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Reports

13 December 2017

Published

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.

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

11 April 2017

Published

Passenger Rail Punctuality

Transport

Information technology

Infrastructure

Service delivery

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.

Conclusion:

Rail agencies are well placed to manage the forecast increase in passengers up to 2019, including joining the Sydney Metro Northwest to the network at Chatswood. Their plans and strategies are evidence-based, and mechanisms to assure effective implementation are sound.

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.

Transport for NSW has undertaken considerable work on developing strategies to increase capacity and maintain punctuality after 2019, but remains some way from putting a costed plan to the government. There is a significant risk that investments will not be made soon enough to handle future patronage levels. Ideally, planning and investment decisions should have been made already.

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.

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.
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.
Sydney Trains, NSW Trains and Transport for NSW should publish Customer Delay results by June 2018.
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.
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.
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).