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Legal and Constitutional Affairs References Committee
20/04/2016
National registration system for paramedics

LAVERTY, Mr Martin, Chief Executive Officer, Royal Flying Doctor Service of Australia

[12:29]

CHAIR: Welcome. Thank you for coming and talking with us today.

Mr Laverty : It is a pleasure.

CHAIR: The committee has received your submission as submission no. 11. Before we commence, do you wish to make any additions or amendments to your organisation's submission?

Mr Laverty : I would welcome the opportunity for a few opening comments.

CHAIR: I now invite you to make a brief opening statement before we go to questions.

Mr Laverty : Thanks, Senator. The question before this inquiry is: should paramedicine take the next step in properly establishing its respect as a profession? The Royal Flying Doctor Service says it is time that paramedicine was properly respected in Australia as a profession on par with that of medicine and that of nursing. So, to the terms of reference of this inquiry, we can say, yes, the next step should be taken for the proper formalisation of a national profession.

In fact, as an employer of paramedics around Australia and indeed for those who are consumers of healthcare services, we want to know: what are we getting when a paramedic provides us with an episode of health care? As an employer, we want to know that across the nation there is a standard of care that we can expect, demonstrated through prequalification and through continuous professional development, but, most importantly, we also want to know that there is a system of monitoring a nationally consistent standard of ethics—not only monitoring but providing that safeguard for both employers and patients alike so that, when those circumstances unfortunately arise where a call on the code of ethics is necessary, we actually have in place a robust national understanding of monitoring and enforcing that standard of ethics where it is appropriate. So, just as there is a national registry for health practitioners in Australia and national boards that oversee other health professions, so too should there be a national arrangement to oversee paramedicine. We think the appropriate place for that to be regulated is of course through AHPRA.

The traditional service that the Royal Flying Doctor Service provides, one of aeromedicine, is a medical mode of care. We employ doctors and nurses to provide our aeromedical retrievals, so that, if you find yourself injured or ill in remote parts of Australia, it is going to be a doctor or a flight nurse that will retrieve and bring you into care. That model, which has operated for some decades now, is because of the acuteness and the variability of the patient load that we serve in remote parts of Australia. But we also employ paramedics, not always in roles as paramedics. We value the professional skill that paramedics acquire through their career, and we employ them in varying roles within our organisations.

In more recent times, we have commenced the operation of ambulance-like transport on the ground. Non-emergency patient transport is one of our areas of expansion in Victoria in particular, where there is not the same call for aircraft to transport patients across what is mostly a regional state. We are now providing non-emergency patient transport on ground, and that is involving the employment of paramedics in growing numbers. But we do think that, if we had a national system of professional oversight, there would be new opportunity for us as the Royal Flying Doctor Service to engage paramedics in the evolving work that we do.

At the moment, we do not know what we are getting when we employ a paramedic, because of the different approach to training and to recognition in different states and territories. We think that, if there were a proper professional framework around paramedics, there would be new confidence that we would have as the Royal Flying Doctor Service to engage paramedics in our work.

The area in which the Royal Flying Doctor Service provides its health care is distinctly different from the parts of Australia where most paramedics work. If you like, paramedicine is more called on in the cities, where there is the support of acute care not that far away. Part of the reason that we employ doctors and nurses in our care in country Australia is that we do not always know what the circumstance or the acuity of the patient is. Therefore we have that additional medicine and nursing care as part of our mix.

But the acuity and the disparity in health outcomes between country and city in Australia I think are relevant to the considerations that you are making. I have been able to provide a copy of our research report, published just last month, and it touches on the work of paramedics nationally. But specifically for country Australia we know that the risk of an accident in country areas is twice that in the city. The risk of death in a motor vehicle accident in a country area is four times that in a city. Similarly, cardiovascular disease on national average is at about a 30 per cent greater risk of cause of death if the cardiovascular incident occurs in a country area as opposed to a city, noting some differences in different states and territories. The point I am making is that about 50 per cent of the work of the Royal Flying Doctor Service is in response to accidents, injury and cardiovascular disease. We should be investing, as a nation, in preventing accidents and injuries from occurring, in better preventing the need for cardiovascular disease to result in myocardial infarction or heart attack. This is the work of paramedics. It is the work of doctors and nurses.

If your inquiry is to recommend, as I encourage it to do, the oversight of the paramedic profession through AHPRA, I would encourage you to go a step further and also recommend that we put effort into properly preventing avoidable accidents and injuries from occurring. My specific recommendation to this inquiry is as follows. The national 10-year accident and injury prevention strategy expired in 2014. There is no national accident and injury prevention strategy at the moment. It ran out of life two years ago.

Our specific recommendation is that you propose that the Council of Australian Governments and the Commonwealth lead that process to put in place a new accident and injury prevention plan. Why? Because, if you are preventing accidents and injury, you are actually preventing the work demand on our health professionals, and paramedics in particular.

We also make a third recommendation: that you focus your attentions on the disparity that exists between city and bush. With the greater risk of accident and the greater risk of cardiovascular death that can be prevented and avoided in country areas, we think there is a role that this committee can play in recommending the proper regulation of the paramedic profession to also prevent the need for paramedicine to have to respond to incidents and acuity that could otherwise be prevented.

