases.
3.3 ICT and digital government
The Digital Government Strategy (the Strategy) was released in May 2017 to build on reforms set out in previous ICT strategies. The Strategy’s priorities and enablers aim to support digital innovation. Targets and measures will need to be set to assess and monitor progress against the Strategy.
The Digital Information Security Policy (DISP) is a key tool that helps ensure a minimum set of information security controls are implemented across NSW Government agencies.

A review of 2016 annual reports found 15 agencies (13 in 2015) did not attest to compliance with the DISP and of the agencies that attested to compliance, 34 reported issues associated with their compliance.

The Strategy’s priorities and enablers aim to support digital innovation. Targets and measures will need to be set to assess and monitor progress against the Strategy.

Failure to comply with the DISP increases the risk of noncompliance with legislation, information security breaches and difficulty restoring data or maintaining business continuity in the event of a disaster or disruption.

3.4 Property and asset utilisation

Property NSW's performance reporting could be
improved. M2012-20 'Government Property NSW
and Government Property Principles' required
Property NSW to set key performance indicators
to measure property and asset utilisation
performance.
 

Property NSW's performance reporting would be enhanced by developing and reporting on customer satisfaction, reporting against set targets and benchmarking cost of service to the private sector.

This chapter outlines our audit observations, conclusions and recommendations specific to NSW Government agencies providing financial services.

Observation Conclusion or recommendation
4.1 Key issues

The SAS Trustee Corporation (STC) Pooled Fund and the Parliamentary Contributory Superannuation (PCS) Fund are not required to comply with the prudential and reporting standards issued by the Australian Prudential Regulation Authority (APRA). Amendments to relevant legislation allows the Minister for Finance, Services and Property to prescribe applicable prudential standards and audit requirements.

Structured and comprehensive prudential oversight of these funds remains important as they operate in a specialised, complex and continuously changing investment market sector, have over 106,000 members and manage investments of more than $42.4 billion.

Recommendation: The Treasury should liaise with
the respective Trustees to implement appropriate
prudential standards and oversight arrangements for
the exempt public sector superannuation funds.

Currently, Green Slips in NSW are the most expensive in Australia. Average premiums for Sydney Metropolitan vehicles increased by 10.4 per cent between 1 January 2016 and 31 December 2016.

CTP reforms are expected to reduce the cost of Green Slips. The State Insurance Regulatory Authority will need to ensure it has appropriate processes in place to track and report against the expected benefits.
4.2 Financial performance and sustainability
Net unfunded superannuation liabilities were $15.0 billion at 30 June 2017.

Under the Fiscal Responsibility Act 2012, the NSW Government’s target is to eliminate unfunded superannuation liabilities by 2030.
The superannuation funds’ strategic asset allocation and investment strategies are monitored and adjusted to help achieve a fully funded position by 2030.
The Home Warranty Scheme commenced in 2011. Over this time total premiums collected have not been sufficient to cover expected claim costs. Funding arrangements introduced during 2016–17 allow the Home Building Compensation Fund to apply to the Crown for reimbursement of unfunded realised losses from under-pricing of premiums.

Other reforms are planned to address the long term sustainability of the home building compensation scheme.
4.3 Investment performance
The NSW Government’s main superannuation funds have maintained the management expense ratio (MER) at consistent levels over the past two years. The Parliamentary Contributory Superannuation (PCS) Fund does not set an MER target. MER is an industry recognised ratio to measure the performance of funds and investment managers.

Recommendation: The Fund Secretary for the PCS Fund, in conjunction with the Trustee, should consider establishing an appropriate management expense ratio target to measure performance.

Published

Actions for Government Advertising: Campaigns for 2015–16 and 2016–17

Government Advertising: Campaigns for 2015–16 and 2016–17

Premier and Cabinet
Justice
Local Government
Compliance
Internal controls and governance
Management and administration
Procurement

The 'Stronger Councils, Stronger Communities' and the 'Dogs deserve better' government advertising campaigns complied with the Government Advertising Act and most elements of the Government Advertising Guidelines.

However, some advertisements were designed to build support for government policy and used subjective or emotive messages. This is inconsistent with the requirement in the Government Advertising Guidelines for 'objective presentation in a fair and accessible manner'.

Advertisements in the 'Stronger Councils, Stronger Communities' campaign used subjective statements such as 'the system is broken' and 'brighter future'. While advertisements in the 'Dogs deserve better' campaign used confronting imagery such as gun targets, blood smears and gravestones.

The Government Advertising Act 2011 (the Act) requires the Auditor-General to conduct a performance audit in relation to at least one government advertising campaign in each financial year. The performance audit assesses whether advertising campaigns were carried out effectively, economically and efficiently and in compliance with the Act, the regulations, other laws and the Government Advertising Guidelines (the Guidelines). In this audit, we examined two campaigns:

  • the ‘Stronger Councils, Stronger Communities’ campaign run by the Office of Local Government and the Department of Premier and Cabinet
  • the ‘Dogs deserve better’ campaign run by the Department of Justice.    

Section 6 of the Act details the specific prohibitions on political advertising. Under this section, material that is part of a government advertising campaign must not contain the name, voice or image of a minister, member of parliament or a candidate nominated for election to parliament or the name, logo or any slogan of a political party. Further, a campaign must not be designed so as to influence (directly or indirectly) support for a political party.

