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Education and Employment References Committee
31/07/2018
Mental health conditions experienced by first responders, emergency service workers and volunteers

HEPHER, Ms Lauren, President, Ambulance Executive Sub Branch, Health and Community Services Union Tasmania

JACOBSON, Mr Timothy, Branch Secretary, Health and Community Services Union Tasmania

KENNEDY, Mr Christopher, Industrial Officer, Health and Community Services Union Tasmania

[ 0 9:21]

ACTING CHAIR: Welcome. I understand that information on parliamentary privilege and the protection of witnesses and evidence has been provided to you. I now invite any, or all, of you to make a short opening statement and, at the conclusion of your remarks, I will invite members of the committee to ask you questions.

Mr Jacobson : I will try to be very brief. You have a copy of our submission. I'm also National Assistant Secretary of the Health Services Union and I was the inaugural secretary of the National Council of Ambulance Unions, the national body union body for ambulance. I have Chris Kennedy with me. Chris worked as an air traffic controller for some 20 years and understands the nature of a highly stressful, critical environment. He has worked for HACSU for six years as an industrial organiser, primarily in ambulance. Lauren is the president of our sub branch executive, the president of our ambulance union sub-branch. She's an intensive care paramedic with 11 years experience.

I want to mention that Peter James, who is a reasonably high-profile member, put in a submission. Unfortunately, he isn't able to hear, and he asked me if I could say that he wasn't able to appear. He's currently receiving specialist treatment in Victoria for chronic PTSD as, sadly, there isn't any treatment available in Tasmania. He's likely to be there for a number of weeks. Peter has 42 years of decorated experience in ambulance.

Most importantly, the biggest issue that we see, particularly in mental health in ambulance, is that, once a paramedic or a dispatcher identifies as having, or potentially having, a mental health condition, it can be a career-limiting or career-ending decision. I understand, having read a number of submissions, that this is a theme through a number of them—it's our experience here in Tasmania. Decisions by ambulance managers to protect workers from further harm can often be more harmful than any subsequent exposure to the individual. Isolation, removing them from the workplace and putting in place non-meaningful duties are all things which can contribute to breaking the resilience of the individual and which further highlight to others not to call out the problem because the same thing will happen to them. That is our experience more often than not. Often this can lead to workers hiding the nature of their condition and not pursuing medical treatment for fear of public discovery, including internal discovery. This sometimes leads to severe consequences, including, sadly, life-ending decisions.

Much work can be done at a workplace: peer support; management; immediate leadership and support; corporate long-term organisational support; meaningful alternative duties; workers compensation advocacy; and help with effective communication, ensuring that medical interventions are the best and most effective available. Saying you have a peer support program or mechanisms available doesn't mean that they're anything more than a pure box-ticking exercise, in our view. Our clear advice from our members is that Ambulance Tasmania has lots of work to do in improving support processes, particularly those identified with mental health issues. Ambulance Tasmania systems and processes are, we consider, ad hoc and immature at best. CISM, which is referred to in a number of submissions, is widely criticised as not being effective or responsive. Individuals involved do their best and work with the processes and resources that they have available, but our information suggests that it's not all it could be. Peer support is premature and underresourced and has a significant shortfall in trained participants for it to be effective. Anecdotes suggest that individuals avoid going to peer support officers for fear of confidence being breached or previous personal conflicts being raised or highlighted, which is the reality, unfortunately, in a small ambulance service. There is a great deal of work to be done for those not identified with mental health issues. We believe that there is significant underreporting of issues. If we dig, in our view we will find a much larger problem than currently has been identified.

Any emergency response could be the next job that becomes too much. One of the previous witnesses talked about the bucket. The bucket analogy is an analogy that is often used in ambulance. The bucket fills up over time. Every job goes into it, and it isn't a particular circumstance or a number of events that can lead to a bucket overflowing for an individual. Those circumstances can differ. It can be a management intervention or a particular case that may not be a critical incident. It may be bullying in the workplace. It may be a number of factors that can lead to the bucket overflowing for certain individuals. So what is a trigger for one individual may not be a trigger for another—and so too for a person making the decision about intervention and whether activation of support processes should or shouldn't occur. So it's not an exact science. Identifying a particular case, whether it be a nasty car crash or whatever, doesn't necessarily mean that in that particular circumstance someone is going to have a mental health issue associated with it. It might be a lower level case where there's an emotional response that can overflow the bucket.

