Consultation response NATIONAL HEALTH WORKFORCE INNOVATION AND REFORM STRATEGIC FRAMEWORK FOR ACTION (FRAMEWORK) for HEALTH WORKFORCE AUSTRALIA

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1 Consultation response on NATIONAL HEALTH WORKFORCE INNOVATION AND REFORM STRATEGIC FRAMEWORK FOR ACTION (FRAMEWORK) for HEALTH WORKFORCE AUSTRALIA PO Box 345W May 2011 Ballarat West Victoria 3350 Page 1

2 Paramedics Australasia Vision Statement Paramedics Australasia places a focus on forward-looking aspects in the delivery of Paramedic Services and the facilitation of the paramedic s healthcare role. Paramedics Australasia s vision is for Paramedic Services to be integrated with other health services so as to create a seamless system of care beginning at the point of need the patient. The paramedic practitioners and Paramedic Service systems of the future should ensure a rapid response providing appropriate levels of care to each patient presentation, and contribute a vital community resource for prevention, evaluation, care, triage, referral and advice. Access to paramedic practice should form an integral part of the care regime available to patients in an interprofessional model of healthcare practice founded on the contributions from a dynamic mixture of professional and related staff at all stages of the patient journey. Page 2

3 Paramedics Australasia (PA) Paramedics Australasia (PA) is an independent incorporated body representing the professional interests of paramedics within the region. Its primary objective is to lead and develop the paramedic profession. PA does this through a range of activities designed to enhance the standards of delivery of Paramedic Services (PS) that will protect the health and safety of the community. PA is concerned with a wide range of functions that collectively assure the competence and fitness to practise of paramedics. These include standards of entry into the profession, education, clinical training, setting of professional practice standards, promoting ethical good practice, providing continuing education, and processes for dealing with poor performance and misconduct. In addition to direct membership-based activities, PA has an abiding interest in policy matters that affect the access, equity, quality and effectiveness of patient care. It supports the development of the profession in the public interest and advocates the profession s policies and views on healthcare issues to government and other external stakeholders. Through its expert practitioner membership, PA is able to capture and express the views of the most significant group of practitioners engaged in PS delivery throughout Australasia. PA has responded to this consultation in the context of the proposals in the discussion paper and the Draft Framework. The observations are oriented towards the potential impact of paramedics in delivering patient care while acknowledging that some issues overlap substantially with related areas or fields of practice. Page 3

4 WRITTEN SUBMISSION to HEALTH WORKFORCE AUSTRALIA to provide comment on the NATIONAL HEALTH WORKFORCE INNOVATION AND REFORM STRATEGIC FRAMEWORK FOR ACTION (FRAMEWORK) Name of stakeholder/organisation: Paramedics Australasia Contact person: Name Les Hotchin Title Mr Telephone secretary@paramedics.org.au The comments provided in this submission are from the perspective of Education providers to the health workforce Health service managers Health workforce planners Health workforce researchers Indigenous health services planners and providers Rural and remote health services planners and providers A regulatory body A professional group/s (Please specify) Paramedic practitioners nationally A consumer group A carer group Government - Commonwealth Government State or Territory Non-government (not for profit) Non-government (private, for profit) Other (Please specify) Page 4

5 SECTION 1 FOREWORD AND BACKGROUND 1. Does your organisation have any comments or advice about the introductory sections of the Framework? In particular we seek your comments about the purpose of the Framework and the commitments that underpin the Framework. Paramedics Australasia (PA) endorses the basic principles for healthcare espoused by the National Health and Hospitals Reform Commission (NHHRC). 1 In keeping with these principles, PA has articulated a vision for the delivery of Paramedic Services (PS)(aka Emergency Medical Services or Ambulance Services). The central tenet of this vision is that PS should be provided in a manner that will optimise community healthcare outcomes through the integration of PS with other healthcare delivery mechanisms. PA believes that healthcare policy should: incorporate PS overtly into the national healthcare reform agenda; recognise the benefits of holistic care delivered by health professionals operating in a multidisciplinary / inter-professional practice environment; ensure an equitable health system by providing PS according to need and regardless of race, creed, gender, location or economic circumstances; establish funding arrangements at Federal, State and Territory levels that facilitate the delivery of integrated healthcare services and optimise the use of available physical and human resources; ensure responsiveness and accountability through appropriate governance structures, with practitioner and community engagement that recognises the legitimate role of stakeholders in the planning and delivery of healthcare; provide adequate educational opportunities for the recruitment, training and professional development of practitioners that will ensure a competent and sustainable workforce; and provide a national regulatory regime for the accreditation of service providers and the independent registration of paramedics that together will ensure consistent service standards and public safety. PA members have participated actively in the consultation forum sessions held by Health Workforce Australia (HWA) and collated and assessed the input of other participants to the process, as well as considering the background document and objectives outlined in the HWA Draft Framework. The Framework objectives are considered to be laudable and are supported. In many ways they mirror the aspirations and recommendations for improved healthcare advocated regularly by PA. 1 Page 5