The ‘Stronger Councils, Stronger Communities’ government advertising campaign was run by the Office of Local Government and the Department of Premier and Cabinet in four phases from August 2015 to May 2016. The total cost of the campaign was over $4.5 million. See Appendix 2 for more details on this campaign.

The ‘Stronger Councils, Stronger Communities’ advertising campaign has not breached the specific provisions of Section 6 of the Act which prohibits political advertising.

Two factors potentially compromised value for money for the campaign. The request for quotes for the design of the Phase 1 advertisement did not reflect the full scale of work to be undertaken, which was substantially greater than initially quoted. Further, the department did not meet all recommended timeframes to minimise media booking costs for all phases of the campaign.

The campaign did not comply with all administrative requirements in all phases. Advertising for Phase 1 commenced before the compliance certificate was signed. There was no evidence that a compliance certificate was signed for Phase 2 extension. The cost benefit analyses for Phase 2 and Phase 2 extension did not sufficiently consider alternatives to advertising, as is required by the Government Advertising Guidelines.

Advertisements adopted subjective messages designed to build public support for council mergers and directed audiences to websites for more detailed information. Campaign research identified statements that were most likely to reduce resistance to mergers. Some advertising content used subjective language, which we consider inconsistent with the requirement for ‘objective presentation’. Evaluations of advertising effectiveness also measured the success of the advertisements in increasing public support for council mergers.

No breach of specific prohibitions in the Act

Section 6 of the Act prohibits the use of government advertising for political advertising. A government advertising campaign must not:

  • be designed to influence (directly or indirectly) support for a political party
  • contain the name, voice or image of a minister, any other member of parliament or a candidate nominated for election to parliament
  • contain the name, logo or any slogan of, or any other reference relating to, a political party.

We did not identify any breach of the specific prohibitions listed above in the advertising content of this campaign.

Request for quotes to design advertisement did not reflect the full scope required

The request for quotes for the design of the Phase 1 advertisement did not reflect the full scale of work that was to be undertaken, and this created a risk to achieving value for money. The Office of Local Government sought quotes for design of a television advertisement only. It did not request an estimate for radio, online advertisements, or translation for linguistically diverse audiences, which were ultimately required for the campaign.
 

A full and fair assessment of which supplier could provide the best value for money could not be made given that the quotes obtained did not reflect the full scope of work. The final amount paid for the design of Phase 1 was 2.7 times the original quote. It is possible that another supplier that provided a quote could have provided overall better value for money.

The Office of Local Government continued to use the Phase 1 supplier for Phase 2 and Phase 2 extension (Exhibit 4). Where there are other suppliers that could feasibly compete for a contract, direct negotiation increases the risk the agency has not obtained the best value for money. The department advised that it continued with the same agency to avoid costs involved in briefing a new agency on the campaign.

The ‘Dogs deserve better’ government advertising campaign was run by the Department of Justice from August 2016, after the government announced its decision to prohibit greyhound racing, and was terminated in October 2016 after a change of government policy. The campaign had a budget of $1.6 million, with an actual spend of $1.3 million. See Appendix 2 for more details on this campaign.

The ‘Dogs deserve better’ advertising campaign has not breached the specific provisions of Section 6 of the Act which prohibits political advertising.

The Secretary of the department determined that urgent circumstances existed that required advertising to commence prior to completing a cost benefit analysis and peer review. There was a concern that industry participants may make impulse decisions to destroy greyhounds without further information on support services; there was also an identified need to promote public greyhound adoptions.

Phase 1 advertisements focused on explaining the reasons for the prohibition on greyhound racing with a reference to a website for further information. While industry participants were identified as the primary audience, media expenditure was not specifically targeted to this group. Phase 2 advertisements more effectively addressed the originally identified ‘urgent needs’ of providing information on support services for greyhound owners and information on how the public could adopt a greyhound.

The urgency to advertise potentially compromised value for money. The department did not use price competition when selecting a creative supplier due to a concern this would add to timeframes. Further, the department did not meet recommended timeframes to minimise media booking costs.

We identified three other areas in Phase 1 advertisements that were inconsistent with government advertising requirements. Advertisements used provocative language and confronting imagery, which we consider to be inconsistent with the requirement for ‘objective presentation’. Two statements presented as fact based on the Special Commission’s Inquiry report were inaccurate; one of these was due to a calculation error. Radio advertisements did not clearly identify that they were authorised by the New South Wales Government for the first few days of the campaign.

No breach of specific prohibitions in the Act

Section 6 of the Act prohibits the use of government advertising for political advertising. A government advertising campaign must not:

  • be designed to influence (directly or indirectly) support for a political party
  • contain the name, voice or image of a minister, any other member of parliament or a candidate nominated for election to parliament
  • contain the name, logo or any slogan of, or any other reference relating to, a political party.

We did not identify any breach of the specific prohibitions listed above in the advertising content of this campaign.
 

Animal welfare concerns were identified as the reason for urgent advertising

A brief prepared by the department in July 2016 raised concerns about the welfare of greyhounds following the NSW Premier’s announcement that the government would prohibit greyhound racing. The brief raised the risk that industry members may make impulse decisions to destroy their greyhounds without information on support that was being offered.