I hope these opening comments are useful, and I am very happy to take your questions.

CHAIR: You have answered all my questions. You may as well go home now! No. Can you just explain the role of a paramedic in delivering the services provided by the Royal Flying Doctor Service?

Mr Laverty : In some parts of Australia, we employ them in the traditional model that you would expect a paramedic to provide. In Queensland—your home state—in particular, we have a small number of paramedics who are part of our healthcare team. When a tasking of an incident occurs, a clinical decision is made as to whether it warrants a doctor, a doctor and a flight nurse, a paramedic. In response to the clinical circumstance, the right health professional is dispatched. We think that is a relevant consideration to your own thinking. We need to ensure that the clinical skill of the health professional matches the circumstance for which they are dispatched. That is not only in the best interests of the patient but it is also the most efficient use of scarce health professional resources. So the very simple way of responding to your question is: we provide the health professional in response to the known clinical circumstance but we also have paramedics working in non-paramedic roles. We have them driving vehicles in Victoria where a paramedic is not actually required but it makes sense to have one available. We have them involving tasking, in making those decisions about what clinical response is necessary to a call. We also have them working in management, I am very proud to say. That general experience is useful across the healthcare organisation, just as it is useful in using their very specific paramedic experience in that more traditional role.

CHAIR: Can you just give the committee some idea of the issues, if there are any, that currently exist in rural and remote areas of Australia in relation to recruiting and employing paramedics?

Mr Laverty : In some parts—and I do not seek to be flippant—we do not have the opportunity to employ the health professionals that you would like. It is relevant for the consideration of this inquiry to think about who is the first responder when an accident, an injury or indeed a cardiovascular incident occurs in many parts of remote Australia. It is usually a family member or a community member. That is not different from anywhere else, but the difference between a city area and a country area is that the community member, family member or volunteer is likely to be at the scene of that event on their own for a longer period while an emergency service is dispatched, be it a flying doctor or be it a state ambulance service. So we think there is something important to understand about the role that family members and community members play, specifically in remote Australia, where it is understood they might be the first responder.

The second is the organised voluntary nature of first responders. In many of the communities that we serve it is understood that a volunteer—a noted or an agreed volunteer—in that community, who might have a first aid certificate or experience, is going to be the first person who provides a response when that incident occurs. In some of our communities, doctors get to know those people over the phone because we deal with them regularly. Note that we do not only have challenges in recruiting and employing health professionals into country Australia—that is no surprise. But what I do not think we have a high recognition of is the importance of supporting community volunteers, particularly in organised structures in community controlled organisations in parts of remote Australia, to make sure that the first aid training and the opportunity to be supported by the Royal Flying Doctor Service and other organisations over the phone as an incident is occurring. That is a very important piece of social infrastructure in Australia.

Senator PERIS: I have just a couple of questions. With regard to the issues you just raised about recruiting for the Royal Flying Doctor Service, do you do anything internally? You said you are not too sure about the degrees that the paramedics might have, but do you have your own stringent recruiting process? Obviously, coming from the Northern Territory, you could respond to a call-out and it means a charter plane two hours away or what have you. You want to get the right person dispatched but there are no doctors, and you are left with a paramedic—could you just elaborate on that, please?

Mr Laverty : There are probably two parts to that. The first is at the recruitment and employment stage. We specify our specific clinical requirements for all of our health staff. For doctors and nurses we do rely on the AHPRA accreditation first for employment as a doctor or nurse. But then the specialist nature of the emergency and remote primary care that we provide necessitates additional training.

All of our flight nurses, as an illustration, need to take on additional specific flying doctor familiarisation simulation training, not only to be inducted into the service but to keep their competencies current—in addition, if you like, to the standard AHPRA requirement for coming to work for the Royal Flying Doctor Service. For the paramedics that we employ it is no different, with one challenge: at the moment we cannot actually rely on a national registration to satisfy ourselves that when we put out an advertisement for recruitment of paramedics that we actually know what we are getting. So that filter occurs internally.

We would benefit by there being a national system, to be able to rely on accreditation before employment within our service. But I think the opportunity of national recognition of the paramedic profession means that we would be in a position to rethink our own clinical service mix. At the moment we have a different approach across different states and territories because of the different approaches of the paramedic workforce within those states and territories. If there were a standardisation and, particularly, if we had that assurance of compliance with the same standards of ethics—I wonder if that has been a focus of your inquiry to date? The benefit of having that monitoring and the ability for there to be a common code of ethics that works across the profession across Australia which gives an additional safeguard to consumers and employers alike? We would be in a position to rethink the way in which we deploy our staff, knowing that we would have great confidence in the pool of national paramedics because they are overseen by this national system of safeguards.

CHAIR: If the Royal Flying Doctor Service needs a nurse, you advertise and then probably you get a dozen or whatever resumes. You read them all and the resumes tell you what their qualifications are. How do you check that?

