Victorian Auditor-General’s report
6 October 2010

Access to Ambulance Services

Audit summary
Ambulance services are an integral part of the health system. While quality of care provided by paramedics is paramount, the outcome for a patient may also be affected by the time taken to respond to an emergency.
Recently there has been concern from some quarters in the community that ambulance response times have been increasing. There is also a view that this perceived deterioration is linked to the amalgamation of metropolitan and rural ambulance services on 1 July 2008.
This audit focuses on ambulance responsiveness, particularly response times to Code 1 incidents, potentially time critical emergencies where ambulance lights and sirens are used to reduce travel time. The audit looked at data for the last six years as well as the circumstances in which Ambulance Victoria (AV) operates, in order to understand the service’s performance. It also examined whether the information the community is getting about ambulance response times is reliable and presented so as to be clear and meaningful.
Conclusions
As with any merger, the amalgamation of metropolitan and rural ambulance services into AV posed risks. For example, expected new synergies might not occur and the different businesses might not be able to work together because systems are incompatible, for cultural or structural reasons, or simply because people resist change.
While AV has achieved much since amalgamation—including moving towards ‘state‑of‑the‑art’ call taking and dispatch for the whole state, and greatly improving strategic planning for rural regions—a number of challenges exist that have yet to be resolved.
The time between the announcement of the merger and its implementation was short and only limited funds were provided to systematically deal with any cultural issues.
Some expected efficiencies have not been realised and the trend of deteriorating ambulance response times evident prior to amalgamation has not been arrested. Ambulances are taking longer to respond to Code 1 emergencies, with the worst performance since 2004–05 recorded in 2009–10. Response times have worsened more in rural regions than in the metropolitan area, and increased funding of $185.7 million over four years from 2008–09 has so far not led to demonstrable improvement.
It is likely the significant increase in demand for emergency services in the past six years has caused most of the increase in response time. To the extent that amalgamation and extra operational funding was intended to avoid this, this has not succeeded.
This points to unfinished work from the amalgamation, particularly addressing cultural issues that have persisted from Rural Ambulance Victoria, and in bedding down more sophisticated resource allocation in regional and rural areas. New funding provided by the Department of Health (DH) also needs to be better aligned with AV operational priorities.
Greater transparency in reporting response time performance and disclosing area‑specific targets that take account of geography and branch staffing is needed to better inform the public about the level of service it can realistically expect. The present reporting of state-wide measures omits the level of detail necessary to give this understanding.
Findings
Response time performance
Performance data shows that ambulance response times have worsened in both metropolitan and regional areas over the last six years. Despite these trends the standard of responsiveness compares favourably with other states. Benchmark data shows that Victoria performs slightly better than New South Wales, its most closely comparable jurisdiction. Notably, no other jurisdiction reports higher quality care to patients.
Metropolitan areas continue to get a more timely service than rural regions. In metropolitan areas, the average response time has risen from just under 10 to almost 11 minutes. In rural regions the average response time increase is greater, shifting from 13 minutes in 2004–05 to 15 minutes in 2009–10. Although small, these rises can make an important difference in those urgent cases where hospital care is vital to recovery.
Response time performance declines as population density reduces and travel distances for paramedics increase. Performance for population centres with fewer than 7 500 people is significantly worse than for larger communities.
There is no credible evidence that the merger of metropolitan and rural services adversely affected performance, as there was a pattern of longer Code 1 response times well before amalgamation. However, it is clear that amalgamation has not yielded the expected improvements in service response times.
The task of providing a timely service throughout the state is challenging, given the travel distances, the unpredictability of when and where emergencies occur and the numbers of paramedic staff available in smaller communities. AV cannot realistically offer similar response times across the state, but it does strive for equity by working to give a similar level of response to communities of similar size. Nevertheless, it struggles to achieve this goal, with disparities in average response time evident in similar populations.
Impacts on performance
Many factors affect AV’s responsiveness, only some of which are within its control. It now has sound techniques to strategically deploy its paramedic staff and fleet resources. This is a major improvement on past methods of allocating rural and regional resources, which depended on relatively unsophisticated tools, compared with the metropolitan area.
This deficiency is now being remedied, and rural and regional areas will both benefit from a more highly developed strategic resource allocation model, as well as new technology that will dispatch ambulances as efficiently as in the metropolitan area.
However, AV is not funded to add the staff needed to improve performance. Although it raises funds directly through fees and membership levies, 59.5 per cent of its revenue is from DH.
DH’s most recent new funding commitment of $55.5 million included $30.6 million for additional paramedics and directed where they should be located. However, this direction did not align with AV’s strategic and operational priorities for where new staff were needed and the type of staff needed. Demand and staffing are not adequately balanced, particularly in rural regions where growth in paramedic numbers has not kept pace with growth in caseload.
AV is also facing increasing demands from higher caseload numbers. The ageing population and the increase in chronic disease are factors driving demand, with Code 1 incidents rising by around 9 per cent across the state in the past three years.
Average case times are also increasing across the state, often as a result of longer time spent in hospital emergency departments. The combination of more cases and longer case times means paramedics are less available to take on new calls and this flows on to extend response times.
AV needs to address its organisational culture where problems with morale exist and where staff feel disconnected from decision-making. These issues are affecting performance in some locations. Many of these issues existed in the former Rural Ambulance Victoria, and have not been resolved by the amalgamation.
Reporting performance to the community
Although AV's performance indicators are relevant, the timeliness measures do not fairly represent the geographical variations in actual performance. The public would better understand the expected ambulance response times in their district if AV published more detailed data, in line with its internal measures and targets.
Consolidated reporting of total case times by DH, and of each component of case time would help clarify accountability and highlight systemic issues that are not evident in the current suite of health service performance measures.
Recommendations
Number	Recommendation	Page	
1.	That the Department of Health reconciles new funding with Ambulance Victoria’s strategic priorities, to identify and quantify any unmet resource needs.	39	
2.	That Ambulance Victoria further develops its system-wide approach to better integrate both metropolitan and rural regions’ needs in its strategic planning.	39	
3.	That Ambulance Victoria continues to review rosters and staffing levels in rural regions to minimise recall of paramedics.	39	
4.	That Ambulance Victoria implements a comprehensive strategy to drive its work on improving organisational culture.	39	
5.	That Ambulance Victoria publicly reports a comprehensive suite of response time indicators, including:
·	national measures of response times at the 50th and 90th percentiles
·	a breakdown of performance by region/locality.	56	
6.	That the Department of Health reports on performance for total case time, broken down by the elements attributable to the Emergency Services Telecommunications Authority, Ambulance Victoria, and hospitals.	56	
Submissions and comments received
In addition to progressive engagement during the course of the audit, in accordance with section 16(3) of the Audit Act 1994 a copy of this report, or relevant extracts from the report, was provided to the Department of Health, Emergency Services Telecommunications Authority and Ambulance Victoria with a request for submissions or comments.
Agency views have been considered in reaching our audit conclusions and are represented to the extent they are relevant and warranted in preparing this report. Their full section 16(3) submissions and comments are included in Appendix D.