The department used the provisions in Sections 7(4) and 8(3) of the Act to expedite the release of advertising due to ‘other urgent circumstances’. This provision allows advertising to commence prior to completing the peer review process and cost benefit analysis.

In introducing the Government Advertising Bill to parliament in 2011, the then Premier noted that exceptional circumstances would cover situations ‘such as a civil emergency or sudden health epidemic’. There is no other guidance on when it is appropriate to use this section. It is at the discretion of a government agency head to determine whether a campaign is urgent.
 

Phase 1 advertisements did not focus on the urgent needs

This advertising campaign had three overarching objectives:

  • to increase public awareness of the animal welfare reasons for the closure of the greyhound racing industry
  • to change the behaviour of dog owners from potentially harming their greyhounds to treating them humanely, by accessing the support options and packages available
  • to promote greyhound adoptions by the public.

Alongside advertising, the department took other steps to engage with the greyhound racing industry. This included direct mail, face to face meetings around the State, setting up a call centre and community consultation through an online survey. Other government agencies and animal welfare agencies were also engaged to reach out to affected stakeholders.

Phase 1 advertising content focused on providing information about the reasons for the closure of the industry. The department’s radio and television advertisements did not refer to support packages or encourage the public to adopt a greyhound. While print advertisements did mention these things, this was only presented in fine print. In all advertisements, audiences were referred to a website for further information.

The focus of advertisements on the reasons for industry closure was not consistent with the identified needs to urgently commence advertising to influence the behaviour of dog owners and encourage the public to adopt a greyhound.

The content in Phase 2 advertisements, which began around four weeks after the first phase, was more explicit in highlighting the services and support for industry members such as offering business and retraining advice. These advertisements also referred audiences to a call centre number as well as the website.

Peer review process limited to influencing second phase of advertisements

In urgent circumstances, the Act allows for peer review to be completed after advertising has commenced. For this campaign, the peer review process was completed on 19 August 2016, two weeks after advertising had commenced. Where advertising commences before the peer review process is completed, the usefulness of peer reviewers’ recommendations is limited to informing subsequent phases of advertising and the post-campaign evaluation.

The peer review report found the messages in Phase 1 advertisements were not clearly defined, and the role of advertising was not clearly defined amongst other campaign activities. These recommendations informed the second phase of advertising, which ran from 27 August 2016 until the campaign was terminated in October 2016.
 

The department could not demonstrate value for money was achieved for creative work

The department provided a fixed budget for creative work when requesting quotes from creative agencies to develop advertising material. This is not consistent with the quotation requirements in the government’s Guidelines for Advertising and Digital Communication Services. This approach creates risks to achieving value for money as creative agencies are not required to compete on price for their services. The department advised that it had pre-set the creative costs based on a comparative government campaign of a similar size. This was done due to a concern that requiring agencies to compete on price would affect the short timeframe given to develop creative material.

Three creative agencies accepted the opportunity to present design ideas for the campaign. The department was unable to provide evidence of how it chose the preferred supplier out of these three agencies. Records are important for accountability and allow a procurement decision to be audited after an urgent decision.     
 

Short notice did not allow for cost-efficient media booking for all phases

Placement of advertisements in various media channels was done through the State’s Media Agency Services contract. This contract achieves savings as the government can use its aggregated media spend to gain discounts from the media supplier.

The Department of Premier and Cabinet provides guidance to ensure cost efficient media booking. For example, media time for a television advertisement should be booked at least 6 to 12 weeks in advance. Radio advertisements should be booked at least 2 to 8 weeks in advance.

The peer review report noted that the department did not have adequate time to look for the most cost-efficient way to advertise. In its response to the peer reviewers, the department acknowledged this to be due to the urgency to start advertising. The media booking authority was signed by the department one day before the campaign commenced.
 

The department used a wide public campaign for a narrow target audience

The campaign identified greyhound industry participants as the primary target audience. In 201516 there were 1,342 greyhound trainers, 1,695 owner/trainers, 983 attendants and 1,247 breeders in New South Wales. The department’s advertising submission identified ‘concerns that industry members could make impulsive decisions, potentially jeopardising the welfare of a large number of dogs, prior to the shutdown of the industry’.

The submission’s evidence of advertising effectiveness focused on increasing the level of wider community support for the ban rather than stopping industry members from making impulse decisions. It used an early opinion poll to show that total support for the ban on greyhound racing rises by 17 points and opposition drops by four points following explanation of the findings of the Special Commission of Inquiry report.

The peer review report noted that the role of advertising was not clearly defined amongst the department’s range of other direct and targeted communications and consultations held with industry members.

No demonstrated basis for use of confronting imagery and provocative language

The Guidelines require ‘objective presentation in a fair and accessible manner’. Neither the Guidelines or Handbook further explain what objective presentation means. We have used an ordinary definition of this term as ‘not influenced by personal feelings or opinions in considering and representing facts’. This is synonymous with terms like ‘impartial’, ‘neutral’, and ‘dispassionate’ and opposite to ‘subjective’. We consider that to meet the current requirements in the Guidelines for objectivity, advertising content should contain accurate statements or facts, and avoid subjective language.

Phase 1 focussed on the ongoing consequences if no action was taken to close the industry. The advertisements used provocative language, for example ‘Up to 70 per cent of dogs are deemed wastage by their own industry. Wastage! Slaughtered just for being slow’. Advertisements used confronting imagery like gravestones, blood smears and gun targets.

