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

• 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

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.

Appendix One - Response from Agency

Appendix Two - Governance Arrangements for NorthConnex

Appendix Three - About the Audit

• 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).

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

Based on forecast patronage increases, the rail agencies will find it hard to maintain punctuality after 2019 unless the capacity of the network to carry trains and people is increased significantly. If recent higher than forecast patronage growth continues, the network may struggle to maintain punctuality before 2019.

A NSW Government priority is to ‘maintain or improve reliability of public transport services over the next four years’. Punctuality is a key element of reliability, and the level of patronage is a critical factor in the ability to maintain punctuality. Increasing patronage places pressure on the length of time trains need to wait at stations to load and offload passengers which can lead to delays. The NSW Long Term Transport Master Plan forecasts that rail patronage could increase by 26 per cent between 2012 and 2031.  

Passenger rail services in NSW are provided under a purchaser-provider model. Transport for NSW enters contracts with:

• Sydney Trains for Sydney suburban passenger rail services
• NSW Trains for services that commence or terminate outside Sydney, including intercity services that operate between Central station and the South Coast, Southern Highlands, Blue Mountains and Central Coast and Newcastle.

Transport for NSW sets performance targets and standards for these services, develops the timetables, procures trains for the service providers, and is responsible for long term planning.

This audit assessed whether these rail agencies have plans and strategies to maintain or improve performance in getting the growing number of suburban and intercity rail passengers to their destinations on time.

Punctuality measurement is satisfactory, but agencies could publish more information

Passenger rail punctuality indicators adopted in NSW are good practice. The key train punctuality indicator is better than indicators used by many other rail operators. It is also better than the on-time-running indicator that it replaced. Unlike the on-time-running indicator, the punctuality indicator classifies trains that have been cancelled or skipped stations as late and results are not adjusted to take account of delays caused by factors such as extreme weather or police operations.

NSW also has a customer delay measure which represents good practice. Work has started on refining and embedding customer delay as a key performance measure for the planned new Rail Operations Centre.

As train frequency approaches a ‘turn up and go’ level of service, rather than running to a timetable, more emphasis will need to be placed on excess waiting time and customer delay when assessing performance.

Measurement of punctuality is reasonably precise. There are some measurement inaccuracies which should be addressed, such as the estimated arrival time of a train being incorrect at some destination stations, but these do not affect punctuality results materially.  

Train punctuality is reported publicly, but not to the detail of the indicators in the contracts between Transport for NSW and Sydney Trains and NSW Trains. There is very limited public reporting of customer delay.

Overall punctuality is good, but some services are relatively poor

System-wide train punctuality has usually exceeded target since 2005, but some services suffer from poor punctuality compared to the rest of the network.  

The part of the network around North Sydney is creating problems for the punctuality of afternoon peak services heading through it and out to Western Sydney and to Hornsby via Strathfield. Transport for NSW and Sydney Trains are well advanced with strategies to address this up to 2019.  

The East Hills express trains in the afternoon peak also performed well below target. The rail agencies recently analysed this issue and believe it relates to the train timetable and signalling which restricts how close trains can run behind each other into Campbelltown. It further advises that this will be corrected over the next three years.  

Intercity train punctuality is below that of suburban trains and there was an extended period of declining punctuality between 2011 and 2014. Transport for NSW suggested that the old age of trains is a factor, and the recently announced intercity fleet acquisition may help address this. Apart from ensuring that train crew and station staff are available and perform their duties adequately, NSW Trains can do little to impact the punctuality of its intercity services directly. Train maintenance, track and signal maintenance, and management of trains on the rail network are performed by Sydney Trains. NSW Trains’ ability to influence improvement is hampered by key indicators in some contracts being undefined. Transport for NSW, Sydney Trains and NSW Trains are now working collaboratively to make improvements to the contracts.

