Introduction

Our objective for this follow-up audit was to assess if the Department of Health (DoH) and St John Ambulance Western Australia (SJA) have effectively implemented the recommendations from our 2013 audit to improve ambulance service management and delivery.

We also looked closely at ambulance ramping which is the practice of leaving ambulances parked outside hospitals while crew wait with patients for admission to a hospital emergency department (ED), to assess its impact on patients and other parts of the health system.

Background

The DoH contracts SJA to provide ambulance services throughout Western Australia (WA). SJA has operated ambulance services in WA since 1922. St John Ambulance (NT) provides ambulance services in the Northern Territory, while in other Australian jurisdictions those services are provided by government entities and regulated by legislation.

The DoH has 2 ambulance service contracts with SJA, one for emergency ambulance services, and one for inter-hospital patient transfers (IHPT). Emergency ambulance services cost the DoH almost $100 million a year under a fixed price contract, and SJA also recovers ambulance fees from patients. The DoH also pays half the ambulance fees of patients over 65 years old, while SJA waives fees for pension card holders. Last year the DoH contributed $45.7 million under this arrangement.

IHPT are provided exclusively by SJA in country WA but in the metropolitan area a panel of contractors, including SJA, provides it. The DoH estimates that the annual cost of IHPT was $19.4 million in 2018-19.

SJA answered 592,079 calls to its State Operations Centre in 2017-18 and attended 335,609 cases: 249,804 cases in the metropolitan area and 67,746 in country areas. The balance were made up of IHPT, neonatal emergency transport and rescue helicopter cases. IHPTs and airport transfers totalled 33,840.

SJA crews ambulances with paid career paramedics in the greater metropolitan area and 15 country towns, but relies on volunteers supported by community paramedics in many country areas. Community paramedics are paid paramedics based in 27 country locations to support, advise and help train volunteers in surrounding sub-centres and occasionally attend major incidents and complex cases. While SJA is contracted for services throughout the state, the WA Country Health Service (WACHS) operates its own ambulance service in Derby, Fitzroy Crossing and Halls Creek.

In 2009 the Government held an inquiry into the ambulance service which endorsed many aspects of the service and SJA’s arrangements with the DoH but made recommendations for improvement. In 2013, we followed up this inquiry with an audit report titled Delivering Western Australia’s Ambulance Services.

The 2013 audit found:

• SJA’s ambulance services had improved overall since the 2009 inquiry, supported by increased funding from the DoH, and despite increased demand across the state and ramping in the metropolitan area
• efforts to address ramping had so far been unsuccessful
• the DoH’s contract management had been effective but inadequacies in the contract between the DoH and SJA needed to be addressed.

In 2013 we recommended that the DoH should improve effectiveness and accountability when contracting for ambulance services by focusing on standards, performance and allocation of risk in a new funding model. We also recommended that the DoH should engage with SJA to find long-term solutions to ambulance ramping. Ramping is the practice of ambulance crews waiting with their patients until there is capacity within the ED to accept the care of the patient and the ambulance is free to respond to another call. We further recommended that SJA should focus on performance targets, clinical governance and improving services in regional centres. The full list of 2013 recommendations and current implementation status is at Appendix 1.

Audit conclusion

The ambulance service is more efficient than it was when we reported on it in 2013. It consistently meets emergency response time targets, and clinical governance and support for country volunteers has improved.

SJA has implemented all recommendations from our 2013 audit, with further work required for 1 recommendation related to engagement with regional services. The DoH has worked with SJA since our last audit to improve the contract but has made limited progress towards a new funding model, including a contract focused on standards, performance and risk, that links funding to performance.

Data collection is extensive, covering measures of SJA’s activity, clinical compliance and incident reporting. The DoH and SJA share patient records for clinical handover. Data collected, however, is not analysed to assess clinical outcomes and how the ambulance service could change to improve them. This means the DoH is not able to assess the impact of ambulance performance on patient outcomes or assess if the ambulance contract makes best possible use of public funds.

SJA often misses targets for less urgent cases during busy periods and the level of service in country areas remains uneven. Resources for country areas have improved, while a small number struggle to maintain volunteer crews. SJA’s response time targets cover around 90% of the state’s population. This leaves around 270,000 people in country WA not covered by response targets. Services for these people depend on the best endeavours of volunteers and are not always timely. The DoH and WACHS need to determine what levels of service they require and work with SJA on the cost of delivering them, and to develop better indicators of country ambulance performance.

Ramping has persisted with a significant increase since mid-2017. To date, it has typically not affected emergency cases as these are given priority, however, response times for lower priority cases have been adversely impacted. The DoH and SJA are affected differently and concerned with different aspects of the ramping issue. SJA is concerned about its ambulances being unavailable to respond to calls while the DoH has focused more on managing patient flow inside EDs. Initiatives to reduce ramping, such as diverting patients from hospital EDs, have met with little success. Eliminating ramping completely requires system wide solutions.

Key findings

WA’s ambulance service is more efficient, but the DoH has made limited progress improving the contract and measuring performance

SJA’s ambulance service has expanded since 2013 and become more efficient in order to meet rapidly increasing demand

Growth in the number of cases attended by SJA ambulances has exceeded the increase in resources deployed by SJA. SJA has managed this by becoming more efficient. It has continued to achieve targets for the time it takes to respond to emergencies despite average cases per ambulance increasing by 27% from 552 in 2012-13 to 699 in 2017-18. However, SJA has not always been able to maintain response targets for lower priority cases.