Our literature review into this area highlighted mixed findings on the effectiveness of confrontational advertising materials. In some cases, shock campaigns may cause an audience to reject or ignore the message, and may even encourage people to do the opposite of the intended behaviour. In other cases, such as in road safety campaigns, this style of advertising can be successful. This shows the importance of conducting pre-campaign research before adopting a confrontational or emotive approach in advertising.

The Government Advertising Handbook recommends that an agency explain the rationale and the evidence for their chosen advertising approach. There was no evidence that the department researched the effectiveness of its advertising approach with its target audience. The department had planned to undertake creative concept testing as part of a strategy to ensure the creative material was understood by its audience. The department advised that due to the urgency of the campaign, it did not have time to conduct this testing.

Not all Phase 1 radio advertisements clearly identified that they were authorised by the New South Wales Government

For the first few days on air, Phase 1 radio advertisements ended by referring the audience to a government website, instead of clearly identifying that it had been authorised by the New South Wales Government. Government authorisations and logos ensure the work and the programs of the NSW Government are easily identifiable by the community.    

The department’s cost benefit analysis did not consider alternatives to advertising

For government advertising campaigns that cost over $1.0 million, the Act requires the advertising agency to carry out a cost benefit analysis and obtain approval from the Cabinet Standing Committee on Communications, prior to commencing the campaign.

The department engaged with audiences through direct mail, face to face forums, and a telephone helpline in addition to advertising. However, the department’s cost benefit analysis did not meet the requirements in the Guidelines to specify the extent to which expected benefits could be achieved without advertising, and to compare costs of options other than advertising that could be used to successfully implement the program (see Exhibit 6).

The cost benefit analysis made optimistic assumptions about the impact of the campaign on greyhound adoptions. It estimated that 2,360 greyhounds would be adopted if the campaign was run. This is significantly higher than the ‘most optimistic outcome’ of re-homing in the Special Commission Inquiry report (we calculated this to be 1,467 greyhounds). There was insufficient evidence to support the higher number of adoptions in the cost benefit analysis.

The sensitivity analysis shows that using the Special Commission’s ‘most optimistic outcome’ figure of re-homing would reduce the net present value of advertising to be negative. Further, the cost benefit analysis also assumed that increased government funding would be made available to animal welfare and rehoming organisations to support more adoptions, but did not estimate or include this cost when calculating the net present value of advertising.
 

There were two factual inaccuracies in key messages used for Phase 1 advertisements

Section 8(2) of the Act requires the head of a government agency to certify that the proposed campaign ‘contains accurate information’. The Secretary of the Department of Justice signed the compliance certificate on 29 July 2016, before advertisements commenced.

We examined the accuracy of factual claims in this advertising campaign, by comparing the key statements to the report of Special Commission of Inquiry into the Greyhound Racing Industry (the Commissioner report). The Commissioner report was quoted by the NSW Government as the basis for its policy to transition the greyhound racing industry to closure.

We identified that two of the key statements used in Phase 1 advertisements to support the animal welfare reasons for industry closure were inaccurate (Exhibit 7).    

Published

Actions for Planning and evaluating palliative care services in NSW

Planning and evaluating palliative care services in NSW

Health
Management and administration
Service delivery
Workforce and capability

NSW Health’s approach to planning and evaluating palliative care is not effectively coordinated. There is no overall policy framework for palliative and end-of-life care, nor is there comprehensive monitoring and reporting on services and outcomes.

Palliative care is an essential component of modern health care services and an increasingly important part of the wider health and social care systems. Palliative care is healthcare and support for people with a life-limiting illness, their families and carers. It is provided by, or informed by, professionals who specialise in palliative care. ‘End of life’ care is provided to people approaching the end of life by health professionals, who may work in the health, community or aged care systems. Not everyone receiving end of life care needs palliative care.

NSW Health has a policy and planning role in palliative and end-of-life care, and it coordinates a wide range of service providers. Local Health Districts (LHDs) provide care services in settings such as homes, hospitals and clinics to patients with varying needs. There are several care providers that can be involved.

Due to this shared nature of palliative care — where many people, services and settings are involved in delivering care to the patient — availability and communication of information is critical. For service planning, data and evidence must be drawn from various sources in a timely and efficient way.

This audit assessed whether NSW Health is effectively planning and evaluating palliative care services, in the context of rising demand, increasingly complex needs, and the diversity of service providers.

Conclusion 

NSW Health’s approach to planning and evaluating palliative care is not effectively coordinated. There is no overall policy framework for palliative and end-of-life care, nor is there comprehensive monitoring and reporting on services and outcomes.  

NSW Health has a limited understanding of the quantity and quality of palliative care services across the state, which reduces its ability to plan for future demand and the workforce needed to deliver it. At the district level, planning is sometimes ad hoc and accountability for performance is unclear.

The capacity of LHDs to use accurate and complete data to plan and deliver services is hindered by multiple disjointed information systems and manual data collections. Further, a data collection on patient outcomes, for benchmarking and quality improvement, is not used universally. This limits the ability of districts to plan, benchmark and improve services based on outcomes data.

NSW Health's engagement with stakeholders is not systematic. The lack of an overall stakeholder engagement strategy puts at risk the sustainability and value of stakeholder input in planning and limits transparency.

