Response from St John Ambulance Western Australia

St John Ambulance Western Australia (St John) welcomes the findings of the 2019 Follow-up Audit of the Delivering Western Australia’s Ambulance Services 2013 audit.

In particular, St John is pleased to have completed all of its recommendations identified in the 2013 audit. We are proud that all recommendations are recognised as being implemented and only one is classed as more needed. Recognition of our motivation to perform well with due acknowledgement of our purpose and culture reflects well on our employees and volunteers without whom the service could not operate in the way it does.

Of the recommendations made in 2019, St John looks forward to the opportunity to work collaboratively with the DoH in order for them to deliver on the recommendations within the implementation timeframe suggested, and steps have already been taken in recent months to address these areas.

Of particular interest to St John were the conclusions on ramping, contract structure and data.

• Though ramping may not be an overall cost to the broader health system, the brunt is born by the ambulance service. In the absence of ramping being reduced its cost has to be returned to the ambulance service in order to maintain a sufficient capacity to respond to the community.
• We acknowledge it is not evidenced that, for the patient being ramped, waiting on the ramp causes adverse patient outcomes. However, a missed response to a patient in the community could well impact on that patient’s outcome.
• St John is keen to work with the DoH to develop a contract structure that links funding and performance, as well as recognising increases in demand that differ from projected index linked increases. St John is of the opinion that this can be achieved within a fit for purpose long term contract that takes into account the interests of all parties across WA Health.
• St John believes that there is a significant opportunity to improve patient outcomes through the mutual sharing of data. An example of this is, through collaboration with Curtin University, St John having access to [anonymised] Out of Hospital Cardiac Arrest (OHCA) outcomes. This has enabled St John to double the number OHCA survivors over the last two years by using data to gain a better understanding of the many steps in the chain of survival and improving each one wherever possible. This is an exciting opportunity for both St John and WA Health.

Response from the Department of Health

The Department of Health (DoH) notes the OAG’s Summary of Findings and supports the recommendations, subject to review of implementation timeframes and finalisation of the Western Australian Government’s position on The Country Ambulance Strategy (Driving Equity for Country Western Australia).

The nature of the procurement relationship between St John Ambulance (SJA) and the Government of Western Australia has evolved over time with DoH moving toward a modern commercial model with strengthened contract specifications and more robust contract management. DoH has end to end responsibility for the safety and quality of the patient journey, while SJA (and other contracted providers) deliver the patient transport component of that journey. The relationship with SJA continues to evolve with both parties demonstrating increasing maturity.

DoH is committed to the continuous improvement of Western Australian ambulance services and is investing significant resources in initiatives aimed to increase the effectiveness and accountability of these services including:

• Developing an inaugural state-wide ambulance policy, in consultation with stakeholders, to articulate the expectations of the WA health system in achieving high quality, high performing, integrated and sustainable services that meet the needs of all Western Australians, and inform procurement and contract specifications accordingly
• Analysing pricing and costing structures
• Introducing expanded mental health patient transport services to address the situation where patients experiencing mental health issues occupy hospital emergency department beds while waiting for more appropriate definitive care
• Effecting contract variation to achieve greater value for money and increase non-emergency transport options (e.g. for transport of medically necessary planned transports for people over 65 years of age)
• Engaging with ambulance consumers and their carers about their lived experience to inform future contract development, focusing in particular on Aboriginal consumers and people experiencing mental health issues
• Implementing interventions to address ED congestion, based on a whole of system patient flow analysis.

Response from the WA Country Health Service

WACHS has progressed the development of the Country Ambulance Strategy which was endorsed by the WACHS Board in October 2018. The priority recommendation within the Strategy recommends the establishment of a state-wide policy on ambulance services as a minimum, to consider enacting legislation in line with other states and territories. Western Australia remains the only Australian jurisdiction where there is no policy or legislation describing ambulance services as an essential emergency service.

Consistent with previous review findings, former OAG recommendations and the recommendations of the Country Ambulance Strategy, WACHS recommends that the OAG consider refining the audit recommendations and reinstate the previous [draft] recommendation to implement legislation or policy. This will define the ambulance service and the standards required to reflect the community’s expectation of the Western Australian ambulance service.

WACHS supports the recommendation to develop ways to better coordinate ambulance and hospital services in country areas, especially for IHPT, and reflect these in the contract. This issue of better coordination and reflection of this in the contract is addressed in a number of the Country Ambulance Strategy recommendations.

In October 2018, the WACHS Board endorsed the development of the WACHS Command Centre. This development is derived from the natural expansion of the current Emergency Telehealth Service (ETS) to include services such as Inpatient Telehealth and Mental Health ETS. The WACHS Command Centre is also planned to provide more transparent patient transport coordination supported by innovative technology. The WACHS Command Centre will provide a 24/7 coordinated clinical support service for all patient transport requirements for WACHS facilities and clinicians through a single point of entry. WACHS will be working collaboratively with SJA and Royal Flying Doctor Service to improve patient coordination across the State.

WACHS supports the recommendation to agree links between funding and performance in the future contract from July 2020 that makes SJA or other potential service provider more accountable for its performance and gives WA Health better information about how its funding is used. WA Country Health Service notes the need for much closer contract management and communications between individual health service providers (those who use the service), Department of Health (who manage the contract) and service providers. Through the recommendations in the Country Ambulance Strategy WACHS is specifically seeking to assume responsibility of contract management for country ambulance services, similar to its role contract managing RFDS services.

Future contracts should include performance measures that can be linked to funding and patient outcome, rather than simple KPIs relating only to response time, with regular contract meetings between those who use the service, those who contract the service and those who provide the service.

WACHS supports the recommendation to review performance targets in any future contract with a view to increasing them where actual performance indicates this is achievable and developing new ones to clarify or replace ‘best endeavours’ provisions. The current ‘best endeavours’ and non-evidenced-based response time indicators do not give an adequate picture of effectiveness of ambulance services nor value for money.

WACHS intends to use service demand information to assist with future definition and agreement on the level of ambulance services required in country towns and have this included in the contract.

WACHS is of the view that country ambulance performance measures need to include service availability and clinical indicators relating to evidence-based practice. The intention is to ensure these are supportive of volunteerism while also holding the service provider accountable. This is a delicate balance and can only be done with policy and contract support.

WACHS supports the recommendation to develop ways to share and analyse information covering the patient journey in order to improve services and to reflect this in the contract. WACHS highlights the need for improved data integration, communications and collaborating with all providers of clinical care across the entire patient journey. There needs to be a mandated and shared clinical governance framework within the policy and contract. A shared technology platform (with all health and service providers) will allow the secure transfer of information and support improvements to patient care as well as potentially increasing health services and efficiencies by tracking patient movement.