6 In particular PA supports the concepts of inter-professional involvement and participative engagement from relevant stakeholders as being fundamental to achieving change. PA also believes that practitioner mobility (supported by meaningful incentives where necessary) is a significant factor in the change process and vital to support Australia s rural and remote regions. SECTION 2 FUTURE AND INTERMEDIATE OUTCOMES 1. Do the future outcomes focus on the most important health workforce issues from your perspective? PA welcomes the work of HWA and its groundbreaking recognition that the delivery of healthcare must be examined in the light of a systems-based philosophy. It acknowledges the recognition being given to the input of paramedic practitioners and HWA s pursuit of projects intended to help create a seamless system of care beginning at the point of need. Australians rely heavily on paramedics and their complementary service providers to respond to emergency and other medical incidents that occur away from established hospital and clinical facilities. The Productivity Commission reports 2 that government sponsored PS providers (aka Ambulance services) attended 3.01 million incidents nationally in (not including figures from the NT). That is a significant number of events. PS delivery undoubtedly has a significant impact within the community and at some stage or other will touch the life of nearly every person with the average Australian needing paramedic care not once but several times in their lifetime. The ubiquitous nature of that care underscores the crucial need for it to be integrated with the broader health system. From the perspective of the profession, the omission of PS from the health reform process is an inexplicable denial of the reality that healthcare begins with the patient at the point of need - which is usually outside the environment of a hospital or clinic. Such denial of primary care is not consistent with real concern for a holistic and patient-focused health system. The profession s concerns run deep and go further. For example, the uncontrolled environment of much PS delivery creates challenges that increase the risks of adverse events and errors that call for compensating excellence in clinical training and practice. It is disconcerting therefore to find the present disconnection of PS from the health system and the paucity of data related to extra- and pre-hospital patient outcomes. There is an urgent need to consolidate information on the total patient journey. This gap in information has been confirmed through direct discussions with the Australian Institute of Health and Welfare (AIHW). 3 2 Productivity Commission, Report on Government Services 2011, Chapter 9- Emergency Services, Steering Committee for the Review of Government Service Provision (SCRGSP) 29 January 2011 accessed on 21 May 2011 at: Page 6

7 More research is needed on the patient journey but that will depend on proper recognition of PS and its consideration as an integral component of national healthcare. Patient safety in PS is another issue that has been poorly studied and documented. The available data needs to be substantially enhanced and effectively disseminated to properly inform practices that hold significant opportunities for improvement. Collaborative action is needed at a national level to better identify patient safety incidents and practices that affect overall patient outcomes as well as the occupational health and safety of practitioners. It is an indictment of the present situation that paramedics suffer occupational injuries and are involved in work related health and disability impacts that vastly exceed the norm for the national workforce. Statistical data related to PS and practitioner occupational classifications likewise have been inadequate to evaluate workforce sustainability and other training and professional development needs. These examples show the need to examine policy, governance and practice issues associated with PS that to date have not been adequately addressed by the health reform process. The previous niche view of PS care and paramedic roles has had other ramifications. Rather than forging a partnership in inter-professional care, practitioner involvement with other healthcare practitioners often has been limited to fleeting interactions with hospital emergency department staff, aperiodic dealings with other hospital and health facility staff during patient transfers, and some limited educational and clinical training experiences. The one-dimensional view that PS consists merely of an ambulance vehicle and its crew responding to an emergency and rushing a patient to a hospital must change. The perception of the paramedic s role needs to based on the delivery of healthcare and key performance indicators well beyond response times and emergency service parameters. Performance indicators must encompass more relevant indicators of healthcare outcomes. It is not surprising that the profession holds great concern at the past (and present) isolation of PS from national healthcare policy, ranging from disparate and fragmented funding, an absence of provider accreditation, and varying practitioner education and clinical training across different jurisdictions. These matters have been outlined previously in PA submissions to government. 4,5 The profession holds a wide array of views on healthcare policy generally, but restricting these observations to the immediate concerns of PS delivery, several critical issues and related proposals for change have been identified for this submission. 6 4 Australian College of Ambulance Professionals, Meeting the Challenge: Submission on National Health Care Reform to the National Health and Hospitals Reform Commission, May 2008 accessed on 27 May 2011 at 5 Australian College of Ambulance Professionals, The forgotten health profession, June 2010 accessed on 27 May 2011 at 6 Ibid Page 7