Over the last two years, NSW Health has taken steps to improve its planning and support for districts. The Agency for Clinical Innovation has produced an online resource which will assist LHDs in constructing their own, localised models of care. eHealth, which coordinates information communication technology for the state’s healthcare, aims to invest in integrating and improving information systems. These initiatives should help to address many of the issues now inhibiting integrated service delivery, reporting on activity and outcomes, and planning for the future.

1. By July 2018, NSW Health should develop an integrated palliative and end-of-life care policy framework that:

  • clearly articulates the interface between palliative and end of life care and outlines the priorities for the respective areas
  • defines policy goals and objectives, and a performance and evaluation framework for palliative care service planning and delivery
  • informs a related workforce plan which supports the policy framework and is linked to the Health Professional Workforce Plan 2012–2022
  • reviews the funding allocation model to ensure future enhancement funds are distributed equitably and transparently based on the need and population of districts.

By December 2018, NSW Health should:

2. assess how the functionality provided in data collection programs such as the Palliative Care Outcomes Collaboration program can be provided across all palliative care services in NSW

3. complete its statewide review of systems and reporting for end of life management including specialist palliative care, and develop a business case to implement a more integrated set of solutions to:

  • support providers delivering end of life and palliative care
  • help monitor service quality and quantity
  • provide comprehensive data for service planning

4. improve stakeholder engagement by:

  • developing a statewide stakeholder engagement strategy that brings together current activity and good practice, and is transparent and publicly available
  • defining accountability for overseeing and implementing the strategy at state and district levels.

1. Performance monitoring is inadequate

NSW Government policy on palliative care is outlined in the NSW Government Plan to Increase Access to Palliative Care 2012–2016 (the Plan). Under the Plan, the overarching policy is ‘to ensure that everyone has access to quality palliative care regardless of their economic or social circumstances, their geographical location or their medical condition.’ Some initiatives under the Plan are still being implemented.

NSW Health only has measures in place to assess some processes and activities for individual initiatives under the Plan. There is no tracking of outcomes relating to the policy goals set out in the Plan, such as increased choice to die at home or the location of the patient’s choice, and improved access to specialist palliative care services. NSW Health has not conducted an overall assessment of the Plan’s outcomes to guide future priorities.

Further, there is no overall performance and reporting framework for palliative and end of life care, meaning there is no monitoring of performance of palliative care services for NSW as a whole. This lack of evaluation and performance measurement impacts on NSW Health's ability to monitor progress and achievements, address gaps in service, and plan for future service enhancement. 

2. Statewide planning and evaluation lacks coordination

Currently, palliative care services are complex to plan and evaluate. Many policies, strategies, guidelines, directives and data collections currently inform services. Even definitions of services vary. The split of policy functions for palliative care and end-of-life care between different branches within NSW Health adds further complexity. These arrangements create the risk of confusion, gaps in advice and support for LHDs.

Consistency is needed in the use of terminology and planning to achieve an integrated approach at all levels, including:

  • standard definitions of palliative care and end-of-life care
  • planning within a single structured policy framework to help clarify what services are to be delivered, who is accountable for delivering them and how to measure their outcomes.

Workforce planning is also affected. While NSW Health has identified significant gaps in the specialist palliative care workforce (especially in regional and remote areas) and it previously made workforce capacity one of its priorities, limited work has been undertaken in producing a statewide strategy to reduce these gaps.

3. District planning is not systematic and some external providers are poorly managed

An integrated approach would inform district-level service planning for palliative care. Planning in the districts we visited was sometimes ad hoc and accountability for performance unclear. Districts would benefit from:

  • better integrating data collection systems with planning
  • clearer guidelines, easy-to-use tools, monitoring and accountability systems.

The recently developed guide – A Blueprint for Improvement, from the Agency for Clinical Innovation – should help districts plan more effectively and consistently as it rolls out more widely in 2017. This takes an integrated approach to palliative and end-of-life care. Only one district we visited has finalised a comprehensive plan using the Blueprint.

Issues with district planning extend to external agreements with service providers, as these are sometimes poorly managed and do not support improved patient outcomes. Examples we reviewed showed a significant reporting burden with process-focused reporting. We also found little evidence of monitoring or action as a result of these reports.

4. Diverse information systems mean data collection and use are inconsistent

NSW Health gathers a broad range of data from many collection points and systems to inform palliative care services at hospital, ward or unit level, and community teams. However, the current data is limited because: 

  • activity is under-reported, particularly in community-based services
  • collection is not universal across districts and services.

Districts also struggle with evidence-based planning and service delivery because multiple information systems mean data may be incomplete or inaccurate. Too often, clinicians and service managers rely on manual collection and paper-based systems. 

eHealth, which coordinates information communication technology (ICT) for the state’s healthcare, is planning a statewide approach to capture information and report on all palliative care activity. The current plans of eHealth to review and improve systems should make data more complete, robust and accessible for quality improvement and planning.

5. An overarching stakeholder strategy would strengthen engagement

Just as data is central to effective planning and evaluation, so too is stakeholder engagement. However, there is currently no explicit stakeholder strategy, which means consultation is inconsistent across the state and not systematic at a district level.

While NSW Health uses a range of platforms to consult, the purpose and value is often not clear to stakeholders. Individual districts have some good practices, but there are limited mechanisms to identify and share these with other areas. A state-wide strategy would improve the quality and consistency of engagement, which will in turn inform service planning and delivery.

