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.

Appendix one - Response from agency

Appendix two - About the audit

Appendix three - Performance auditing

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.

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. 

Appendix one - Response from the Agency

Appendix two -  National and NSW data on palliative care activity and outcomes

Appendix three -  About the audit

• ageing ICT equipment and inadequate wireless networks
• variable student access to devices at school
• variable teacher access to centrally provided devices for use outside of the classroom.

Information and communication technologies (ICT) are pervasive in modern life. Australian research has identified that the workforce demand for digital literacy and advanced digital skills is growing across most areas of work. There is broad agreement internationally and in Australian school systems that digital literacy is a core skill for the workforce and students will need to be confident with ICT. Education systems around the world are using ICT in classrooms to support learning and employment goals.  

The New South Wales Department of Education’s (the Department’s) overall strategic directions for teaching and learning with ICT are set in the 'Strategic Information Technology Plan 2016–19'. The Department centrally provides a base level of resources to schools for ICT and schools supplement funding from their existing school budget and Parents and Citizens Associations. Each school decides how to allocate these funds to meet local needs. Schools also set expectations for how teachers and students will use technology to help deliver outcomes.

This audit assessed how well New South Wales public schools are using ICT to improve teaching and learning. It focussed on planning and teacher and student use of ICT. We examined whether:

• the Department identifies key strategic opportunities to enhance the use of ICT platforms and technologies in schools
• teachers are integrating ICT into classroom practice
• the Department monitors the impact of ICT on student learning.

Old equipment and wireless networks are not keeping pace with modern demands

The Department’s vision for ICT is to enable ‘any learning opportunity, anywhere, anytime’. This vision is at risk due to an ageing stock of devices and wireless networks. The average age of devices in New South Wales schools is over four years. Older devices are less reliable, require greater maintenance and support, and cannot run demanding applications. Further, many school wireless networks are beyond the end of their useful life. This limits the number of teachers and students who can access online content on wireless networks at the same time.

The central funding model for ICT in schools is not meeting current needs

Funding for the Technology for Learning program to deliver ICT in schools has not increased since 2004, despite an increase in the number of students and emphasis placed on ICT in teaching and learning during this time. Schools supplement funding for ICT from their existing school budget and Parents and Citizens Associations.  

The Department’s current funding model for ICT is not adequately addressing a growing gap in the provision of contemporary ICT in classrooms between schools able to access funding from other sources and those which cannot. The Department needs to review whether the Technology for Learning program is equitable in equipping all schools with the modern technology needed to achieve its vision.

Many teachers are not provided with devices for use outside of the classroom

School Principals we interviewed reported that technology is an essential part of a modern classroom and teacher access to devices outside of the classroom can impact how they use ICT. This is because, in practice, teacher working days extend outside classroom hours and teachers need access to devices for activities such as lesson preparation and student assessment. The Department provides teachers with access to a suite of software tools for these tasks.

The Commonwealth Government’s Digital Education Revolution program provided teachers of secondary school students with laptops from 2009 to 2013. The Department’s evaluation of the Digital Education Revolution program found that teachers reported greater confidence with, and use of, ICT throughout the program.  
Providing desktop computers, laptops or tablets for teachers is now a school level decision and arrangements vary across schools. Each school must trade-off between allocating devices for students and teachers. Most other States and Territories provide all teachers with a laptop for use in and outside of the classroom or offer subsidised access to one.  

There is limited teacher professional learning in the use of ICT

The Department’s research has identified that professional learning is an important factor in how effectively teachers use ICT to enhance teaching and learning. Despite this, the Department provides few courses on using ICT in the classroom directly, and most of these are offered in Sydney. This limits accessibility for teachers outside of the metropolitan area. Schools we visited reported that the costs of courses and providing relief teachers limits the number of external courses or events that teachers attend, especially for rural and regional schools. Increasing the use of online learning would improve access for teachers in these areas.  

The Department is not adequately monitoring trends in professional learning in ICT or evaluating the overall effectiveness of courses. A recent upgrade to the professional learning system may provide the Department with better quality data to do this.

Greater monitoring and reporting on technology use in schools is required

The Local Schools, Local Decisions policy gives schools greater authority to make strategic decisions on the use of ICT appropriate to their local contexts. To support this, the Department needs to better monitor current trends, and identify emerging needs to determine future direction and how best to support schools.  

For example, the Department does not currently know how many devices are allocated to teachers or how many schools have implemented a student Bring Your Own Device scheme. This affects how schools are using ICT, and places demand on the network and the type of support the Department must provide. An assessment of the ICT maturity of schools would help the Department target its resources to schools requiring greater assistance with planning.

