Reports
Actions for Health 2020
Health 2020
This report analyses the results of our audits of financial statements of the Health cluster for the year ended 30 June 2020. The table below summarises our key observations.
1. Financial reporting
Financial reporting |
Unqualified financial audit opinions The financial statements of NSW Health and its 25 controlled entities received unqualified opinions. The number of corrected and uncorrected misstatements increased from the prior year. Misstatements related predominantly to the implementation of new accounting standards, asset revaluations and accounting for new revenue streams to cover the cost of HSW Health’s response to the COVID-19 pandemic. Qualified compliance audit opinion We issued a qualified audit opinion for the Ministry of Health’s Annual Prudential Compliance Statement for aged care facilities operated by NSW Health. We identified 18 instances of material non-compliance with the Fees and Payments Principles 2014 (No. 2) (the Principles) in 2019–20 (30 in 2018–19). |
Financial performance |
NSW Health received an additional $3.3 billion in funding to cover costs associated with its response to the COVID-19 pandemic. The impacts of the COVID-19 pandemic on the cluster were significant for health entities and included changes to operations, increased revenues, expenditure, assets and liabilities. Cancellation of elective surgery and decreased emergency department presentations meant that despite the pandemic, activity levels at many health entities decreased. Health Pathology and HealthShare were notable exceptions. In the period to the 30 June 2020, NSW Health reported that over 900,000 COVID-19 tests were conducted. Health Pathology conducted over 500,000 of these tests. Health Pathology's surge requirements were enhanced through arrangements with 13 private sector providers. HealthShare purchased $864.2 million of personal protective equipment. Overall, NSW Health recorded an operating surplus of $3.1 billion in 2019–20, an increase of $2.0 billion from 2018–19. As in previous years, the surplus largely resulted from additional revenue received to fund capital projects including the construction of new facilities, upgrades and redevelopments. In 2019–20 additional Commonwealth and State funding for the purchase and stockpiling of personal protective equipment also contributed to the operating surplus. |
Overtime payments | The Ambulance Service of NSW’s (NSW Ambulance) reduced their overtime payments to $79.7 million in 2019–20 ($83.1 million in 2018–19). Overtime payments in 2019–20 included $6.8 million related to the response to the 2019–20 bushfire season. NSW Ambulance overtime payments represent 16.8 per cent of total overtime payments in the cluster. |
2. Audit observations
Internal control deficiencies |
We identified more internal control deficiencies in 2019–20. The number of repeat issues from prior years also remains high. NSW Health addressed 18 out of the 25 information system control deficiencies during the year. Several key agreements lacked formal documentation. This included agreements between the Ministry and health entities, between health entities and agencies in other clusters and between the Ministry and health departments in other jurisdictions. |
Infrastructure delivery | NSW Health had 44 ongoing major capital projects at 30 June 2020 with a total revised budget of $12.3 billion. The revised total budget of $12.3 billion is $2.0 billion more than the original budget. NSW Health revises budgets when it combines project stages. |
This report provides parliament and other users of the Health cluster’s financial statements with the results of our audits, our observations, analysis, conclusions and recommendations in the following areas:
- financial reporting
- audit observations.
The impacts of the COVID-19 pandemic on the cluster were significant and included changes to the operations of the health entities and increased revenue, expenditure, assets and liabilities.
As a part of this year's audits of health entities, we have considered:
- financial implications of the COVID-19 emergency at both health entity and cluster levels
- changes to agencies' operating models
- agencies' access to technology and the maturity of systems and controls to prevent unauthorised and fraudulent access to data.
Financial reporting is an important element of good governance. Confidence and transparency in public sector decision making are enhanced when financial reporting is accurate and timely.
The response to the COVID-19 pandemic primarily impacted the financial reporting of NSW Health through:
- additional revenue from the State government in the form of grants and stimulus payments
- additional revenue from the Commonwealth government under the National Partnership Agreement for COVID-19 to cover part of the cost of responding to the COVID-19 pandemic
- increased expenses, largely due to increased payments to private health operators to maintain their viability during the COVID-19 pandemic and later to assist with public patient elective surgery waitlists and increased cleaning costs
- increased purchases of personal protective equipment.
Chapter one outlines the impacts of NSW Health’s response to the COVID-19 pandemic. This chapter outlines our other audit observations related to the financial reporting of agencies in the Health cluster for 2020.
