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Community Affairs References Committee
05/06/2012
Health services and medical professionals in rural areas

MUNDY, Mr Gregory Philip, Chief Executive Officer, Council of Ambulance Authorities

CHAIR: Welcome. I know very well that you know about parliamentary privilege and the protection of witnesses and evidence.

Mr Mundy : Yes.

CHAIR: Do you have any comments to make on the capacity in which you appear?

Mr Mundy : The council represents the 10 ambulance services of Australia and New Zealand.

CHAIR: Thank you. We have your submission. You were very early in; it is No. 6. I now invite you to make an opening statement and then we will ask you some questions.

Mr Mundy : Ambulance services are a very important $2 billion part of Australia's health system—about two per cent of the total; I did the arithmetic. They are important not least in rural areas, which I will get onto. We provide care to approximately three million patients a year. Ambulance services are perhaps the largest part of our health system that has no formal federal involvement. It is entirely a state matter and is actually explicitly not included in the national health reform agreement. There is a little section of things that are not covered and ambulance services are on that list.

We find that many people have only a limited or an out-of-date understanding of the role of ambulance services. It is part of our job at the Council of Ambulance Authorities to do something about that. It is no good complaining about it. We need to tell people what we do and what is important, and that is really a large part of my job. In rural Australia, ambulance services are provided by a mix of paid and volunteer staff in diverse models around the country. One of the things that follows from the fact it has always been a state and territory responsibility is that the services are significantly different in each of the jurisdictions.

Nationally, there are just over 13,000 staff—that is, full-time equivalents—of whom over 80 per cent are what we call operational staff, the people who might go out in an ambulance and do something. There are about 4½ thousand volunteers and we measure them by headcount because full-time equivalent does not mean anything to volunteers. About 93 per cent of those are what we call operational staff. All of these statistics are contained in this report and I brought some hard copies for committee members if you would like them, or they are on the web if you prefer to access them that way. About 30 per cent of the response locations—that is, the ambulance stations around Australia—are exclusively staffed by volunteers. Western Australia, South Australia and Tasmania are the states that are most reliant on volunteers as a proportion of their total staffing. New South Wales has a large number of volunteers, but it has a large number of everything. It has more volunteers than South Australia, but they make up a smaller proportion of total staff.

Ambulance services face pretty much the same recruitment and retention issues as other rural and remote health services, which I am sure you have heard a lot about—I think this is the last, or close to the last, in the series of hearings. We have listed some of those in our submission. One that is unusual to ambulance services in a health context is the change in gender structure of the ambulance workforce. It is unusual. Not many parts of the health workforce would identify the changing gender balance as an issue. It has always been thus. But it is something that ambulance services are pleased to be coming to grips with. It has implications for things like workforce planning—the more people take leave, the more people you need. It has implications for organisational culture, rosters and so on. We are unlike other health services in that one respect.

Educational opportunities for paramedics are quite good and are improving. Reviewing our submission, which was done last December, we probably had a slightly overly pessimistic view of the education opportunities for paramedics. You heard from the people from Charles Sturt University first up today. They are turning out a large number of rurally trained, degree trained paramedics, which we see as being a very good thing. I can remember being told by the people from Charles Sturt University that something like 70 per cent of the accountants in western New South Wales trained at Charles Sturt University. The point of that story is that it is evidence of the fact that, if people do a significant proportion of their education in a rural area, the chances of them remaining to practise in that rural area are demonstrably and measurably increased. Accountancy is a different field to medicine, but the same thing holds true. One factor that cements their local allegiance is when they marry one of their fellow students—that probably doubles the chance that they are going to stay in that community.

The CAA is involved with the higher education sector. We accredit the universities that provide paramedicine degrees. There are 15 universities in Australia and New Zealand—two are in New Zealand—that provide an undergraduate degree. We are gradually working through a schedule of 15. We look at the courses, we look at what they do and we match it with the requirements. We have a definition of the skills that we think are required. Both parties, I think, find that a very useful and satisfactory arrangement. They have up-to-date information from the principal employers about what is needed in paramedicine, and they can tell their students that their courses have been accredited by the employers that employ 90-plus per cent of their graduates.