The Department does not regularly monitor or report on student capabilities with ICT. A national assessment found that the ICT literacy of a sample of Year 6 and Year 10 New South Wales students fell between 2011 and 2014. The fall was greater in New South Wales than in other States and Territories. Without more regular assessment or reporting, the reasons behind this fall and the distribution of student capabilities between schools will remain unknown. 

By July 2018, the Department of Education should:

1. Review the Technology for Learning program and school ICT support resourcing to determine whether resourcing is adequate for modern school requirements.
    
2. Develop a program to improve wireless networks in all NSW schools, for instance by expanding the Connecting Country Schools Program to all NSW schools.  
    
3. Implement an assessment of school ‘ICT maturity’ and use this to target assistance to those schools requiring support with forward planning for ICT.
    
4. Improve the use of evidence to inform plans and strategies, including:
   • more detailed monitoring of teacher and student access to and use of ICT
   • evaluating the impact of teacher professional learning on student outcomes 
   • further examining the links between ICT and student outcomes.
      
5. Improve teacher access to devices for use outside of the classroom to improve how effectively they integrate ICT into teaching and learning.
    
6. Improve teacher professional learning by providing more:
   • online learning opportunities for teachers in regional and remote areas
   • courses focused on pedagogy to make best use of ICT.
      
7. Identify the ICT skills students need, and provide teaching resources to develop these skills and monitor their achievement.

Appendix One - Response from the Agency

Appendix Two - About the audit

Appendix Three - Performance auditing

NSW Government agencies use contingent labour to help deliver services to the community. The NSW Public Service Commission (PSC) defines contingent labour as people employed by a recruitment agency and hired by government agencies to provide labour or services. Agencies use contingent labour to fill a gap in skills or capability, for example, to fill a position while a staff member is on leave or where specialist knowledge may be needed on a short-term basis. The PSC estimated that in 2016 the contingent workforce represented 2.3 per cent of the public sector workforce, equivalent to 7,571 full-time employees.

The PSC recommends that contingent labour only be used when it is the most efficient and effective option available to respond to an agency’s business needs. It also recommends that agencies’ use of contingent labour be informed by workforce planning. 

Government spending on contingent labour has increased significantly over the last five years, from $503 million in 2011–12 to $1.1 billion in 2015–16. To reduce spend in this area, the NSW Government has introduced the Contingent Workforce Renewal Strategy, overseen by NSW Procurement. The Strategy aims to achieve greater efficiency and effectiveness in the use of contingent labour. It has four pillars:

• prequalification scheme – a list of approved contingent labour suppliers
• vendor management system – an information system to manage contingent workers
• managed service provider – a recruitment agency broker
• contractor management organisations – organisations that manage a contingent labour database, which agencies can source labour from.

The prequalification scheme is mandatory for public sector agencies. Agencies are progressively rolling out the other pillars. The vendor management system and managed service provider are together called ‘Contractor Central’.

Within the context of sector reform aimed at promoting efficiency and effectiveness, the objective of this audit is to assess whether agencies’ approach to purchasing and managing their contingent workforce meets business needs and delivers value for money. In making this assessment, we reviewed three agencies each at a different stage of the reform:

• Department of Education (Education) – Contractor Central introduced in August 2015
• Department of Industry (Industry) – Contractor Central introduced in November 2016, after our review
• Transport for NSW (Transport) – Contractor Central not in place.

The use of contingent labour neither informs nor is informed by agency level workforce plans

None of the three agencies we reviewed had an agency level workforce plan in place. Agencies could not demonstrate that they had analysed their use of contingent labour at an agency level, including how it is being used to address any skills gaps. An agency’s executive is responsible for ensuring that an agency level workforce plan is in place. An agency level workforce plan helps hiring managers to make decisions on the best resource strategy to meet their business needs. This is important because contingent labour should only be engaged after considering all other recruitment options and the agency’s workforce plan.

Contingent workforce data is not always reliable or accurate

The accuracy and reliability of contingent workforce data varied significantly across the three agencies we reviewed. In Industry and Transport, information on contingent labour is difficult to obtain because it must be drawn from different data sources, affecting its accuracy, reliability and timeliness. This information is also incomplete, with these agencies not having a full picture of their contingent workforce. Quality data is important because it improves an agency’s capacity to plan and monitor its use of contingent labour to ensure it meets business needs.

At the time of our review, only Education, through Contractor Central, was able to obtain timely and accurate data on its use of contingent labour. Contractor Central has also improved its reporting capability, with the agency’s executive now receiving quarterly reports on its contingent workforce. In contrast, executives in Industry and Transport received ad-hoc reports on the use of contingent labour that only gave them limited oversight of their contingent workforce.