A stakeholder engagement strategy would integrate current initiatives, such as the two major networks that consult with health planning staff and clinicians. But it will also need to extend the feedback gathered from families, carers and volunteers, and from the peak bodies that represent them. 

Published

Actions for NorthConnex

NorthConnex

Premier and Cabinet
Treasury
Transport
Compliance
Infrastructure
Internal controls and governance
Management and administration
Procurement

The processes used to assess NorthConnex adequately considered value for money for taxpayers.This report also found that the impact of tolling concessions on road users and the motorway network was consistent with policy objectives described in the 2012 NSW Long Term Transport Master Plan.

NorthConnex is a nine-kilometre tolled motorway tunnel between the M1 Pacific motorway at Wahroonga and the M2 Hills motorway at West Pennant Hills. The total cost for the project is $3.1 billion. NorthConnex will be funded through toll charges, and contributions from the NSW and Australian Governments of up to $405 million each. In January 2015, the NSW Roads Minister signed the final contracts for NorthConnex.

By December 2017, the Department of Premier and Cabinet should:

1. publish an updated ‘Unsolicited Proposals – Guide for Submission and Assessment’ which clarifies obligations with requirements in other NSW Government policies such as the NSW PPP guideline and Infrastructure Investor Assurance Framework. The update should require:

a) a business case to be prepared, and a business case gateway review completed, as part of the assessment of the detailed proposal (currently stage 2)

b) probity reports must be completed and considered before the decision to proceed to the next stage.
 

The Department of Premier and Cabinet and NSW Treasury should immediately:

2. improve record keeping to ensure compliance with the State Records Act 1998 and the NSW Government Standard on Records Management.

 

Published

Actions for Universities 2016 Audits

Universities 2016 Audits

Universities
Asset valuation
Compliance
Cyber security
Financial reporting
Fraud
Information technology
Internal controls and governance
Procurement

No qualified opinions were issued on the universities’ financial statements and the quality and timeliness of financial reporting continued to improve. The report found that all NSW universities recorded a surplus in 2016 with combined revenue growth exceeding expense growth by 1.1 per cent. Universities have diversified revenue sources and are now less reliant on government grants. Combined overseas student income exceeded domestic student income for the first time in 2016.

This report analyses the results of the financial statement audits of the ten NSW universities and their controlled entities for the year ended 31 December 2016. The table below summarises key observations.  

This report focuses on key observations and common issues identified from our financial audits of the ten NSW universities and their controlled entities in 2016. The universities are listed in Appendix Three.

In this report, parliament and other users of universities’ financial statements are provided with an analysis of universities’ results and key observations in the following areas:

  • Financial Performance and Reporting
  • Financial Controls
  • Governance
  • Teaching and Research.

Snapshot of NSW universities

A snapshot of NSW universities for the year ended 31 December 2016 is shown below.

Financial performance and reporting are important elements of good governance. Confidence in public sector decision making and transparency is enhanced when financial reporting is accurate and timely.

This chapter outlines audit findings on financial performance and reporting of NSW universities for 2016. 

Appropriate financial controls help ensure the efficient and effective use of resources and the implementation and administration of university policies. They are essential for quality and timely decision making.

In 2016, our audit teams made the following key observations on the financial controls of NSW universities.

Governance refers to the high-level frameworks, processes and behaviours that ensure universities meet their intended purpose, conform with legislative requirements, and meet expectations of probity, accountability and transparency.

This chapter outlines audit findings on the governance of NSW universities and their controlled entities. 

Teaching and research are core activities of universities. The quality of teaching is a key driver for growth and attracting students. Through research, universities contribute to economic growth, lead innovation and improve their global rankings.  

This chapter reports on teaching and research in NSW universities for 2016.

Published

Actions for Medical equipment management in NSW public hospitals

Medical equipment management in NSW public hospitals

Health
Compliance
Internal controls and governance

In an audit of medical equipment in NSW hospitals, the NSW Auditor-General, Margaret Crawford found that the management of PET-CT scanners could be enhanced by better performance reporting and replacement planning, and that biomedical equipment needed more timely testing and maintenance.

The NSW Auditor-General examined the management of:

  • a high-value piece of equipment primarily used for diagnosing cancer - Positron Emission Tomography and Computed Tomography (PET-CT) scanners
  • a small sample of lower value but critical medical equipment known as biomedical equipment.

Medical equipment needs to be properly managed over its lifecycle, from planning to acquisition, operation and disposal, to ensure patient safety and quality of care.

This audit assessed how well NSW hospitals managed medical equipment to meet the needs of patients. We examined the management of:

  1. Positron Emission Tomography and Computed Tomography (PET-CT) scanners, a high-value piece of equipment commonly used for diagnosing cancer
  2. a small sample of lower value but critical medical equipment known as biomedical equipment.  

We examined five hospitals for this audit: Lismore Base Hospital (in the Northern NSW Local Health District (LHD)), Liverpool Hospital (South Western Sydney LHD), Nepean Hospital (Nepean Blue Mountains LHD), Royal Prince Alfred Hospital (Sydney LHD) and Westmead Hospital (Western Sydney LHD).

Conclusion 

Management of PET-CT scanners

PET-CT scanners were well managed, though could be enhanced by better performance reporting and replacement planning.