Mr Laverty : We are able to rely on the national AHPRA system of certification at the moment. But there is then a process of requiring the additional experience to work in the extraordinary environment. I do not say this flippantly, but we are asking our health professionals to get into small aircraft and to go into different parts of Australia where, initially, those health professionals have never been before, to work in circumstances where they do not necessarily know what they are going to discover at the other end. Yes, they are supported by our clinical environment back at base but, most importantly, they are trained specially within the Royal Flying Doctor Service to meet our own RFDS clinical guidelines.

As an organisation we have had to develop our own internal clinical guidelines to oversee our health workforce because of the unique nature of the remote environments within which we work and also because of the nature of the doctors, nurses and paramedics who are very often working in very difficult circumstances. I do not want to suggest for a moment that paramedics and health professionals in city areas do not work serially in difficult circumstances from time to time. But we are working in remote Australia, in the extremes of our climate and with the difficulty of our poor communications system that still exists across remote Australia—even with satellite phones you still do not have the type of connectivity that you want for the clinical support while you are there.

We have to make sure that our doctors, nurses and paramedics are top-notch before we employ them. So there is a pretty rigorous process of screening, but then training on arrival as well. We would benefit if part of that were done for us by there being a national system of paramedic recognition, so that we did not ourselves have to guess—to test and work through—

CHAIR: Yes, but you can do that with the nurses, though, right?

Mr Laverty : Absolutely.

CHAIR: Yes, that is right—so that is the point I am making: you can do it with nurses and doctors but you cannot do it with paramedics because they do not have a national register.

Mr Laverty : But in addition you would have the confidence that there is a national board overseeing the setting of professional standards and to certify what professional development is required, to then provide this safeguard around practice of ethics. Why not bring that across to the paramedic profession as well, knowing that it would make life easier for us, as a large employer across Australia, to deliver our healthcare services?

Senator PERIS: What is your view about similarities in that industry—paramedics, doctors and nurses?

Mr Laverty : The appropriate clinical skills should be applied to the appropriate clinical circumstances. We do not have enough health professionals in Australia today as it stands. We know that we will have a shortage of doctors and nurses by the time we get to 2025. If I remember my numbers appropriately we will be short 3,000 doctors, and I think the number of nurses is close to 90,000 too few, given projections around population and health professional growth.

Therefore, as a nation it warrants us to use only the right clinical skills in the right places. So we see the appropriate opportunity for a greater recognition of the role of the paramedic through national certification and regulation, which then means that you can make a more confident decision about the deployment of your health professionals—doctor, nurse or paramedic—because you know that some of the background work around their professional development and their training has already been done. You can actually better utilise your resources, to put it in economic terms.

We think there is only benefit from the proposition that your inquiry is considering. I will be honest and say that I struggle to see the detriment. The time has come: why would you not move to this system of national recognition?

Senator PERIS: I guess also that in the role you play in the Royal Flying Doctor Service not only do you act upon life-and-death situations but you also have people in that industry getting on a charter plane out to these remote communities. There are thunderstorms and lightning to dodge, so it is a huge risk—and a very important one.

CHAIR: That is why I am not a flying doctor, because I hate flying!

Senator PERIS: Yes!

Mr Laverty : It is not for the light-hearted—

Senator PERIS: No.

Mr Laverty : but I think we are all grateful that there are doctors, nurses, paramedics and allied health professionals who are willing to work in the service of people who live, appropriately, in remote parts of Australia and who will continue to do so while ever they have access to health care.

Senator PERIS: Okay, thank you.

CHAIR: Questions pop in and out of my head all the time—one too many knocks on the footy field, sadly! With the register, what sort of information would you like to be able to see when you are looking at an individual, potentially to employ them?

Mr Laverty : That they have met the national standards that the board overseeing paramedicine has agreed are appropriate. The benefit of the board of medicine and the benefit of the board that oversees nursing and midwifery in Australia is that you have academic-practitioner experts—clinical experts—who actually agree on the types of standards that should be applied to their professions. And, importantly, they keep them contemporary. As new knowledge, as changes in clinical practice come along, in opportunities to vet and approve and expand professional development, it is taken care of through the oversight of the board. These are not boards of do-nothing. They provide a very important oversight of the development of the profession as clinical and research changes come along. I would like to see a similar board overseeing the paramedic profession that regularly attests as to what are the requirements for entry—what is the basic requirement of university qualification first—and to keep that monitoring of changes in clinical practice to ensure that the standards reflect the time.

CHAIR: If there has been some disciplinary action or anything like that, would you suggest that that be on that information register?

Mr Laverty : The exact same standards as apply to medicine and nursing. I could not think of an argument as to why you would not apply the same framework to the registration that we are promoting for paramedics. My point about having for the first time for the profession a common agreement of the standard of ethics and a body to monitor and, when necessary, to oversee the testing and policing of those standards of ethics is only going to be in the benefit of health consumers, employers and governments who are the principal funders of these services alike. It therefore makes sense that where there are professional discipline matters occurring there be a record for that to be held so that the employer and the health consumer, in turn, is able to have access to that knowledge.

CHAIR: Mr Laverty, I think we have run out of time. Thank you very much for your time.