8 These proposals emanate from consideration of what might constitute the most appropriate role for PS and paramedics within the healthcare system that will realise long term optimal outcomes. PA believes that a new paradigm of PS care is needed beginning with (summarised): 1. Recognition of regulated PS as an integral part of the healthcare system, operating within a national performance framework incorporating defined standards for service delivery and in conjunction with paramedic practitioners, that will provide optimal pathways of patient care from the point of initial needs identification to final resolution/outcomes; 2. Provision of base funding for community and emergency oriented PS on a national basis financed through general revenue or by a national levy in the form of an increased Medicare contribution. This funding should be designed to provide greater certainty and clarity of funding, greater equity in access, minimise unnecessary overheads and administration costs and harmonise the available levels and standards of PS across different jurisdictions and regional areas. It should replace the current multitude of jurisdictional funding arrangements with a single national system of funding for PS providers with a mandated national system of provider licensing and accreditation; 3. Recognition of paramedicine as a distinct field of health care in which paramedics are the recognised health professionals, with consequent access to educational support and scholarships, specific rural and remote area support, continuing professional development assistance, and Medicare coverage consistent with that applying (after the present reforms) to other health and allied health professions. The desired outcome should include support arrangements to suitably foster rural and remote practice to better service Australia s more remote communities; and, 4. The independent national registration of paramedics within the general framework applicable to other health professions established by COAG as the National Registration and Accreditation Scheme under the Australian Health Practitioner Regulation Agency. The outcome should be a single national regulatory regime for the registration of all paramedics embracing the private, public, not-for-profit and defence sectors. PA also has identified a number of subsidiary and consequential developments that will complement these long term objectives. These include, inter alia, that: 1. PS providers operate under a national licensing system that incorporates regular accreditation to benchmarked service and safety standards and collaborative clinical governance regimes. The system should also enable specific performance auditing for those entities (government or private) that operate as public PS providers. 2. The licensing and accreditation of PS providers should be conditional on the demonstrated adoption of the general philosophy of health care embodied in the Principles for Australia s Health System articulated by the NHHRC and reinforced by more recent work of the HWA. Page 8

9 3. Where PS is provided as a contracted service by an entity acting as a primary agent of government service delivery, the contracted PS provider should be subject to the same ethical, integrity and accountability provisions as other government agencies/departments. 4. Accredited PS provision should incorporate a broad range of health service deliverables with the implementation of a national scheme of mandatory performance reporting on a regular basis. This reporting may expand on the initial work done by the Australian Productivity Commission. PS providers should be required to report their service outcomes transparently across key healthcare performance indicators, as well as reporting any sentinel events to appropriate quality oversight and healthcare review bodies. 5. The contribution of PS to national healthcare objectives should be captured by the collation of specific data linked to PS funding and performance, with public reporting of outcomes and within the datasets of the Productivity Commission, the Australian Bureau of Statistics (ABS) and the Australian Institute of Health and Welfare (AIHW). 6. Accreditation of PS providers should require the implementation of a rigorous patient data collection and information dissemination process that will capture key patient journey outcomes compatible with national e-health medical records and hospital systems. 7. Accredited PS providers should be required to implement transparent complaint management and resolution mechanisms. These complaints processes should ensure adequate sharing of complaint and outcomes data to prevent blame shifting, inform best practice and identify systemic provider problems separately from practitioner competency issues. 8. In conjunction with the introduction of national paramedic registration and competency frameworks, workforce sustainability and occupational models should be developed that recognise the diverse educational pathways for paramedics. Workforce cohorts should encompass public, private and defence personnel with the harmonisation of titles and scopes of practice between various civilian and military occupational groups to reduce the potential loss of valuable personnel on transitioning to different workforce roles. 9. In concert with national paramedic registration, there should be independent accreditation of paramedic educational programs that reflects the scope of stakeholder interest in the program objectives. These processes should have practitioner and community engagement. Program accreditation should be performed under principles no less transparent and representative than those developed under the AHPRA regulatory regime. 10. Noting that PA is supportive of existing and proposed HWA arrangements for more structured clinical training of health professionals (vide CSSP proposals), specific provision should be made to include appropriate and educationally sound workforce integrated learning linked to paramedic courses and at a sufficient level commensurate with the clinical demands of professional practice. Accredited PS providers should be designated as clinical placement facilities and their obligations and contributions to clinical training brought within the same operational parameters as for other recognised health facilities. Page 9