Ambulance Tasmania, in our view, are significantly underresourced. Ambulance utilisation rates are high. Ambulance ramping is at record levels, and this adds to the pressure of fast-tracking recovery or pushing the next dispatch and corner cutting, which can generally undermine any opportunity that an employee might have to debrief on a case. In fact, often you'd have to move from one case to another without appropriate debriefing. We're seeing that more often than not. Ambulance utilisation rates mean that the amount of time that specific ambulances are on the road is getting longer and longer, which means that employees are unable to debrief and access in work time the appropriate level of support that they need.

ACTING CHAIR: Mr Kennedy, did you wish to make an opening statement?

Mr Kennedy : Yes, if I could. You would see in our submission that we've asked for a number of recommendations. Coincidentally, we strongly agree with the submissions that others have made particularly, though, Australia21 and those recommendations made by the National Council of Ambulance Unions, of which we are a member.

In addition to those recommendations in our submission on the page labelled 'In summary', we believe that the Senate should be making strong recommendations around reviewing workplace culture, attitudes, systems and processes to ensure that corporate culture does not inhibit someone's recovery. We believe, on advice, that recovery from PTSD and other mental health conditions is actually possible and that the earlier the appropriate treatment is commenced the better it is for that particular individual. We'd be seeking that the Senate makes recommendations around a set of best practice recommendations. Managing exposure to trauma, minimising risk in the first place, early intervention programs, assessments and review, peer support, debriefing, aftercare and follow-up are all critically important. More research and data to assist developing those best practice processes would be ideal, with a view to seeking a national approach. We believe that there is capacity to establish a national body of key industry stakeholders with experts to develop and make those recommendations and to get programs rolled out in all jurisdictions of equal value. We see that, in some jurisdictions, they take this more importantly than others, or, at least, on the surface, that's how it appears. If we do have a national approach, we think it should be managed by the Council of Australian Governments.

Currently, employers have an interest in both minimising claims via the workers compensation system and supporting staff. These two things are diametrically opposed.You can't be minimising your legal and financial position whilst you're supporting a staff member, and that's really problematic in the overall workers compensation system, so we seek that the Senate recommends ways in which employers must be advocates for their employees in the first place. If the workers comp system or the workers comp liability were handled by an independent body away from the workplace, something of that nature might be beneficial. Certainly a concept of liability minimisation isn't in the interests of the worker.

Self medication occurs for various reasons across our members in our service and in other services. In our view, too often covert investigations or premature accusations are made. These always have a really negative outcome. It appears that most organisations seek to catch someone rather than help someone. We would like a best practice model to be developed with a view that it should do no harm in the first place. Unfortunately, Ambulance Tasmania has no effective general drug and alcohol policy.They've got a policy, but it doesn't work.

Again, we've heard in evidence and in various submissions that psychological support services offered by EMS organisations are widely varied. Some services have teams of dedicated paid professionals right through to basically no support at all or relying on colleagues to provide the psychological support. Unfortunately, in our view, sadly, AT, or Ambulance Tasmania, is in the latter category. We rely heavily on individuals in the service who are employed in a different function to provide psychological support. Even within the state, we see that there are significant discrepancies across EMS. The police service, for example, have a fully paid psychologist, and they have a much more robust and a more mature peer support program. We have an EAP, or Employee Assistance Program, which is primarily run by the state government. It's the same process or the same agency provided to administration clerks in the Department of Health or the department of education, and they are the same people that are providing services to our ambulance employees. You can obviously see that there are problems with that level of support if you don't have the appropriate people trained. I had a report on Friday from one member who advised me that they were given scripture from the Bible as a primary way of coping, in terms of EAP, and also given advice that perhaps this job isn't for them. So we think there are problems in the EAP space.

Obviously staffing levels and utilisation, which Tim mentioned, are extremely important. It's multifaceted. Fatigue, workload, downtime, recovery, resilience and psychological well-being are all affected by unsafe staffing levels, and these are also impacted by things like ambulance ramping.