The PET-CT scanners we reviewed were well utilised and there was prompt reporting of scan results by specialists to referring doctors.  

In 2015–16, 10 per cent of PET-CT scans were inpatient services (funded mostly by NSW Health), 60 per cent were Medicare-funded outpatient services, and the remaining 30 per cent were privately referred outpatient services not funded by Medicare. Service costs for privately referred scans not funded by Medicare were met by a range of sources, including hospitals’ general purpose funds and patient out-of-pocket charges. Across the five hospitals, out-of-pocket charges varied and ranged from $250 to $950 per scan.  

While responsibility for providing PET-CT services has been delegated to Local Health Districts, NSW Health could assume an enabling role in collating performance reporting to inform service planning and benchmarking.

There was little equipment replacement planning for PET-CT scanners, making it unclear when and how equipment might be replaced, including what model of funding might apply.

Management of biomedical equipment

Improvement is needed in the timeliness of testing and maintenance for biomedical equipment. Outdated and inefficient information systems used for day-to-day management of biomedical equipment need to be improved or replaced.


Only about half of the items of equipment included in our sample had testing and maintenance completed according to scheduled intervals or within 30 days of the scheduled date. These intervals were set under the Australian/New Zealand Standard 3551 ‘Management programs for medical equipment’, which requires regular testing and maintenance of biomedical equipment to ensure it is safe and suitable for clinical use.

The information systems used to record service histories of biomedical equipment were inefficient and inadequate for effective planning, monitoring and reporting of testing and maintenance. The implementation of a state-wide asset management system, Asset and Facilities Management Online (AFM Online), which will replace existing systems, has experienced delays. In addition, hospitals did not maintain adequate oversight of testing and maintenance that was outsourced to external contractors.

Management of PET-CT scanners

PET-CT scanners were well utilised and reports were promptly sent to referring doctors

PET-CT scanners in Liverpool, Westmead and Royal Prince Alfred Hospitals were utilised to over 85 per cent of capacity. Utilisation at Nepean Hospital (around 60 per cent) was lower due to the age of the equipment and insufficient ‘uptake rooms’ for patients to receive radioactive injections. Lismore Base Hospital had a lower population to service and scheduled its PET-CT patients into three days a week to optimise efficiency.

PET-CT services were generally available to patients in a timely way and reports were promptly sent back to referring doctors. While clinicians we interviewed advised that there was generally no delay in patients accessing PET-CT scanners, only one hospital collected patient waiting time data to confirm this view.

Funding of PET-CT scans is complex

The funding of health services in NSW public hospitals involves a complex arrangement between the Australian and NSW Governments. In 2015–16, 10 per cent of PET-CT scans were inpatient services (funded mostly by NSW Health), 60 per cent were Medicare-funded outpatient services, and the remaining 30 per cent were privately referred outpatient services not funded by Medicare. Service costs for privately referred scans not funded by Medicare were met by a range of sources, including hospitals’ general purpose funds and patient out-of-pocket charges. Across the five hospitals, out-of-pocket charges varied and ranged from $250 to $950 per scan.

Better performance reporting could enable better planning of PET-CT scanners

NSW Health has delegated the planning functions for many pieces of high-value medical equipment, including PET-CT scanners, to Local Health Districts. This is intended to ensure local decision-making that is responsive to local community needs.

While local planning and service delivery is delegated to each Local Health District, under the Health Administration Act 1982, the Secretary of NSW Health is responsible for planning the provision of comprehensive, balanced and co-ordinated health services throughout New South Wales.

NSW Health could enable better service delivery and planning by collating and sharing performance information about PET-CT services across Local Health Districts.  

Equipment replacement planning was unclear 

Planning for future replacement of PET-CT scanners at the hospitals we examined was unclear, including when equipment would be replaced and what funding model might be applied. A better practice would be to have a clear equipment replacement plan for existing scanners that would ensure clarity about when equipment will be replaced, whether the replacement scanner should be leased, purchased or shared, and possible funding sources.

Management of biomedical equipment 

Equipment testing and maintenance did not always comply with intervals set under the Australian/New Zealand Standard All hospitals we examined adopted the Australian/New Zealand Standard 

All hospitals we examined adopted the Australian/New Zealand Standard 3551 ‘Management programs for medical equipment’ (the Standard) for managing medical equipment, the purpose of which is to ensure that equipment is safe and suitable for use. The Standard requires the regular testing and maintenance of biomedical equipment at predetermined intervals.  

Our review of three years of service records for 50 items of biomedical equipment found that:

  • nineteen (38 per cent) items of equipment were tested and maintained within the intervals determined by hospitals under the Standard
  • five (ten per cent) had at least one instance where they were tested and maintained less than 30 days later than when the work was due
  • thirteen (26 per cent) had at least one instance where they were tested and maintained one to six months later than when the work was due
  • six (12 per cent) had at least one instance where they were tested and maintained more than six months later than when the work was due
  • seven (14 per cent) were lost, removed from clinical use or unable to be unidentified.

The Standard envisages that there may be circumstances when testing and maintenance does not occur according to schedule, and sets out a procedure that should be followed when testing and maintenance is overdue. This procedure was not followed in any of the hospitals we reviewed.  