Section highlights
- Unqualified audit opinions were issued for all health entities’ financial statements, although more misstatements were identified than last year.
- NSW Health recorded an operating surplus of $3.1 billion, an increase of $2.0 billion from 2018–19. This is largely due to additional capital grants for new facilities, upgrades and redevelopments and additional Commonwealth and State funding for the purchase of personal protective equipment.
- NSW Health’s expenses increased by 5.5 per cent in 2019–20 (7.0 per cent in 2018–19) despite the impact of the COVID-19 pandemic. The primary causes for the growth in expenses are increases in:
- employee related expenses due to higher employee numbers, increased overtime and a 2.5 per cent award increase
- payments to private health operators to maintain their viability during the COVID-19 pandemic and later to assist with public patient elective surgery waitlists
- payments to private health operators due to the first full year of operation of the Northern Beaches hospital.
- The Ambulance Service of NSW (NSW Ambulance) continued to report higher overtime payments than other health entities. However, despite the response to the 2019–20 bushfire season, their overtime payments were lower than last year. NSW Ambulance paid $79.7 million in overtime payments in 2019–20 ($83.1 million in 2018–19).
- A qualified audit opinion was issued for the Ministry of Health’s Annual Prudential Compliance Statement for aged care facilities operated by NSW Health. There were 18 instances of material non-compliance with the Fees and Payments Principles 2014 (No. 2) (the Principles) in 2019–20 (30 in 2018–19)
Appropriate financial controls help ensure the efficient and effective use of resources and administration of agency policies. They are essential for quality and timely decision making.
The primary impact of the COVID-19 pandemic on the effectiveness of the internal controls of NSW Health and health entities relates to the effectiveness of controls implemented by HealthShare relating to the stocktake of personal protective equipment inventories. Inventory managed by HealthShare increased by 2,746 per cent during 2019–20. HealthShare’s inventory controls did not maintain pace with the sudden, significant increase.
The impacts of NSW Health’s response to the COVID-19 pandemic are outlined in chapter one. This chapter outlines other observations and insights from our financial statement audits of agencies in the Health cluster.
Section highlights
- The number of internal control deficiencies has increased since 2018–19. More than a third of control deficiencies are repeat issues.
- Control deficiencies that relate to managing employees’ leave and employee’s time recording continue to be difficult for entities to resolve, particularly during the ongoing response to the COVID-19 pandemic.
- Several key agreements were undocumented. These included agreements between the Ministry and the health entities, between health entities, and between the Ministry and entities in other clusters and jurisdictions. These related to:
- a loan arrangement between the Ministry and HealthShare for $319 million.
- Northern Sydney Local Health District's use of land and buildings owned by the Graythwaite Charitable Trust
- agreements for the treatment of New South Wales residents while they are interstate, and interstate residents receiving treatment while they are in New South Wales from Queensland, Victoria, South Australia and the ACT for both 2019–20 and 2018–19.
- NSW Health reported that they completed nine major capital projects during 2019–20. As at 30 June 2020 there were 44 ongoing major capital health projects in NSW. The revised capital budget for these projects in total was $2.0 billion more than the original budget of $10.3 billion. NSW Health reported the budget revisions are largely the result of combining project stages.
Appendix one – List of 2020 recommendations
Appendix two – Status of 2019 recommendations
Appendix three – Financial data
Appendix four – Analysis of financial indicators
Appendix five – Analysis of performance against budget
Copyright notice
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Auditor-General’s Report to Parliament
Health 2020
11 December 2020
This corrigendum has been prepared to amend the following text within the Auditor-General’s Report to Parliament on Health 2020, dated 10 December 2020.
NSW Health emergency department treatment times
On page five the original text was as follows:
NSW Health also measures the percentage of patients whose clinical care in emergency departments is completed within four hours. The measure is used as an indicator of accessibility to public hospital services.
NSW Health aims to complete clinical care in the emergency department for 81 per cent of patients within four hours. In 2019–20 NSW Health reports it completed clinical care within four hours for 72.1 per cent of patients (a 7.3 per cent decrease from 2018–19).
At Western Sydney Local Health District, 59 per cent of patients were treated within the targeted timeframe. NSW Health attribute this to the profile of patients presenting in emergency departments and additional time taken processing COVID-19 patients to ensure staff safety.