As to our communications staff, in particular: our view is that the communications centre is significantly understaffed. This adds to extreme pressure in that workload environment. It also adds to poor decision-making, at times, which impacts on the on-road crews, which impacts on their psychological welfare.

I think the current circumstances are well known in Tasmania. We heard earlier from Senator Urquhart that we have a ramping problem. Unfortunately, just given the nature of our service, and in terms of our ability to surge and to expand and the lack of resources, or space, even, available in hospitals, that's not going to change anytime in the short term, and it's probably not going to change anytime in the medium term.

ACTING CHAIR: Thanks, Mr Kennedy. Ms Hepher, did you have anything to add?

Ms Hepher : No, but if you want to ask me some questions—

ACTING CHAIR: We will come to questions. Before we get to questions, we have had a request from the media to film and take photos. Does anyone have an objection? Does anyone in the back have any objections? No? We'll deem that's okay to happen.

Mr Jacobson, on behalf of all the senators here, could you pass on our best wishes for a speedy recovery to Mr James.

Mr Jacobson : I will, absolutely. He'll be very happy to hear it.

ACTING CHAIR: Senator Urquhart.

Senator URQUHART: Can I just start off with the ramping. I know that we hear a lot about ramping, on social media and on the news every night. I'm talking about Tasmania, but it appears that it's more broad and is also in other states. I was in Perth a couple of weeks ago at the Royal Perth Hospital, and actually witnessed the ramping there amongst ambulances. So it seems as if it's across the country. Can you talk about what the impact is on your members and how that can be addressed? I know you talked about funding, but how can it be addressed and what's the impact?

Ms Hepher : Primarily, when we're ramped, as was spoken about before, we are sitting at hospitals—or standing, a lot of the time—with more patients than we've generally brought in. What we do in Hobart particularly—but I know that Launceston and the regional hospitals do it as well—is this. If there are lots of low-acuity cases that we are ramped with, we consolidate. So we're swapping care between paramedics, where we're getting as many people as we can safely look out for, in that space, so we can free resources back up. That's stressful.

I don't believe that it's best practice for that patient to be handed over four or five times before they receive their definitive care. There are specific dangers involved in that environment for their continuity of care, and the risk of error occurring for them is quite high in that space.

Psychologically, we're working in an environment that we're not particularly trained for. We hear a lot of rhetoric from members saying, 'If we had wanted to do ward nursing, we would've done nursing.' And you can see the stress on your colleagues' faces when they're walking through the door. They're doing job after job after job with no space between them. They don't often have time to go back and restock at the station before going to the next call, while you're standing in a corridor drinking a cup of water with a patient, going, 'What a good day to be at the hospital!' It's not that those patients don't deserve care; it's that the entire emergency system at that point in time is ramped like the ambulance system is.

The difficulty with Tasmania particularly is that we are so little. You would've seen photos in the media this week—which we might not have had anything to do with. There are 11 vehicles at Hobart Hospital. That is all of the resources in Southern Region, bar maybe one or two extra responses that could be mounted.

Senator URQUHART: They're all ramped, so they're not available to go out?

Ms Hepher : That's it. And while those trucks are at the hospital, there is no-one looking after the community. And I know that, as a clinician—that, if I'm delayed in this hospital system, and if my son has a problem out in the community or if Chris's dad has a heart attack, no-one can go to them. It is incredibly stressful to have that burden on your shoulders.

Senator URQUHART: I just want to go to the 10-point plan that the CAA submission talked about. They also talked about it during their evidence here. How well is that being implemented? Is the culture actually changing? What are the best-practice initiatives and are they being implemented?

Mr Kennedy : I think in general terms the 10-point plan is a good start. That has been rightly developed with staff associations, being the National Council of Ambulance Unions and the CAA. There is a lot of science behind how we got to those 10 points. Unfortunately, having been involved in the process of editing that plan, I know it sort of started out with about 18 points and it ended up with 10 of not quite the same things. The problem with it is that it's an aspirational document. There is no time line. There is no, 'You must do it in a particular way.' There is no percentage of annual revenue or annual budget that you put towards implementing those things. I think that some of the services, from what I'm hearing and from some of the other submissions I've read, are a lot more mature and a lot further down the track than I think Ambulance Tasmania are, in general terms. We have a document that's been signed up to by an organisation which isn't really us, and at some point we'll get to that, but at the moment we've probably got bigger things to concentrate on.