Long tenure of contingent workers is an issue in agencies

We found that the maximum tenure of contingent labour varied across agencies from nine to more than 20 years. In Education and Transport, staff reported that hiring managers assume contingent workers are automatically renewed at the end of their contract, with no formal consideration about whether contingent labour is still needed. Also, contingent labour is used for significant capital projects in the information technology and infrastructure areas where a project may run for several years.

None of the agencies reviewed undertook an analysis to determine how to reduce tenure while ensuring business needs are met. This is particularly important for long-term use of contingent labour for large capital projects. Understanding whether contingent labour represents best value compared to other recruitment options, such as secondments or temporary employment, is essential. Contingent workers are engaged under different working conditions to employees. Long tenure can pose an industrial relations risk to agencies because contingent workers may believe they are entitled to the same working conditions as employees.

On and off-boarding processes could be strengthened

Agencies have processes to engage and release contingent labour, also called on boarding and off-boarding. This includes access to IT systems, building access, and the return of property. However, not all agencies had on boarding or off-boarding checklists with specific requirements for engaging or releasing contingent labour. In addition, agencies’ off boarding guidelines did not always provide for knowledge transfer. This was identified as a key risk by staff because it is important to ensure that critical skills and knowledge are retained.

Risk that agencies are being overcharged when engaging contingent labour

We found that in agencies without Contractor Central, there is limited assurance that recruitment agencies charge in line with the prequalification scheme fees. NSW Procurement estimates that the government was overcharged $1.3 million in 2015–16. In addition, there is a risk that hiring managers do not have sufficient information to benchmark pay rates when negotiating contingent labour engagements. Agencies with Contractor Central may be more likely to get reasonable rates by using a recruitment broker who has specialised market knowledge.

No system in place to monitor the performance of contingent workers

None of the agencies we reviewed had a system in place to monitor the performance of their contingent workforce at an agency level to ensure it delivers value for money. Hiring managers are not required to evaluate whether contingent labour delivers the services for which they are hired. For example, hiring managers do not routinely assess and centrally document the quality of services provided, including whether services are delivered on time and within budget. This means contingent workers who are not performing may be re-hired by other managers or agencies. With the implementation of Contractor Central, there is the means to capture agency-wide information on the performance of contingent workers.

Contractor Central has the potential to improve value for money

Contractor Central has the potential to improve value for money. This is because the recruitment broker has specialised market knowledge and is able to promote competition, and benchmark and negotiate pay rates. In addition, the new software can streamline invoice processing and ensure correct supplier rates are charged. Education reports that it achieved a net saving of $944,600 from August 2015 to May 2016 due to the introduction of Contractor Central. Industry also expects to achieve similar results with Contractor Central, which it advised was implemented in November 2016.

The Department of Industry and Transport for NSW should, by December 2017:

1. improve the accuracy and reliability of their data on contingent labour

2. routinely report the use of contingent labour to agency executive.

The Department of Industry, Department of Education, and Transport for NSW should:

by December 2017:

3. ensure agency-wide on-boarding and off-boarding guidelines or checklists detail the specific requirements for engaging or releasing contingent labour, including provisions for knowledge transfer.

by March 2018

4. ensure that contingent labour informs and is informed by workforce planning, by:

• analysing agency-wide business needs, staff capability, and skills gaps
• understanding how gaps are filled by contingent workers or other recruitment options
• assessing whether long-term contingent worker engagements are the most economical and effective labour option
• evaluating whether contingent workers meet agency business needs and deliver value for money.

5. assess and centrally document the performance of their contingent workforce to ensure that services are delivered as contracted

6. implement processes to ensure that hiring managers consider other recruitment options prior to engaging or re-engaging contingent workers.
    

Sector-wide learnings

This audit identified learnings that government agencies across the sector should consider when procuring and managing contingent labour:

1. Contingent workforce planning should be part of an agency’s broader workforce planning.

2. Using information systems to manage and procure contingent labour improves the accuracy, reliability and timeliness of contingent labour data. This information enables agencies to consistently assess contingent labour rates and to identify persistent skills gaps in their workforce.

3. Routine reporting of contingent labour to agency executives provides oversight of an agency’s use of contingent labour.

4. Hiring managers should consider all recruitment options, with advice from human resources staff, before engaging contingent labour to ensure that it is the most appropriate solution for a specific need.

5. Regularly assessing long tenure contingent labour engagements helps to ensure that such engagements are still the most economical and effective labour option.

6. Planning the engagement of contingent workers, including provisions for knowledge transfer, maximises the potential to obtain value for money from the use of contingent labour.

7. Assessing and centrally documenting the performance of contingent labour against agreed deliverables helps to ensure services are delivered as planned, including in terms of quality, and timeliness.

Appendix one - Response from the Department

Appendix two - Survey of disability service providers

Appendix three - About the audit