There are particular challenges in rural service delivery. The volume and frequency of ambulance work—I guess like other health work—correlates with the volume and distribution of people, and both of those are uneven in rural areas. That is a logistical challenge for us, bearing in mind that one of the things that people want from an ambulance service is capacity. Like emergency departments in hospitals, they want one to be there when they need it. No-one actually wants to be in it. But it is about having the capacity to deal with the unexpected. When you have an unevenly distributed population, that is a tricky thing to do.

Paramedics, like other health professionals, need to be purposefully employed. They need to practise their skills; otherwise they decay. That is not a financial or fee-for-service scale issue, as it is for many other health professions. It is not a case of, 'Is there enough work here so that I can make a living?' which is a genuine question because they are salaried employees. But it is a workforce issue nonetheless—how do we make sure that paramedics have enough meaningful work to do to keep their skills up to date and to keep them satisfied in their roles? That is an issue that underpins some of the thinking about community paramedicine, which I will come to in a second. I note that one of your terms of reference—reference (b)—is about Medicare locals. We are very keen to engage with Medicare locals as they get up and running. My view is that it is quite early days for many of them. Some of them are still appointing their staff as we speak. They seem very keen to engage with us, both the statewide bodies and particularly the Medicare locals. Much of that correspondence, or phone calls, would not cross my desk, but just last week someone asked me if I could find someone from an ambulance service in rural New South Wales to go along to a whole series of forums that they were organising around the Blue Mountains area. I saw that as a very positive sign.

I think it actually reminds us that it is probably incumbent on everyone in the health system not to wait for the other one to ring. We know that there are 62 of these things out there and we know they are relevant to our work, and if they have not rung us because they do not know who we are then we should ring them, go and say hello and introduce ourselves. I do not know that you can mandate sensible behaviour like that—

CHAIR: In my experience, no.

Mr Mundy : but I do think that is actually what is required. One of our challenges in engaging with Medicare locals is that they have a very different scale of operation to ours. Ambulance services are sensibly and probably necessarily organised on a statewide basis. It would be difficult to do it efficiently any other way. Medicare locals are by their very nature local. We also need to deal with the local healthcare networks who are, of course, on a rather larger scale, generally speaking, in most states than Medicare locals are. So as ambulance services we need to focus in both directions.

The reason why we need to talk to them and them to us is that you need local working protocols. Health care is a team operation; it is a team of healthcare providers and also patients. It is the behaviour of those people collectively that produces health outcomes, and it is important that everyone knows what everyone else can do in the system. I was talking to Dr Kirkpatrick as she was leaving, and she said, 'Oh, I meant to make the point about the importance of teamwork in rural healthcare provision,' so I have made it for her.

Senator NASH: She can consider it made now!

Mr Mundy : She can consider it done.

So we need to engage with local healthcare networks—particularly for emergency work, which is the core ambulance role—and with all health services, including primary, hospital, aged care, mental health and drug and alcohol in the context of community paramedicine.

The last thing that I want to speak about in my introductory comments is about community paramedicine. There are many people in Australia and overseas—in New Zealand, Canada, the United States and the UK—who see community paramedicine as part of the solution or, at least, as a major contribution to rural health service provision. Rural is only one example of community paramedicine practice now, but it certainly was its starting point. Our view is that there is some real promise in this area. There are some real success stories but, as in other areas of health service provision, there are no silver bullets. Nothing happens automatically untouched by human hand and not managed to achieve a successful result.

For a definition of community paramedicine, this one comes from the International Roundtable on Community Paramedicine, which we are a member of. They define it as:

… a model of care whereby paramedics apply their training and skills in “non-traditional” community-based environments, often outside the usual emergency response and transportation model). The community paramedic practices within an “expanded scope”, which includes the application of specialized skills and protocols beyond the base paramedic training. The community paramedic engages in an “expanded role” working in non-traditional roles using existing skills.

That comes from this document, which I will table. It is a submission from our Canadian equivalent, the Emergency Medical Services Chiefs of Canada to the Canadian parliament dated 4 January this year.