Senator URQUHART: What's bigger than somebody's life?

Mr Kennedy : I think the bigger thing is that we need to improve the resourcing that's currently available. I don't think that the resourcing in general terms is particularly scientifically based; I think the resourcing is very much budget driven. We can see the statistics in terms of the growth in workload. If you look at the 10-year trend in Tasmania, it's more than double what it was 10 years ago, but certainly the amount of ambulances on the road and the amount of crews that are in the service hasn't doubled. We've also probably got in general terms a reduced footprint of emergency department size and/or ability to cope with cases or to at least manage their flow through because of other changes that have occurred from both shades of government.

I think at the moment the bigger fish to fry is that we need to be addressing and reducing our overtime burden because the overtime burden is particularly high at the moment. I think that, generally speaking, the lack of resources and the lack of throughput at emergency departments causes us a lot of problems. We had some cuts to the ambulance service about four or five years ago in budget processes, and pretty much the whole admin team got ripped out and replaced with DHHS at the time as backup, but it's not really there. So we've got no-one to manage these types of projects. The people that are doing these types of projects are doing them effectively off the side of their desk whilst they're doing other stuff, and the other stuff always seems to have a higher priority.

Mr Jacobson : Essentially, breaking it down, the real issue right now is that caseload and demand outstrip any other work that's going on in ambulance. It's a regular occurrence that education staff and ambulance management staff are tasked in vehicles to respond to cases because of the circumstances we have with ramping. So the really important things that need to happen for the long-term safety or administration of the service are the things that fall off the side of the desk as a result of it.

Senator O'NEILL: So you're saying, Mr Jacobson, that you're in constant crisis?

Mr Jacobson : Yes, absolutely.

Senator URQUHART: Talk to me about workers comp. We had the Police Association earlier, who talked about the step-downs having an enormous effect on their members. I guess that has an effect on every worker, but especially if we're talking about members with mental health issues. Talk to me about the workers comp system and how streamlined that might be for people with mental health issues in this state.

Mr Jacobson : There are two things. One is that we just find it quite bizarre that the government might announce a policy for reducing or essentially getting rid of step-down provisions for one element of its workforce given what we know, particularly about the front line—that is, nurses in emergency departments, ambulance workers, fireys et cetera—as to why there would be some favouritism applied in those circumstances, particularly given that the statistics in relation to PTSD in ambulance are that it is higher in our space. So there doesn't seem to be any science around that decision at all. So it's quite concerning and upsetting for us that that's the approach that the state government's taken

In terms of PTSD—and the Australia21 report makes reference to this as well, and I think others do, and Chris mentioned it earlier—the problem with workers compensation and the way that the system is at the moment is that it is litigious. If an employee puts their hand up, particularly where they have a serious mental health issue, the potential is that they will be exposed to even more trauma, largely as a result of the systems, the administrative processes and the nature of the worker's comp system itself. Sadly, as the secretary of a branch, I personally am not able to do a lot of the general work of the union these days, but I take a particular interest in PTSD, and I have a number of cases that sit with me at the moment that I deal with. It seems to me that that the trauma associated with the workers compensation system can often be as great as the trauma associated with the events.

The problem with paramedics is that, as we said, once you self-identify that you have in some cases a serious mental health issue, you've killed your career. It's a high-paid, well-respected career. Often PTSD emerges late in a worker's career. The mid-50s tends to be the time that paramedics retire or look to retirement. There is a shorter work life than in most other occupations, simply as a result of the mental health issues. So often, where you have had a very successful career, when you have a mental health issue it's a career-limiting and career-ruining circumstance for employees. So what we want to see is a worker's comp system that supports people with PTSD and that brings mental health out of the shadows and into the light, where people feel free and able to ask for help as early as possible and, when in fact the bucket floods over, they're given the best possible treatment.