The original text has now been changed to:
NSW Health also measures the percentage of patients with total time in the emergency department of four hours or less for each local health district. The measure is used as an indicator of accessibility to public hospital services.
Local Health Districts | Target % (2019–20) | Actual % (2019–20) |
Central Coast | 77.0 | 59.9 |
Far West | 90.2 | 86.6 |
Hunter New England | 81.0 | 72.5 |
Illawarra Shoalhaven | 79.0 | 60.2 |
Mid North Coast | 82.0 | 76.7 |
Murrumbidgee | 85.3 | 81.9 |
Nepean Blue Mountains | 79.0 | 65.5 |
Northern NSW | 81.0 | 78.2 |
Northern Sydney | 79.0 | 73.9 |
South Eastern Sydney | 78.0 | 70.3 |
South Western Sydney | 78.0 | 61.2 |
Southern NSW | 85.0 | 83.0 |
Sydney | 76.0 | 70.9 |
Sydney Children’s Hospitals Network | 80.0 | 72.1 |
Western NSW | 85.9 | 81.0 |
Western Sydney | 78.0 | 59.0 |
St Vincent's Health Network* | 75.0 | 65.4 |
The above changes will be reflected in the version of the report published on the Audit Office website and should be considered the true and accurate version.
Actions for Managing demand for ambulance services 2017
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
Actions for Planning and evaluating palliative care services in NSW
Planning and evaluating palliative care services in NSW
NSW Health’s approach to planning and evaluating palliative care is not effectively coordinated. There is no overall policy framework for palliative and end-of-life care, nor is there comprehensive monitoring and reporting on services and outcomes.
Parliamentary reference - Report number #291 - released 17 August 2017
Actions for 2016 - An overview
2016 - An overview
This report focuses on key observations and findings from 2016 audits and highlights key areas of focus for financial and performance audits in 2017.
Financial reporting | |
Observation | Conclusion |
Only one qualified audit opinion was issued on the 2015–16 financial statements of NSW public sector agencies, compared to two in 2014–15. | The quality of financial reporting continued to improve across the NSW public sector. |
More 2015–16 financial statements and audit opinions were signed within three months of the year end. | Timely financial reporting was facilitated by more agencies resolving significant accounting issues early, completing asset valuations on time and compiling sufficient evidence to support financial statement balances. |
NSW Treasury’s early close procedures in 2015–16 were again successful in improving the quality and timeliness of financial reporting, largely facilitated by the early resolution of accounting issues. For 2016–17, NSW Treasury has narrowed the scope of mandatory early close procedures. |
The narrowed scope of mandatory early close procedures may diminish the good performance in ensuring the quality and timeliness of financial reporting achieved in recent years. To mitigate this risk, NSW Treasury has mandated that agencies perform non-financial asset valuations and prepare proforma financial statements in their early close procedures. It also encourages them to continue with the good practices embedded in recent years. |
Although most agencies complied with NSW Treasury’s early close asset revaluation procedures we identified areas where they can improve. | Asset revaluations need to commence early enough to ensure all assets are identified and the results are analysed, recorded and reflected accurately in the early close financial statements. |
Number of misstatements | |||||
Year ended 30 June | 2015-16 | 2014-15 | 2013-14 | 2012-13 | 2011-12 |
Total reported misstatements | 298 | 396 | 459 | 661 | 1,077 |
All material misstatements identified by agencies and audit teams were corrected before the financial statements and audit opinions were signed. A material misstatement relates to an incorrect amount, classification, presentation or disclosure in the financial statements that could reasonably be expected to influence the economic decisions of users.
Significant matters reported to the portfolio Minister, Treasurer and Agency Head
In 2015–16, we reported the following significant matters to the portfolio Minister, Treasurer and agency head in our Statutory Audit Reports:
Appropriate financial controls help ensure the efficient and effective use of resources and the implementation and administration of agency policies. They are essential for quality and timely decision making.
In 2015–16, our audit teams made the following key observations on the financial controls of NSW public sector agencies.