We have had a number of community paramedics and initiatives in Australia in recent years and we are currently at the CAA working with Health Workforce Australia on a project looking at expanding the scope of the work of paramedics, which is part of a larger Health Workforce Australia project on expanded scope of practice for a number of professions. The other three of their current batch of four are in hospitals. Details of all of their projects are on their website.

The proposals in the paramedicine project are currently still under consideration for funding by Health Workforce Australia, so I will not go into details of what they are until—or unless—they get a tick. They are basically looking at using the skills and capacity of ambulance service paramedics to help make local health and other care systems work better. They are seeking to use factors such as the potential downtime between emergency events while people are waiting for the next emergency incident to occur. They are seeking to use the existing structure and infrastructure of ambulance services. They are seeking to use the high level of skill of today's paramedics and their capacity to deliver care in the field and do things proverbially by the side of the road, which is part of their normal role. They also have a genuine after-hours capacity. In many places they are the only real 24/7 health service around. They are also backed up with fairly advanced communications infrastructure and there is always someone they can talk to back at base to provide advice on other resources or to send messages to other healthcare practitioners and so on and to transmit quite high-quality data about patients and their care needs to and from.

The idea behind these projects is to use these attributes to respond to patients who experience health crises either after hours or in nursing homes, people who are otherwise out of reach. That means out of reach of other health services. They typically aim to: minimise hospitalisation; avoid unnecessary hospitalisation; avoid or delay admission to residential aged care by treating people on the spot and treating them in a timely fashion or by fixing them up promptly and then referring them on to other health services, such as their regular GP or other primary healthcare providers in the morning; avoid excessive travel in taking people to distant health facilities by treating them locally; and also prevent neglect through not being treated, which might happen otherwise.

Community paramedicine is not a brand new idea. The term started to be used around 2005. But it is something of a residual definition. This definition comes from Professor Peter O'Meara, who teaches paramedicine at La Trobe University now, having been at Charles Sturt. He says paramedics are increasingly becoming first-line primary healthcare providers in many small, rural communities as the provision of other health services contract. It is not a new idea but it is certainly not a redundant idea either. It is potentially an extremely useful contribution.

There are some things that we and the Council of Ambulance Authorities think we need to be mindful of. One is that we must not compromise our capacity to respond to emergencies. That is why ambulance services are there in the first place. We need to check the cost effectiveness of using paramedics to provide other services. It is not a cheap intervention compared with some others, but it depends what the other options are. We need to take a broad view about the economics of using ambulance services in this way. It may well be that paramedic intervention costs more than, say, a nursing intervention. But if by intervening at two o'clock in the morning you prevent a hospital admission then it might actually be a very cost-effective intervention. We have not really got the body of research knowledge yet to work out which are the ones that make sense and which are the ones that may be a bit of a stretch.

We need to deal with one of the intrinsic features of our health system that is problematic for many reasons, and that is that it is split into many different separate parts. So you can have a fantastic community paramedicine project that prevents people from being admitted to hospital in measurable ways with demonstrable dollar savings; the problem is that the cost of doing that is in the ambulance service and the benefits are all in the hospital. Unless you have some way of linking those two piles of dollars together it is not going to be a sustainable healthcare system. Those sorts of issues, coming back to the teamwork thing I was talking about before, can be structural impediments right through our health system. The gain and the cost need to match up somewhere in order for the service to be sustainable.

Putting these things in place, as I think I said before, is not magic; it is hard work to do the implementation. We need specific local protocols and locally negotiated arrangements. Things like Medicare Locals and healthcare networks are critical to this. We need good understanding between healthcare providers on their role and scope. We need a level of trust between practitioners both in general and in particular. There are workforce management issues that need to be worked through. We think the current Health Workforce Australia project will help in this regard. It will give us maybe six more examples of projects on the ground that we can learn from and try to quantify some of the things that I was talking about before. We will certainly seek to share the learnings from these projects and other ones throughout our membership, and internationally through bodies like the International Roundtable on Community Paramedicine, which as it happens meets next week. So I will be telling them about these projects too.