Senator URQUHART: In your submission you note that there's a peer support program but that, due to the lack of resources, there will not be any more training this year. How would that affect your members?

Ms Hepher : You heard from Jack earlier that the peer support program seems to have missed the entire volunteer cohort. There are more volunteers in Tasmania than there are salaried staff for the ambulance service, so to miss that proportion of our workforce is concerning. Chris spoke about people doing projects off the side of their desk. Both the CISM people within Ambulance Tasmania and our internal peer support program are on-road workers. They've got a day job, so they're doing this job on top of the job that they're already doing. I think the way that they manage the on-call aspect of it is by diverting a phone number to themselves so they'll be on a roster for who's on call. They've got busy lives. People have got families. It's a good start. I'm not going to criticise either of those programs. They're a good start, but I just think we need to give them more resources and take them more seriously for the benefit of our members and for the wider workforce of Ambulance Tasmania. You can't do something like this as one-tenth of what it needs to be. You need to get in and give this your all. I don't feel that we've done that yet.

Senator URQUHART: I have a number of other questions, but if we run out of time I'll put them on notice.

Mr Kennedy : Could I just comment on the second part of the question, which was around the August training. Approximately a year ago we trained about nine people in peer support for a specific purpose. That group or cohort were selected from basically the people who put their hands up. I think nearly everyone who put their hand up got trained in it. My understanding is that there is to be a second round for a similar number of people put through the system this year. It's supposed to start now. I've seen the operational rosters. It's not rostered for. It's not in the training program or calendar. It's not going to happen.

Senator URQUHART: Is that funded and run by Ambulance Tasmania?

Mr Kennedy : It is. From our point of view, the more people who have that training the better the system has to be. As Lauren mentioned, the people who are doing this already have got a day job—or, in most cases, they've already got a shift work job—and they're on call on their days off or are on call between their shifts to provide peer support. They may or may not be close to the person who needs the support—for example, the on-call person might be in Burnie but the person who needs support is in Huonville. It's not terribly practical because of the numbers involved so far.

Senator URQUHART: Okay. Thanks.

Senator DUNIAM: Thank you very much for coming along today and, indeed, also for your submission. I want to go to the recommendations that are entitled 'In summary'. I want to go to the part where you talk about the communications centre. I gather the point being made there is that the communication centre has come to resemble more of an administrative or commercial type call centre as opposed to what it ought to be. Can you explain the design and nature of the centre?

Mr Jacobson : I'll get Chris to pull it out.

Senator DUNIAM: In broad terms.

Mr Jacobson : The State Operations Centre isn't a call centre; it's an ambulance response centre. It is the first point of contact. If someone calls triple 0 and are put through to ambulance, a call taker will take the call. They don't know what is there—it could be a low-acuity case or it could be a very serious event. There are also the cases of delayed responses, as Lauren mentioned. If you have 11 ambulances ramped at a hospital on a particular day and you are very low in terms of resources, it's possible that the person who made the call will wait longer for an ambulance to respond and appear on the scene, so that call taker can often be on the phone to that person for that whole period. They are, essentially, in some cases talking them through CPR et cetera. It is just as critical an environment as ambulance itself. PTSD, workload and all those issues that we've spoken about are just as pertinent in the State Operations Centre as they are anywhere else.

Mr Kennedy : I think the commentary around the communications centre more resembling a commercial call centre was specifically in relation to the workload that comes in via the phone. It's considered to be: you were working for 44 minutes an hour because that's how long the phone was open for. What you do post a call, during a call and all those types of things are generally unassessed in terms of the people who are designing the workplace. They are designing it as if it were the Vodafone call centre, the Telstra call centre or the Qantas call centre. Potentially there's no consideration of the importance of the work and what the impact of that is. We find that, with the current communications centre or the SOC, which is what we refer to it as, the design has come from a budget that hasn't really expanded from the budget position that was established 10 or 15 years ago. The workload in there has gone up significantly but the staffing hasn't.

We currently don't have enough staff members to allocate enough annual leave to the amount of staff who are there on an annual basis, so people have massive leave credit issues at the time that they're breaking. You're paying overtime to get people holidays, you're paying overtime to cover the people who are breaking and you're paying overtime just because of the structural issues in the room.