Financial controls | |
Observation | Conclusion |
More needs to be done to implement audit recommendations on a timely basis. We found 212 internal control issues identified in previous audits had not been adequately addressed by 30 June 2016. |
Delays in implementing audit recommendations can impact the quality of financial information and the effectiveness of decision making. Agencies need to ensure they have action plans, timeframes and assigned responsibilities to address recommendations in a timely manner. |
Agencies continue to face challenges managing information security. Most information technology issues we identified related to poor IT user administration in areas like password controls and inappropriate access. | Agencies should review the design and effectiveness of information security controls to ensure data is adequately protected. |
We found shared service provider agreements did not always adequately address information security requirements. |
Where agencies use shared service providers they should consider whether the service level arrangements adequately address information security. |
Thirteen of 108 agencies required to attest to having a minimum set of information security controls did not do so in their 2015 annual reports. | The 'NSW Government Digital Information Security Policy' recognises the growing need for effective information security. With cyber security threats continuing to increase as digital services expand we plan to look at cyber security as part of our 2017–18 performance audit program. |
We identified instances where service level agreements with shared service providers were outdated, signed too late or did not exist. | Corporate and shared service arrangements are more effective when service level arrangements are negotiated and signed in time, clearly detail rights and responsibilities and include meaningful KPIs, fee arrangements and dispute resolution processes. |
Internal controls at GovConnect, the private sector provider of transactional and information technology services to many NSW public sector agencies were ineffective in 2015–16. We found mitigating actions taken to manage transition risks from ServiceFirst to GovConnect were ineffective in ensuring effective control over client transactions and data. | The Department of Finance, Services and Innovation should ensure GovConnect addresses the control deficiencies. It should also examine the breakdowns in the transition of the shared service arrangements and apply the learnings to other services being transitioned to the private sector. |
Maintenance backlogs exist in several NSW public sector agencies, including Roads and Maritime Services, Sydney Trains, NSW Health, the Department of Education and the Department of Justice. | To address backlog maintenance it is important for agencies to have asset lifecycle planning strategies that ensure newly built and existing assets are funded and maintained to a desired service level. |
Actions for Purchasing Hospital Supplies: Follow-up of 2002 Performance Audit
Purchasing Hospital Supplies: Follow-up of 2002 Performance Audit
Periodically we review the extent to which agencies have changed their practices as a result of our audits. This gives Parliament and the public an update on the extent of progress made.
In this follow-up audit, we examine changes following our September 2002 report, to assess whether NSW Health has improved its buying of hospital supplies using electronic systems.
NSW Health spends over $1.3 billion on hospital supplies. It is the largest expenditure area after employee costs. Reform of this area has the potential to make significant savings that could be redirected to frontline services.
As part of our series of audits in the area of e-government, our previous audit looked closely at the extent to which technology was being used to deliver potentially major savings in purchasing hospital supplies. This is a key area of so-called “process re-engineering” in the “e” field, and NSW Health provided an ideal case study.
Whilst implementing large-scale e-procurement has many technical aspects, it is not chiefly a technical issue. The key requirements for success reside in effective change management, in particular being clear as to who has the authority to make change decisions and be held accountable.
This audit looks at NSW Health’s successes to date, and its frustrations and challenges in making further progress in this field. Many of the issues raised in this report may provide lessons for any agency that is seeking to drive a significant change program.
Parliamentary reference - Report number #145 - released 23 November 2005
Actions for Emergency Mental Health Services
Emergency Mental Health Services
It is estimated that one in five people will be affected at some stage by a mental health problem or illness. The increasing prevalence of mental illness means that at some point in time most of us will either be affected or we will know of someone who is.
Although most people with mental illness can be treated in the community, at times some may require emergency treatment or admission to hospital for shortterm intensive therapy.
Not only are more mental health patients presenting to an emergency department for treatment than ever before, they are reportedly sicker and a greater number require admission to a hospital bed for further treatment. And, because of its very nature, those suffering from acute mental illness may not understand what is wrong or be able to communicate their problems clearly.
This makes access to emergency mental health services a significant issue for government that requires continuing attention.
The focus of this report is on the provision of 24-hour crisis services to adults. Emergency mental health services play a vital role in providing timely and appropriate care. Without proper treatment the severity of the illness may escalate, increasing the risk of self-harm or harm to others.
There have been many changes to mental health services over the last decade to deal with increasing demand. Much has been done to improve access to, and the quality of emergency services through significant increases in funding, the opening of new beds and the employment of more mental health staff.
Yet recent reviews have highlighted problems with accessing mental health beds and inadequate levels of psychiatric support in rural areas.
I believe that our report will provide valuable assistance to area health services on alternative models of emergency mental health care that better manage patient risk and further improve service quality.
Parliamentary reference - Report number #136 - released 26 May 2005