The DoH has made limited progress in implementing a new funding model and a contract focused on standards, performance and risk

Our 2013 audit recommended developing a new funding model focusing on standards, performance and risk. The current contract, which was extended in 2018 to 2020, made no substantial changes to the funding model. It does not connect funding with performance or demand for services, or provide a clear view of the cost of services such as IHPT, or facilitate in-depth analysis of complex matters such as the impact of ramping on response times and patient outcomes. While SJA is motivated to perform well by its mission and culture, weaknesses in the contract mean the DoH does not have a clear view of how its funding is being used and if it’s getting value for money.

The contract sets target times for ambulances reaching patients but they don’t apply everywhere and it is unclear how meaningful they are for less urgent cases

The contract sets target times for ambulances reaching patients in major country towns and the metropolitan area where around 90% of WA residents live and work. They do not apply in country areas more than 10 kilometres from the town centres of the 15 country towns where career paramedics are based. Outside this range, ambulance crews are required to use their best endeavours but their performance is not assessed against targets.

The time it takes for ambulances to reach patients is important for emergency cases but there is little clinical evidence that these response time targets are the most useful measure of paramedic or volunteer performance for ambulance activity in less serious cases. However, there is no widely accepted alternative. The DoH and WACHS need to determine what levels of service they require and work with SJA on the cost of delivering them. They also need to develop better indicators of country ambulance performance. The DoH informed us that it is preparing a statewide policy on ambulance services that will address these issues.

SJA has improved its clinical quality controls but the contract gives the DoH no visibility of cases that do not meet guidelines or ways to assess their significance

SJA has substantially improved its internal clinical quality controls and in 2017-18 achieved 95% against its target of 90% compliance with the clinical guidelines agreed with the DoH. However, how individual cases comply with the guidelines is not independently audited and the contract does not give the DoH any visibility of the 5% of cases that did not comply. This contrasts with other jurisdictions where ambulance services are part of the government health system and a single authority holds the data. WA patients can complain to the Health and Disability Services Complaints Office and the DoH has access to detailed clinical data for critical incidents. But the lack of broader access makes it harder for the DoH to assess the continuous improvement in patient care over time that is required by the contract.

SJA and the DoH collect patient data but neither has access to data covering the whole patient journey that they could use to improve services

SJA and the DoH keep patient records and patient data is included in the clinical handover from ambulance to ED. However, SJA and the DoH do not combine their data to analyse all aspects of the patient journey from the call for an ambulance to when they leave hospital. This limits the ability of both the DoH and SJA to use patient-centred data to improve services.

SJA has improved clinical governance and support for volunteers but coordinating services in country areas remains a challenge

SJA and WACHS report difficulties coordinating services despite SJA’s creation of regional offices to respond to local needs

SJA’s regionalisation project established offices in Albany, Bunbury, Northam, Kalgoorlie, Geraldton and Broome to support sub-centres and be more responsive to local needs. However, SJA and other local health services do not always coordinate effectively in country areas, and neither SJA nor WACHS have developed quantitative performance targets for community paramedics.

The coordination of IHPT in country areas is a concern to both WACHS and SJA. Timely availability of patient transport crews cannot always be guaranteed to coincide with the requests from country hospitals whose capacity to receive patients also cannot be guaranteed. Conversely, country hospitals may not always take account of the limitations of the country ambulance system when requesting IHPT services.

SJA has developed criteria with the DoH and WACHS for allocating career and community paramedics to country areas and employed more of them to support volunteers

SJA uses a set of objective criteria to allocate career and paid community paramedics to volunteer ambulance stations. These include the number of cases in the previous year, volunteer capacity, geography and the proximity to a neighbouring community paramedic.

There are now 5 more community paramedics than there were in 2013-14, bringing the total to 27. Since 2013-14, 1 community paramedic in Kununurra and 2 in Karratha have been replaced by full-time career paramedics, reducing the total by 3. However, SJA has appointed 8 more, 1 each to Onslow, Paraburdoo, Denmark, Wundowie, Ravensthorpe, Coolgardie, Corrigin and Dalwallinu. This has increased the level of support and the quality of training provided to volunteers in the country.

SJA has strengthened the way it maintains standards of patient care in all its services, metropolitan and country

SJA more effectively maintains standards of patient care in all its services, metropolitan and country, than we found in 2013. In addition to increasing the number of community paramedics to support country volunteers and monitor their performance, it has increased clinical audits in country areas and appointed 3 clinical quality managers to focus on clinical standards and carry out the audits. This means WA residents, including those in country towns, can have greater confidence in the quality of their ambulance services.

Ambulance ramping at hospitals has increased and there is no agreed plan to reduce it

Ambulance ramping has increased

Ambulance ramping has increased in recent years despite attempts by the DoH and SJA to reduce it. To date, ramping has not typically affected emergency cases because these are given priority, but it has reduced average response times for lower priority cases. SJA fell short of response time targets for lower priority cases more often and by a greater margin last year whenever total ramped time at all metropolitan hospitals exceeded 24 hours in a day.

There is little evidence of its impact on patients’ health outcomes or system costs

Despite the increase in ramping of lower priority patients and the potential for discomfort this may cause, there is no available research showing these patients suffer long-term health impacts as a result. There is also little available evidence that ramping imposes material costs on the health system.

The DoH and SJA do not have an agreed plan or strategy to reduce ramping

The DoH and SJA have not found a way to reduce ramping. This is, at least in part, because the DoH and SJA are affected differently and are concerned with different aspects of the issue. However, rather than focus on ramping as an isolated issue, it may be better to address it as a problem of managing patient flow into and through the hospital system. For example, hospitals we spoke to told us that delays in transport for mental health patients often led to them occupying ED beds for long periods.