Two out of five audited hospitals used risk rating to oversee equipment maintenance

Only two out of five hospitals we examined used risk rating, under which equipment is classified according to clinical risk, to prioritise equipment maintenance and to determine appropriate frequencies for equipment testing and maintenance.  

Some hospitals had inadequate oversight of work performed by external contractors

There was variable oversight of outsourced service contracts for high-risk biomedical equipment. In some cases, hospitals did not maintain complete histories of testing and maintenance work performed by contractors. Some contractors had incorrectly recorded items they had tested, or had refused to provide details of testing and maintenance performed.

New peer review process may improve assurance over testing and maintenance

NSW Health has started a peer review process in a small number of hospitals. This process covers a range of performance indicators relating to equipment management practices, including the auditing of test and maintenance records for two pieces of equipment per hospital. There is opportunity to build upon this effort by including all hospitals in the peer review process, and by expanding the sample of equipment subject to records audit.  

Hospitals’ record keeping of testing and maintenance service histories was inefficient and inadequate

The Standard requires that adequate and traceable equipment maintenance histories be kept. We found that hospitals’ record keeping of equipment service histories was inefficient and inadequate. None of the hospitals used an information system that provided the full three-levels of capability outlined below:

  • storing equipment information electronically, allowing easy retrieval
  • managing service requests and holding full service histories and test results
  • automatically generating reports to allow risk based prioritisation of equipment maintenance, repairs and replacements.

There is an urgent need to implement the state-wide asset management system for biomedical equipment

Hospitals advised that the current outdated systems will be replaced by a state-wide asset management system, Asset and Facilities Management Online, though this implementation has experienced delays.

There was good governance over equipment acquisition, replacement and disposal

All hospitals had formal processes for acquiring and replacing biomedical equipment, including management committees to oversee equipment needs. Equipment disposal processes were aligned with relevant standards and policies.

All hospitals purchased the majority of their biomedical equipment through HealthShare, the central procurement agency of NSW Health. This contributed to cost savings across the health system.

Management of medical equipment in the NSW public health system

In New South Wales, responsibility for the management of public hospitals is devolved from the NSW Ministry of Health to 15 Local Health Districts and two Speciality Health Networks.The Secretary of NSW Health retains a function under the Health Administration Act 1982 to plan the provision of comprehensive, balanced and co-ordinated health services throughout the State.

Every year, the Ministry of Health and Local Health Districts sign a service agreement that sets out the expected performance from Local Health Districts and the funding they will receive to provide their services. Under these arrangements, responsibility for managing medical equipment is delegated to Local Health Districts.  

Medical equipment is used to diagnose, treat and manage patients. It includes items as diverse as patient beds, dialysis machines, operating tables and heart monitors. The good management of medical equipment contributes to ensuring patient care and safety, as well as keeping the cost burden on the public health system low.

The New South Wales public health system uses a wide range of medical equipment. Most of this equipment is used in hospital settings, however, some is also used in community health centres and patients’ homes. The cost of individual items ranges from less than $100 to several million dollars. In total, about $1.2 billion, or six per cent of NSW Health’s total asset value, was for medical equipment.

The approach used to manage medical equipment varies between hospitals, and between expensive and less-expensive items. Different service models are also used, for example, some items may be purchased in one hospital, but leased in another.  

About the audit

This audit assessed how well NSW public hospitals managed medical equipment to meet the needs of patients. We looked at the lifecycle of biomedical equipment, which comprises planning, acquisition, operation and maintenance, and then replacement and disposal. The audit questions in relation to each stage of the lifecycle are summarised in Exhibit 1. 

By June 2018 

  1. NSW Health should review all services provided by Local Health Districts which use high-value medical equipment (with establishment cost that exceeds $3 million), to determine whether state-level coordination, service benchmarking and equipment usage reporting is warranted.

  2. NSW public hospitals offering PET-CT services should collect and use patient waiting time data (the difference between the date of referral and the actual date of the scan) as part of improving service efficiency and meeting patient needs.

  3. Local Health Districts should ensure that there is a formal equipment replacement plan at the time of procuring high-value equipment, for both new and existing services. The plan should include an estimated time of replacement. The Ministry of Health should regularly review capital funding implications from these planned equipment replacements.

By June 2019

4. NSW public hospitals should review internal business rules and processes for biomedical equipment management to ensure that:  

a) equipment is accessible by service technicians for testing and maintenance work, including establishing internal processes to assist service technicians in gaining access to equipment that has missed previous testing and maintenance attempts in accordance with the Australian/New Zealand Standard 3551

b) adequate maintenance records are kept, including descriptions of testing and maintenance work carried out in accordance with the Australian/New Zealand Standard 3551

c) there is regular reporting to Local Health District Chief Executives on the compliance of equipment testing and maintenance, including equipment that is tested or maintained later than scheduled intervals

d) there is specified statement of risk tolerance for late equipment testing and maintenance and mechanisms to appropriately prioritise equipment testing and maintenance.

5. Ministry of Health should encourage that all NSW public hospitals have their biomedical equipment management practices reviewed under the new peer review process, and that the review sample from each hospital be increased to more than two pieces of equipment per hospital.

6. Ministry of Health should complete the implementation of AFM Online for biomedical equipment management.

Appendix One - Response from NSW Health

Appendix Two - About the Audit

 

Parliamentary reference - Report number #286 - released 25 May 2017