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Legal and Constitutional Affairs References Committee
National registration system for paramedics

MOUNTAIN, Associate Professor David, Emergency Physician Representative, Australian Medical Association


Evidence was taken via teleconference—

CHAIR: Thank you, Professor, for coming and talking with us today. The committee has received a submission from the Australian Medical Association as submission No. 2. Do you wish to make any additions or amendments to your organisation's submission?

Prof. Mountain : No, I do not need to make any changes.

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

Prof. Mountain : I am the Australian Medical Association's representative for the emergency physicians group on the Federal Council. I am also a practising emergency physician in Perth, in Western Australia. I have had a number of different roles as an emergency physician, including head of department in one of the major departments in Perth. Of course, I have had lots of interaction with paramedics and prehospital staff over the years.

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

Prof. Mountain : Obviously our submission strongly supports the idea that paramedics should be part of a national registration organisation. We think it is important, given the fact that they are such an important part of emergency services and emergency health care, that within the regulatory framework they have proper standards—that the type of care they provide is properly regulated and that their teaching and training, and the standards for that training, are properly regulated as well, so that people are confident about the level of care they are going to get and so that those standards are maintained.

CHAIR: Can you give the committee an idea of the contribution paramedics make to the Australian healthcare system?

Prof. Mountain : They are an essential part of the prehospital healthcare system—that is, how people come to hospital in the first place if they are acutely unwell. Obviously, there is also a part of the system that is run by ambulance officers that delivers people for appointments. But, in terms of acute care or emergent care, they are a vital part of the system because they provide the skills and expertise to stabilise people before they get to hospital, prioritise care for people so that they get to the right place at the right time and initiate treatment for patients who are out in the community and acutely unwell. Of course, they are first responders to major problems like cardiac arrest, other major trauma and severe illnesses. Those skills have been developed over the last 15 to 20 years. They used to be mainly volunteers. Now of course it is a fully professional service, with much improved outcomes over that time because of the professional service that is being provided.

CHAIR: Can you comment on what I assume would be a bit of an issue, which is that the definition of 'paramedic' is sometimes blurred. What are some of the issues that arise from that?

Prof. Mountain : It is a problem when you have services that are a combination of fully professional or paid officers and then sometimes volunteer officers. In parts of the country, the service is virtually all volunteer officers because either there are not the resources or there is not the work to justify having fully paid staff. That means that, if you use the term loosely, 'paramedic' can sometimes cover people who are volunteers who do not really have paramedic skills and have not been trained to the same level as paramedics. It causes confusion, I suppose, about what services they should provide, the skill levels they have and the techniques that they should be able to apply in emergency situations.

I think it is important that there is a definition of what a paramedic is and what they can do and what should be expected of them in particular circumstances if they are actually called paramedics. As with most things in medicine, it is important that, when somebody has a particular title, people are aware and understand that that comes with a reasonable expectation of what those people can do, there are standards applied to that and there are a backup set of written regulations or standards that people can go to so they can understand what those people are really expected to do.

CHAIR: I assume it is because they are not qualified, but why are some paramedics not authorised to give medication?

Prof. Mountain : Some people are not authorised to give medications because they have not been trained in using those medications or understanding when it would be appropriate to use them. Obviously, if you are giving drugs like morphine or you are using paralysing agents because you are intubating patients et cetera, it is really important to know what those drugs do, when it is appropriate to use them and when to be careful about their use. Those things take time. You require a fair bit of training beforehand. You have to understand the drugs that you are using. You also have to understand the physiology of those drugs; you have to understand how they interact with patients of different types and with other medications on board. These are not easy things. They are not things that you can just pick up or follow an absolute protocol for, so you have to have training and experience to be able to use them.

CHAIR: So national standards for paramedics could obviously be a benefit in that area.

Prof. Mountain : Yes. It is always a problem in any area, when you have people prescribing or using drugs, if they do not have a full understanding of how those drugs work or how they interact with patients. That can be problematic, and we have seen that in various areas. But I think that, when you have properly set up regulations and properly trained people, you can be much more confident that they understand what they are doing and that they will use drugs appropriately and in the right scenarios.

CHAIR: Yes. At things like big festivals, like the Big Day Out and these sorts of things, unfortunately we do see the public dabble in drug-taking and excessive alcohol and things like that. Do you think the fact that some paramedics are not authorised or qualified to provide medication could lead to some large risks or issues for the event organisers and people who are in charge of these events?

Prof. Mountain : I do not think that it is such a big issue. Most of those events are in built-up areas—occasionally they are going to be in more isolated venues, but most of the time they are in built-up areas. So, for most of the issues that are being dealt with, there would be a paramedic or someone who is trained and can manage those sorts of problems and get somebody to hospital in a reasonably short period of time. There will be volunteers at the events themselves who do the initial stabilisation. For most of those patients the initial stabilisation is to manage the airway, and, if they arrest, to start CPR. But there are not specific treatments or antidotes available, and it is almost impossible initially to work out exactly what people have taken anyway, so it is pretty standard treatment and it is really stabilisation and getting them somewhere to a definitive treatment service and also to intensive care units if they are really in trouble. So I do not see those particular events as being somewhere where having the full range of interventions is a particularly major issue—particularly, as I said, as, most of the time, there will be a fully trained paramedic available at those events and they will be there fairly quickly.

CHAIR: I think that, as Senator Bilyk said, there is this illusion in the public domain that people who are at these big events are qualified to provide any type of medication.

