Reports
Managing demand for ambulance services 2017
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.
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.
Parliamentary reference - Report number #295 - released 13 December 2017
Energy rebates for low income households
The Department of Planning and Environment provides more than $245 million in energy rebates to around 27 percent of NSW households. This report highlights that the department is not monitoring the rebate schemes to understand whether they are delivering the best outcomes.
Most rebates are ongoing payments applied directly to energy bills reducing the amount payable by the householder. The structure of these rebates is complex and can be inequitable. Some households are eligible for four different rebates, each with its own eligibility criteria. Also, some households in very similar circumstances receive different levels of support depending on what type of energy is used in their home or which adult in the house is the energy account holder. For example, a household using both electricity and gas receives more assistance than a household with electricity alone even if total energy bills are the same.
By September 2018, the Department of Planning and Environment should:
- Ensure effective strategies are in place to make information about rebates available to all eligible, low-income households
- Evaluate alternative models and develop advice for government to reduce complexity and improve equity of ongoing rebates
- Establish measurable objectives for schemes that provide ongoing support, and monitor and measure performance of all schemes against objectives and outcome measures
- Assess the impacts of the forecast increase in embedded networks and develop strategies to manage any increased administrative risk
- Strengthen assurance that EAPA is being provided in accordance with its objectives and guidelines by implementing accreditation and compliance programs
- Ensure those eligible for EAPA financial support are not disadvantaged by inflexible payments, inconsistent provider practices, or inability to access an EAPA provider in a timely manner. Options include:
- moving from a fixed-value voucher to a flexible payment based on need irrespective of energy type
- establishing a ‘Provider of Last Resort’ facility for households that cannot access an EAPA Provider.
Parliamentary reference - Report number #292 - released 19 September 2017
Building the readiness of the non-government sector for the NDIS
The Department of Family and Community Services has managed the risks of the transition to the National Disability Insurance Scheme (NDIS) in New South Wales effectively by increasing the overall capacity of the non-government sector and investing in provider capability.
The National Disability Insurance Scheme (NDIS) is a major reform that aims to change the way disability support is provided and received. Responsibility for overseeing the system to support people with disability in New South Wales will transfer from the NSW Government to the National Disability Insurance Agency (NDIA), an independent statutory agency of the Australian Government. Eligible people with disability will receive individual funding from the NDIA and purchase support from their chosen service providers, rather than being referred to services funded or provided by government. The NSW Government will transfer all disability services it currently provides to the non-government sector.
Approximately 78,000 people received NSW Government-funded disability support in 2015–16 at a cost of around $3.3 billion. An estimated 142,000 people will have an individual NDIS support plan in New South Wales, with total funding rising to around $6.8 billion in 2018–19. NDIS trials began in New South Wales in 2013. The full scheme was introduced in July 2016 and is scheduled to be operating across the state by July 2018.
This audit assessed the effectiveness of the NSW Department of Family and Community Services' (the Department's) management of the risks of the NDIS transition in New South Wales. It focused on the Department's work to build the readiness of the non-government sector for the NDIS. To make this assessment, we asked whether:
- the Department supported the non-government sector to build capacity to meet the expected increase in demand under the NDIS
- the Department supported disability service providers in NSW to improve their capability to deliver NDIS services
- the Department's work to prepare for the NDIS has been coordinated with the Australian Government's NDIS readiness work.
In addition to the audit questions above, this audit identified principles governments should consider when building the capacity and capability of the non-government sector to deliver human services.
Conclusion
The Department of Family and Community Services has managed the risks of the transition to the NDIS in New South Wales effectively by increasing the overall capacity of the sector and investing in provider capability building initiatives. More work is needed to build the sector's capacity to provide services to people with more complex support needs and to help existing providers complete the transition to the NDIS successfully.
The Department expanded the capacity of the non-government sector over the past decade in a way that was consistent with NDIS objectives. The development of a national market and workforce for the NDIS is an Australian Government responsibility and the Department has supported the Australian Government's work. More targeted work will be needed to build the capacity of the non-government sector to provide services to people with the most complex support and access needs.