Tim mentioned someone taking a bad call. An example was given to me on the weekend of where a team leader was operating the communications centre with two staff short, so they were missing two staff. They took a very distressing phone call at approximately seven o'clock in the morning. They got off the console at about 1 pm. That was the first opportunity they had to have a break.

Ms Hepher : Even to get out and go to the bathroom.

Mr Kennedy : And that distressing phone call lasted from approximately 7 o'clock to about 8:30. It was a life-ending, devastating phone call that she was taking and it didn't end well. But even after that bad call she couldn't even get two minutes out of the room to breathe and have a conversation with someone—because there wasn't anyone there; it was the weekend.

Ms Hepher : And that is not an unusual situation; that is their day for the SOC staff.

Senator DUNIAM: I want to go to the issue of best practice generally—that has been referred to a couple of times here—and perhaps also with reference to the standards of training that are provided to managers. Also, in your recommendations, you make reference to mandatory training with regard to mental health first aid. I would perhaps also like to look at the communications centre as well. Is there another jurisdiction either internationally or a state or territory, that leads the way in terms of best practice that we as a committee could be looking to?

Mr Jacobson : We would consider best practice as a global set of issues. While some ambulance services do better in some areas, we don't think there is any one model in terms of the broad set of what are considered—

Senator DUNIAM: Perhaps in training. Is there somewhere that does training better than we or others do?

Ms Hepher : Canberra or Victoria would be the two leaders, from what I have read at the moment.

Mr Kennedy : Queensland has a very good peer support program, at least on paper. The problem with the Queensland model, however, I think, is that the staff in general have lost faith in it. On paper, it is magic. But I'm not sure the practice of what they have got is the reality.

Mr Jacobson : In terms of best practice, that comes down to research, evidence, early intervention—all those sorts of things. No, I don't think anyone does any of that well.

Senator DUNIAM: Okay, you've snuffed that one out. Thank you.

Ms Hepher : I will tack onto the end of that that it needs to be context specific. What might work for Victoria is that they have resources—and wider health resources as well. We heard about Peter, who is over in hospital in Melbourne because Tassie doesn't offer any program like that. There might be some recommendations that are great for the mainland that don't fit Tasmania because we don't have that access.

Senator DUNIAM: Of course—taking all that into context as well.

Senator O'NEILL: We have heard very disturbing evidence here this morning about what I have described as the toxic nature of many workplaces—and I think your evidence has further revealed that. Could you explain to me why it is that there seems to be an acceptance that treatment for PTSD, having finally been determined as a reality—for example, Mr James; and that is on the public record now—cannot be delivered for Tasmanians on this island? Do you have any idea about that, Mr Jacobson?

Mr Jacobson : It is probably more a question for the government. It is about funding priorities, I would have thought. But I think the same could be asked in relation to many services in Tasmania. We have a health system that is under serious pressure wherever you look. So I think the broad answer is that the Tasmanian health system isn't funded particularly well. And we know that in Tasmania, particularly in terms of mental health, a lot of ramping, a lot of the people sitting in our emergency departments right now, are mental health cases. That is simply because there aren't sufficient inpatient services. Nor are there sufficient community resources for those people.

Senator O'NEILL: Another inquiry running concurrently—access to mental health services in rural and remote areas—is exploring the responsibility of the colleges that train psychologists and psychiatrists in terms of dealing with this workforce distribution problem across the country. You talk about the complexity of the nature of identifying the problems within the workforce. We have also heard evidence this morning about increasing complexity in the type of work that you are being asked to do. Could you give me a bit of a sense of the changing nature of the work and your anecdotal understanding of the link between what is going on in the broader community and the increasing anxiety and distress for your workforce?

