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

This report found that in 2015−16, 75 per cent of prisoners who needed a prison-based therapeutic program did not receive one before the earliest date they could be released. Timely access to prison-based therapeutic programs can be a factor in parole refusal and can potentially exacerbate overcrowding in the prison system. The audit looked at a selection of moderate and high intensity programs that aim to reduce reoffending by addressing addiction, violence, domestic abuse, sex offending and general offending.

When a prisoner enters custody in New South Wales, there is an expectation that they will be offered therapeutic programs that reduce their risk of reoffending. Relative to the costs of providing them, these programs have wide-ranging benefits for prisoners and the broader community, and provide significant savings to the justice system. Corrective Services NSW has lead responsibility for ensuring relevant and effective programs are provided, and for the Premier’s Priority of reducing reoffending by five per cent by 2019.

In New South Wales, a significant majority of people convicted of an offence will eventually be reconvicted. Of those convicted of an offence in 2004, 79 per cent had been reconvicted of another offence by 2014 – half within the first year of their initial offence. The total cost to the community of reoffending is difficult to fully quantify. However, the potential to reduce costs to the prisons system alone by reducing reoffending is significant given the average costs of a prison stay is $167 per prisoner per day over an average 218 day sentence. Total prison system costs in New South Wales were $720 million in 2016.  

To help achieve its mandate to reduce reoffending, Corrective Services NSW delivers therapeutic programs in prison and the community, along with a range of vocational, education, supervision, case management and health and wellbeing general services. These programs and services contribute to the central goal of reducing the likelihood that prisoners will return to prison. This audit assessed whether selected therapeutic programs are available, accessible and effective in reducing the risk of reoffending. More detailed information on the programs selected is in Appendix 3.

75 per cent of prisoners who needed programs did not complete them before the earliest date they could have been released for parole 

In 2015–16, 75 per cent of prisoners with an identified program need did not complete a program prior to the earliest date they could have been paroled. If prisoners do not complete programs before their earliest parole date, they can be released having had no, or incomplete, interventions while in prison to address their offending. They can also be refused parole by the State Parole Authority, adding unnecessary length to the time spent in jail and exacerbating overcrowding. Parole refusal data from the State Parole Authority indicates that non-completion of programs was a factor in 84 per cent of 302 parole refusals in 2015. 

Program resourcing at the prison level is inadequate to meet increased demand

Lack of availability of programs to meet demand is a key factor preventing prisoners from completing programs in time for release. The 20 per cent increase in the prison population between 2011–12 and 2015–16 has placed a significant strain on resources. While more programs are being delivered, the overall proportion of prisoners receiving them before release has not. Prisoner case management is not performed in a timely and consistent way, resulting in prisoners missing opportunities to be referred to programs, particularly if they have shorter sentences. For example, 27 per cent of prisoners with more than six months to serve had not completed an assessment required to determine eligibility for an EQUIPS program in the past four years.

The mix of available programs may be out of step with the needs of some prisoners

Since 2012, Corrective Services NSW has increased the number of moderate-intensity EQUIPS domestic violence and aggression programs provided and more prisoners overall are now able to participate in programs. Over the same period, the number of intensive programs delivered for sex offenders has decreased and the number of intensive programs for serious violent offenders has remained the same. This is despite increasing proportions of prisoners sentenced for sexual assault and related offences, and serious violent offences.

Corrective Services NSW uses a risk-assessment model to determine which prisoners are eligible for existing programs, but does not regularly review whether there are gaps or insufficient program coverage of some therapeutic needs.

Corrective Services NSW does not collect robust and comparable information on program quality and outcomes 

Program performance reporting at the prison level focuses on program throughput, such as the number of programs delivered and the number of prisoners participating. Corrective Services NSW does not routinely collect information on program implementation that would provide insights at the prison level into whether programs are being run effectively, and are achieving their intended goals.

Corrective Services NSW has not systematically evaluated its therapeutic programs to confirm they are effective in reducing reoffending

Programs being delivered in New South Wales prisons are based on international evidence about the success of the specific methods and approaches used. This is a good foundation, but Corrective Services NSW is unable to show that its programs are effective in the New South Wales context, and that they are having an impact in achieving the Premier’s target of reducing reoffending by five per cent. Evaluations of some programs have been conducted, but these were mostly inconclusive because of challenges with data collection, such as developing significant enough sample sizes. A lack of consistent forward planning has also affected the rigour of some evaluations.  

With the roll out of an additional $237 million investment in reducing reoffending, Corrective Services NSW proposes to focus efforts on evaluating the effectiveness of its programs by engaging external experts and increasing resourcing in its own evaluation unit. A systematic forward program for independent evaluation, which identifies solutions to existing data gaps and builds on past studies, is needed to support this.  

Challenges for Corrective Services NSW

Corrective Services NSW, a division of the Department of Justice, operates 34 custodial correctional centres across New South Wales, including two that are managed by private companies. It is responsible for delivering correctional services and programs that reduce reoffending and enhance community safety. Corrective Services NSW has lead responsibility for the Premier’s Priority of reducing adult reoffending by five per cent by 2019. To assist in achieving this target, Corrective Services NSW delivers therapeutic programs in prisons that aim to reduce the likelihood that prisoners will reoffend once released.  

Prison overcrowding

Prior to 2011, the prison population had been decreasing, which resulted in the closure of Berrima, Parramatta and Kirkconnell Correctional Centres, the downsizing of Grafton Correctional Centre, and a reduction in total capacity of 900 beds. However, since 2011–12 the prison population has increased by approximately 30 per cent, reaching a record of around 12,900 prisoners in March 2017 (latest available data).  

Corrective Services NSW should by December 2017:

1.  Implement a systematic approach to the use of convictions, sentencing and case management data to ensure that gaps in program offerings can be identified and addressed.

By June 2018:

2.  Clearly establish program delivery staff resourcing benchmarks, based on individual prison profiles, that would meet demand and ensure prisoners receive timely assessments, comprehensive case management and relevant programs before the earliest date they can be released.

3.  Establish consistent program quality and outcomes performance indicators at the prison-level, and monitor and respond to these quarterly.

4.  Develop and implement a detailed forward program of independent evaluations for all prison-based therapeutic programs, that includes identified data requirements for prisons to collect and provide.

Appendix One - Response from Department of Justice

Appendix Two - Response from the Audit Office

Appendix Three - About the audit