Initiatives are in place or are planned to deliver good punctuality until 2019

Patronage increases, which can lead to overcrowding and trains having to wait longer at stations, are likely to present a significant challenge to maintaining punctuality into the future.

Based on patronage projections, the rail agencies have strategies to maintain punctuality up to and including joining the Sydney Metro Northwest to the network at Chatswood in 2019. These include improving infrastructure at particular parts of the network, increasing staff training, reducing the number of speed restrictions, and a new Rail Operations Centre. The projects are being managed by experienced staff, with good governance arrangements, quality assurance processes and planning systems in place. New timetables should provide more services and cater for more passengers, including off peak. They should increase network efficiency through better utilisation of capacity, but some passengers may face longer journey times and more may need to change trains mid-journey.  

The planned Rail Operations Centre has the potential to make operational decision-making more customer-focussed, by placing more emphasis on minimising customer delay during disruptions. If implemented well, it will also generate information to help agencies better identify the root cause of incidents that delay trains and improve communication with passengers so they can make better real-time travel decisions.

Predicted passenger growth presents a risk to punctuality after 2019

The rail system will struggle to maintain punctuality much beyond 2019 based on current patronage forecasts and system limitations.

From 2024, the Sydney Metro City and Southwest will help by extending the metro network from Chatswood under Sydney Harbour, through the city and out to Bankstown. Announced fleet upgrades will also help. Transport for NSW advises that it is also working with the Greater Sydney Commission to ensure network capacity constraints are considered in future urban planning.

In addition to investment in new metro networks, sustained and substantial investment needs to be made into the existing heavy rail network to meet demand and ensure its ongoing reliability. Transport for NSW has been developing strategies for this purpose, including an Advanced Train Control system. Its aim is to put a costed plan to the government by the third quarter of this (2017) calendar year. Given the likely lead times involved with major infrastructure projects, there remains a significant risk of poor punctuality after 2019.

Punctuality could be at risk sooner if recent patronage growth continues

If patronage continues to increase at a faster rate than forecast, particularly during the morning peak, the network will struggle to cope before 2019. Transport for NSW forecast that between 2011 and 2026 morning peak rail patronage would increase each year by approximately 3.3 per cent. Between 2011 and 2016 the number of passengers travelling to the city during the morning peak grew by an average of 4.4 per cent each year, including annual growth of 6.6 per cent since May 2014.

A good understanding of patronage levels, trends and drivers is critical to effective planning. The audit identified some shortcomings in measurement of peak passenger loads. Transport for NSW advised that measurement approaches have been improved recently, and this will soon flow into improved data quality.  

Given the increasing flexibility in work practices available to many city workers, the relatively new field of behavioural insights may offer opportunities to ‘nudge’ some passengers away from travelling at the height of the peak with benefits for them and the network.

1. Transport for NSW should ensure that programs to address rail patronage growth over the next five to ten years are provided to the government for Cabinet consideration as soon as possible.
    
2. Sydney Trains and Transport for NSW should:
   a) maintain effective oversight and resourcing for all strategies designed to address rail patronage growth
   b) adjust strategies for any patronage growth above projection.
    
3. Sydney Trains, NSW Trains and Transport for NSW should publish Customer Delay results by June 2018.
    
4. Transport for NSW, Sydney Trains and NSW Trains should agree by December 2017:
   a) specific performance requirements for intercity train, track and signal availability and reliability
   b) guidelines for train priorities during disruptions and indicators of control centre performance in implementing these guidelines.
    
5. Sydney Trains, NSW Trains and Transport for NSW should by June 2018:
   a) improve the accuracy of patronage measurement and develop a better understanding of patronage growth trends
   b) address small errors in the adjustment factors used for determining a train’s punctuality status
   c) improve their understanding of the factors impacting on intercity punctuality.
    
6. Transport for NSW should, commencing June 2017, explore the potential to use behavioural insights to encourage more passengers to travel outside the height of the morning peak (8 am to 9 am).