Mr Jacobson : That is a very good question. We ran a work-value case a couple of years ago. Ambulance work has changed in the last 20 years since the work was initially valued in Tasmania. An assessment of the value of that work was made in about 1989. It hadn't been reassessed for 20 years, so we ran a significant case around that. The analogy that was given, particularly in terms of the opening submissions, was that, in 1989, essentially the scope of work that was performed by a paramedic could be put in the centre circle of a football ground. Largely, it was going out and responding to a case—performing basic emergency first aid et cetera and getting people back to hospital as quickly as possible. The circumstances now are that the treatment happens as you get to the patient. So the earlier the treatment the better it is for the patient but also economically for the health dollar as well. So more interventions are happening and that scope of practice is now the same size as the football ground itself.

Senator O'NEILL: We seem to understand that in terms of body part medicine, but in terms of mental health it doesn't seem to be applied.

Mr Jacobson : No, it's not. I think what has happened in that period is that, whilst the scope of practice has changed—the extent to which an ambulance paramedic is required to exercise skill—the extent to which the ambulance service has maturely responded to mental health in its workforce is still back in the 1989 circumstances.

Senator PATRICK: I want to go back to the ramping issue. I haven't seen that in any of the submissions. Normally when we think about ramping we think about patients—and clearly there is a new dimension that you have opened up in my own mind. Clearly it is a lack of throughput issue for the hospitals. So, in some sense, that particular issue is outside the control of the ambulance service. Do you make representation to the hospitals and are they responding to that? Secondly, have you heard the bucket metaphor being used around the place for a long time? Would Mr Kirby, the CEO of the ambulance service, be likely to understand the metaphor if it is mentioned? Are they aware of it?

Ms Hepher : Mr Kirby will absolutely know what the bucket is—

Senator O'NEILL: It sounds like you need to get a hole in the bucket!

Ms Hepher : Yes! I is common terminology. I trained in Victoria. Both ambulance services that I have worked for have the metaphorical bucket. Your first question goes back to ramping—my favourite thing ever! Yes, we do make representations to the hospital. In that situation I mentioned before, the entire emergency department is essentially ramped with us. They struggle as much as we do, so we need to be very careful that it is not an 'us versus them' issue. The thing that gets us all through there is our morale and the professional relationships we have with the staff in that department that might get things done quicker or—

Senator PATRICK: It is almost like you have a procedure in place to deal with that that makes it normal.

Mr Jacobson : Unfortunately, yes. Ambulance ramping used to be peculiar but it has become normalised. It has become accepted. Certainly decision-makers, policymakers, politicians seem to think it is an acceptable part of our system these days—which, in our view, is unacceptable.

Ms Hepher : I'd like to see some statistics on it.

Mr Jacobson : The fundamental issue is that, with ambulance ramping, ED presentations are complex but the reality is that we simply don't have enough beds in our hospitals in Tasmania.

ACTING CHAIR: Is there any data available on ramping?

Ms Hepher : That is a very difficult question. Internally, we met with some representatives from the ED the other day, for Hobart specifically, at quite a high level. There was discussion about who was gathering statistics and who was gathering that data. As far as I am aware, Ambulance Tasmania does not collect that as a statistic per se. We could probably extrapolate that out of the data that we have. But I'm not sure the hospital kept any data.

Mr Kennedy : I think different organisations have collected things in different ways. The word 'ramping' has to be used for you to be ramped. You might be the hospital for 20 minutes but you are not ramped yet because 'we haven't told you you are ramped'!

Ms Hepher : You haven't been triaged; you have to be told that you are ramped. You are just delayed from the second you walk in the door. That skews all of that data immensely.

Mr Kennedy : There are some solutions out there but primarily they require emergency staffing changes. For example, the ACT has a policy of 30 minutes from triage and exit. So the ACT in particular has very little ambulance ramping because, after 30 minutes, they leave the patient and say, 'See you later.' They do a handover, of course; but their policy is that they won't keep an ambulance at the hospital for more than 30 minutes—ever. I think that would be a really great thing.

ACTING CHAIR: And that means the ambulances can then get back out on the road and restock and do all the things they need to do.

Mr Kennedy : Yes.

ACTING CHAIR: Thank you very much for your evidence today. If there is anything else you think the committee needs to know, we are more than happy for you to talk to the secretariat and get that information to us. Also, I think there will be some questions on notice if you are happy to take them. We haven't set a date. We will get back to you on that. Thank you for your evidence.

Proceedings suspended from 10:06 to 10:19