The Department invested in provider capability building by funding programs that were delivered in partnership with sector peak bodies. The larger programs were evaluated and received positive feedback, but many providers will need more support to transition to the NDIS. The overall impact of the programs on provider readiness for the NDIS is not clear because baseline information on provider capability was not collected and targets for improvement were not set.
The Department managed the transition coordination risks by establishing comprehensive governance arrangements, contributing to the Australian Government's sector development work through national policy coordination forums and sharing lessons from New South Wales.
Building the capacity of the non-government sector
The Department supported an increase in the capacity of non-government providers
The Department started building the capacity of the non-government sector before the NDIS was developed. This included moving services provided by government into the non‑government sector, funding early intervention and community-based disability support, and introducing some individual support packages. The Department checks that the business and operational systems of non-government disability providers are adequate. However, its understanding of the outcomes for people using the services is limited.
Service gaps are possible for people with more complex support or access needs
There are risks to the supply of services to people who have more complex support or access needs, including people who need specialist clinical support, people in remote areas, Aboriginal and Torres Strait Islander communities and culturally and linguistically diverse communities. The Department has supported the NDIA's initial market development work and funded some programs to help providers build their capacity to support these groups. However, there is a risk the market will not expand quickly enough to meet the increase in demand for services.
Sector sustainability depends on support from outside the disability services sector
The sustainability of funded disability services provided by the non-government sector depends on support from outside the sector. Most people with disability receive significant unpaid support from family members, so carers will play a key role in the sustainability of the NDIS. There are opportunities for organisations that do not provide specific disability services to contribute to sector sustainability by providing some NDIS services. To do this, many will need help to make their services more accessible and inclusive to people with disability.
Helping non-government providers develop their capability
The Department invested in capability building programs for providers
The Department has spent more than $30 million over six years on programs that aim to improve the capability of disability support providers. This work began before the NDIS was established and was adjusted to focus on NDIS readiness from December 2012. It was guided by an industry development strategy that was developed after consultation with the sector and delivered in partnership with sector peak bodies. This approach gave the sector some responsibility for developing its own capability, which is important because the sector will not receive support from the NSW Government after the transition to the NDIS.
The overall impact of the programs on the capability of providers is not clear
The overall effectiveness of the Department's spending on provider capability is not clear. The Department had some information on the general financial health and organisational capability of providers from previous industry development work. However, baseline information on provider capability was not collected before programs commenced and targets for improvements in provider capability were not set. Without this information, the Department cannot demonstrate clearly that the capability building programs it funded represent good value for money.
Most providers will need more support to transition to the NDIS effectively
In late 2015, the Department assessed the transition progress of providers in New South Wales. This assessment indicates almost one third of providers are highly likely to need additional assistance to transition to the NDIS successfully, with only 14 per cent unlikely to need further assistance. We conducted a survey of 299 providers in New South Wales in August 2016. Most reported that they feel they are on track to transition to the NDIS successfully. Sixty-two per cent said the Department-funded programs and resources they had used had improved their readiness for the NDIS. Fifty-four per cent said the changes made because of using these programs and resources had a lasting impact on their organisation.
Coordinating sector development
Governance systems and planning processes for the NDIS transition were established
The Department developed governance arrangements for the transition in New South Wales. It contributed actively to the development of national policy and strategy documents including a strategy for national market development.
The Department shared sector readiness lessons with the Australian Government
Two NDIS sector readiness programs funded by the NSW Government were later expanded to national programs through funding from the Australian Government. New South Wales only received around five per cent of the total Australian Government funding for NDIS sector readiness initiatives. A report by the Australian National Audit Office in 2016 found there was limited evidence of a strategic approach by the Australian Government when allocating this funding to states and territories.