I have brought along the data that I incorporated in these comments, the Canadian submission and the source of the quote from Professor O'Meara for the committee, and can provide soft copies if you prefer.

CHAIR: Thank you.

Senator NASH: Could you explain the following statement in your submission:

For volunteer ambulance officers who are recruited from within the local community there are specific issues that impact the retention of these staff including:—

and this is the bit I am interested in:

relations with local government and professional personnel, level of formality, training barriers ...

Mr Mundy : Can I take that as a question on notice?

Senator NASH: Certainly.

Mr Mundy : It was dug up by our previous research assistant from a piece of survey research. I have been on the phone to two people today saying, 'What actually did they have in mind?' I will chase them down and send you the answer. It intrigued me too.

CHAIR: In WA I can guess, but I would like to see your answer first.

Mr Mundy : I think it might be in the capacity as employers.

Senator NASH: I am interested in the relationship at the local level. Concerning the main barriers to improvement of patient coordination under patient transport, you talk about the barrier being the complexity or availability of funding for both health services and ambulance service resources. Do you want to take that on notice as well?

Mr Mundy : No, it is the point I was making before that the buckets of money have a tendency to be separate so that hospitals have money to pay for patient transport, ambulance services can be funded to provide for patient transport and health insurance can pay for patient transport. Every jurisdiction in Australia does it differently and, what is more, they change it from time to time. So it is quite complex and that is a problem for patients not just for healthcare practitioners because patients move.

I came across a website that was designed for grey nomads and they set out to explain to their fellow grey nomads what the arrangements were for user payment for ambulance services in every jurisdiction in Australia. It ran to three pages. I thought, 'That's good. I should take the three pages and put them in the glove box.' It is very complicated and there are lots of rules that are there for quite good reasons, but they are particular reasons and they are not generalised.

Senator NASH: Thank you.

Senator MOORE: You talk about the scope of practice and that is a core aspect when we are looking at the whole medical playing field. Are you aware of any discussions that have gone on with other players, in particular the AMA, about their views about enhancing or changing scope of practice for paramedicals?

Mr Mundy : We have not had any specific discussions with the AMA and whether that is because, as it is for many people, ambulance services are a little below the radar. It might also be due to the fact that we do not raise the competition issues in the way that some other health professionals do vis-a-vis doctors. When paramedics dispense Narcan, for example, to someone having an overdose, they do not do it on their own authority; they do it on the authority of their medical director who is a doctor. It just happens to be the way paramedicine is practised. They are all under the clinical supervision of the ambulance service, which is directed by a medical practitioner, employed by the ambulance service. The sorts of division of labour issues that might arise, say, with nurses do not arise in that context because we are not actually stepping on anyone else's authority to dispense or asking them to stretch it. Also, no-one else wants to do it by the side of the road, in the middle of the night. So there is not as much competition for what our people do as there might be in other areas of health care. With genuine respect, if you talk to emergency physicians and so on, which I do, they know that what paramedics do out on the road or in people's houses is so critical to the health outcomes that they can achieve for those patients once they get handed over that there is quite a strong relationship and mutual respect.

The expanding scope of paramedic practice helps people like emergency physicians and trauma specialists get the outcomes that they do. Also, it is now not uncommon for people to be given thrombolytic drugs in the ambulance, so you start attacking the problem, as it were, even before they get to the hospital door. I guess this is a bit out of scope with a rural focus but, particularly in metropolitan areas, ambulances will take heart attack patients directly to a catheter lab to have the angioplasty done rather than having them queue up in an emergency department, because saving about 20 minutes is actually quite significant.

There are not quite so many choices the further away you get from metropolitan areas, but the point I am making is that the division of labour has the potential to be productive and cooperative. It works slightly better for us than it does for other medical professions, if I can put it that way.

Senator MOORE: It would need to be renegotiated with change of practice?

Mr Mundy : Yes.

CHAIR: You are tabling those documents, aren't you?

Mr Mundy : Yes.

CHAIR: You took a question on notice?

Mr Mundy : Yes, I did, about the good local government.

CHAIR: Thank you.