Prof. Mountain : Yes. It is a bit of a myth in general. Even fully trained paramedics are not trained or able to prescribe all medications. There is a very controlled list of medications. They have got an evidence base in the prehospital environment that the guys are trained to use in particular circumstances, but they are pretty controlled as to how and when they can use those drugs and they certainly do not have a full armament open to them—and that is sensible, really. It is a pretty uncontrolled environment, the prehospital environment, and also it is very difficult in that often you are not dealing with a controlled situation where you actually know the diagnosis, so you are really just trying to stabilise the patient and make sure that you can get them to hospital in reasonable shape so you can get some definitive testing to try to work out what is going on.

CHAIR: Can you just explain why you support paramedics joining a national registration and accreditation scheme and what you think some of the benefits would be for the health care system in Australia.

Prof. Mountain : The reason we are supportive of that is that we think that, for any group of true medical professionals—people who are routinely involved in looking after sick patients and clearly have an evidence based practice—it is good that that practice is standardised to a reasonable degree and that members of the public can be sure that those professionals are actually maintaining standards and have actually been trained appropriately and that, when those people arrive, if they do not behave well, there is a body that will actually look after the public's interests as well. Paramedics are, clearly, a group who are professionals who deliver evidence based services to the public and are people who the public should expect to maintain good standards of care and should be well trained before they are out there delivering these sorts of services. Part of the problem has been that paramedics have not been as well organised as some of the other professions, so it was harder to introduce those standards with the initial introduction of a national registration scheme. But they are clearly a group that the public would expect to have good quality training and standards, and they would want them to be maintained and to have a body that is making sure that those standards are maintained.

CHAIR: In today's society we see a lot of people moving from state to state because of work and where their partners also then have to transfer to another state. Where their partners are paramedics, surely it would be better if those paramedics did not have to go through another training session or get another accreditation because they are in a different state.

Prof. Mountain : Yes, absolutely. One of the advantages of having a national registration scheme is transferability. If you are registered in one state, you can then go and work in another state, with a relatively minimal change of paperwork. But the public wants to know that when people are moving between states that they are going to be able to practice and work to the same standard. Obviously one of the important issues of having any registration scheme is that you want to make sure that a doctor is a doctor anywhere in the country, and that is with the same for paramedics.

CHAIR: Thank you.

Senator PERIS: Professor Mountain, in your opinion, who should meet the financial costs and resources required to introduce a national registration system? Are you aware or have you done any sort of calculations on how much it would cost to set up?

Prof. Mountain : I am not aware of how much it will cost for the paramedics. Certainly we know what the costs are for the medical profession. But a lot of those institutions and organisations had been set up for a long time before being asked to set up. But we know that the costs from the medical registration scheme and the national registration scheme have increased for doctors. Even though it was promised that they would not, they did.

I think the paramedics have some other issues in that they have to set up boards and national systems that have not been in place or are not necessarily always in place even at a state level, so there may be additional costs. I think, to be honest, that the government does need to be involved in providing the funding for those set-up costs. There is a strong public interest in making sure that this progresses and that national standards and national training programs are put in place. I think they will improve the quality of care in the prehospital environment and also improve the overall standards for paramedics. I think they have a very good standing with the public already, but this would improve it further. It will also improve their standing with other health professionals, if they are properly organised. But I think there is a strong public interest in making sure that this progresses and that state governments and possibly the federal government should be involved in, at least, the start-up funding required to put those organisations in place.

Senator PERIS: Earlier we heard from Professor Eburn who, in his submission, said that we know that in Western Australia and the Northern Territory there is no ambulance legislation. Would you share his view that it is long overdue and that both the state and the territory need to have legislation?

Prof. Mountain : Any time that you have groups of professionals who are allowed to administer drugs, treat patients or provide wide ranging services, then that should be backed up by legislation. It clearly makes it much more difficult, if there are problems or issues, if you do not have properly organised legislation that backs those things up. It makes it difficult for the person who is the professional, but it also makes it very difficult for the pubic as well. You then have to go to common law remedies or common law issues, if you have problems, and that makes it much more cumbersome and difficult and less, I suppose, targeted to the actual issues or problems that are being dealt with. So, yes, I think it is completely obvious that you should have a legislative background to these sorts of changes. Maybe that should go into a national registration scheme, and then, as it has been for the registrations of other professional organisations, it should be mirrored across the country. If you do not have proper—you have to then go to common law remedies or common law issues if you have problems and that makes it much more cumbersome and difficult and less targeted to the actual issues or problems that are being dealt with. I think it is completely obvious that you should have a legislative background to these sorts of changes. Maybe that should be national, going to a national registration scheme, and then mirrored as it has been for the registrations of other professional organisations mirrored across the country.

CHAIR: Do you envisage ongoing costs for this national register?

Prof. Mountain : There are always ongoing costs. As I said, with medicine, those ongoing costs have actually been much larger. They predicted that it would be, as always with these things, cheaper and that there would be no increase in costs. In fact, the cost of medical registration has almost doubled under the national registration scheme. It seems to be the nature of the beast that whenever you set up a national bureaucracy that it seems to be bigger, more cumbersome, and take many more resources. I cannot see any reason why that would be any different for this registration board.

CHAIR: Do you think the national registry would cover any other issues the AMA may recognise or single out?

Prof. Mountain : What sort of issues?

CHAIR: Any that the AMA may have thought about but that we, or the terms of reference, have not.

Prof. Mountain : No, there was not anything in particular that we were going to add to what has already been submitted.

CHAIR: Professor Mountain, we have run out of time. I thank you very much for coming along and talking to us today.

Prof. Mountain : It is a pleasure.