The Department has monitored transition issues and mitigated these where possible
The Department has monitored administrative issues for providers, which have included the changes in funding arrangements and registering for the NDIS. It has taken action to mitigate these where possible, although some issues, such as the operation of NDIA administrative systems, are beyond its control.
The National Disability Insurance Scheme (NDIS)
The NDIS is a fundamental change to the disability support system
The NDIS is a major reform that aims to make significant changes to the way disability support is provided and received. Under the NDIS, the administration of funding for disability support in New South Wales will transfer from the NSW Government to the National Disability Insurance Agency (NDIA), an independent statutory agency of the Australian Government. The NSW and Australian Governments will both contribute to funding the NDIS. The size of the disability services sector in New South Wales is expected to more than double when the NDIS is fully operational (Exhibit 1).
| Measure of sector capacity | Pre-NDIS (2015-16) | NDIS (2018-19) |
|---|---|---|
| Funding for services | $3.3 billion | $6.8 billion |
| People receiving support | 78,000 | 142,000 |
| Workforce required | 25,000-30,000 | 48,000-59,000 |
| Number of providers | 699 | Determined by the market |
One of the main objectives of the NDIS is to increase the choice and control that people with disability have over the support they receive. Under the NDIS, people with disability receive individual funding packages which they can use to pay their chosen providers for the support they need, instead of being referred to services that are deemed appropriate for their needs. This is a fundamental change to the nature of disability support. Before the NDIS, people with disability were moved around the system according to decisions made by government or other organisations providing disability support. Under the NDIS, the funding will move around the system based on the choices people with disability make. The development of the new market for NDIS disability services is expected to take up to ten years because the changes to the system are so extensive.
In addition to increasing choice and control for participants, the NDIS aims to:
- improve outcomes for people with disability by intervening early to help reduce the need for support later in life
- increase integration by helping people with disability access mainstream government services such as health and education
- increase the involvement of people with disability in the community by making it easier to access community services such as sports clubs and community groups.
The transition to the NDIS is underway
The transition to the NDIS is underway in most Australian states and territories, following trials over the last three years. In New South Wales, a trial site was established in the Hunter area in July 2013. Early roll out of the NDIS began in July 2015 for people aged under 18 in the Nepean Blue Mountains area. On 30 June 2016, about 7,800 people had an NDIS plan in the Hunter trial site and around 1,800 people had a plan in the Nepean Blue Mountains area.
The full roll out of the NDIS began in about half of New South Wales in July 2016. The NDIS will start operating in the rest of the state from July 2017 and the transition is scheduled to be completed by July 2018 (Exhibit 2).
For the rest of the transition, the Department of Family and Community Services should:
- Work with the Australian Government, NDIA and other NSW Government agencies to identify gaps and develop the capacity of specialist clinical services, focusing on regional and rural areas.
- Continue to implement projects to increase the number of organisations that can support Aboriginal and Torres Strait Islander and culturally and linguistically diverse communities.
- Target remaining capability building assistance to less prepared providers, including via one-to-one support and mentoring in identified areas of weakness.
- Continue working with the Australian Government and the NDIA to ensure lessons from sector capability programs are shared.
Principles for developing the non-government sector
- Commence work to increase the capacity of the non-government sector early to allow time for service capacity to be built in a sustainable way.
- Decide whether to increase the capacity of the sector by supporting existing providers to expand their operations, attracting new organisations from outside the existing provider group, or some combination of these.
- Tailor approaches to supporting groups that have additional support or access needs because of cultural or geographic factors.
- Define the desired outcomes for people using services and, where possible, include outcomes in service delivery contracts.
- Invest in the sector by partnering with sector peak bodies to deliver capability programs.
- Include one-to-one support and mentoring in capability building programs where possible to improve the targeting of support to the specific needs of providers.
- Collect baseline information on provider capability before commencing programs and build robust tracking and evaluation into their design.
- Establish whole-of-government governance arrangements to ensure roles, responsibilities and accountability for delivery are clear.
Parliamentary reference - Report number #280 - released 23 February 2017