10 11. The regulatory (registration) regime for paramedic practitioners should embody an independent process with community and practitioner membership, that is capable of dealing with matters of professional competence and fitness to practice. Investigations must comply with accepted principles of fair and open enquiry, natural justice and transparency, with the outcomes of any enquiries subject to mandated reporting and sharing of data in a manner sufficient to adequately inform the profession and other key stakeholders. 12. To deal with matters related to the quality of service delivery, the regulatory regime for PS providers should incorporate an independent service complaint mechanism with community and practitioner membership, This scheme must comply with similar principles of fair and open enquiry, natural justice, transparency and reporting of outcomes as for practitioner investigations. The level of transparency should be such as to prevent blame shifting and to identify systemic provider issues. These provider and practitioner review mechanisms should be interrelated so as to properly inform best practice. To assist consumers they may benefit from a one-stop-shop or single point of contact approach. 13. PS providers should be required to establish open communication channels including website information that provides effective information to assist the public in understanding the expectations of individual care givers and service delivery and the available complaint mechanisms and procedures for lodging practitioner and service provider complaints. 14. The provision of time critical PS does not come without risks to practitioners, patients and the public. From the limited data available, Ambulance officers and paramedics have been reported as having the sixth highest rate of occupational injuries and the sixth highest rate of new mental stress claims for men. 7 Paradoxically, while a serious and growing problem, 8 there is little available Australian data on how risks vary by gender, age, job title, location (e.g. urban vs. rural) or by years of experience. Nor are data available on causative or associated factors such as patient weight for lifting injuries, weather related to falls and collisions, injured workers OSH training, previous injuries, etc.. Just as medication errors and infections pose particular risks in relatively uncontrolled environments, practitioner and patient safety go hand in hand. As a significant workforce related issue, there should be an immediate move to align the HWA workforce studies with a comprehensive review and development of complementary quality and safety frameworks for PS delivery. These should be consistent with and complement those standards and reporting criteria being developed for healthcare by the Australian Commission on Safety 7 Australian Safety and Compensation Council. Compendium Of Workers Compensation Statistics Australia May Accessed at: 0/Completeversion_WorkCompStats0405.pdf. No longer available. 8 USDepartment of Healthcare Research and Quality, Agency for Healthcare Research and Quality, Patient Safety Primers: ARHQ Patient Safety Primers Systems Approach accessed on 25 May 2011 at Page 10

11 and Quality in Health Care (ACSQHC) 9 and replicate the underlying principles of (say) the 2010 Canadian Report on Patient Safety in Emergency Medical Services Noting that patient interventions within PS are performed by individual practitioners, government should review its use of terminology, with the use of Paramedic Services (PS) in preference to Ambulance services to better describe the scope and nature of paramedic health care. Similarly, to protect the public, the use of the term paramedic should be restricted. It should be used to describe a health professional who complies with a formal code of professional conduct and whose education, training and skills enable them to deliver a range of PS procedures and interventions within their scope of practice. 1a. If yes, are they achievable through implementation of the Domains/Objectives and Strategies listed in this Framework in conjunction with other major national health reforms? PA is acutely aware that change brings challenges to old ways of thinking. It is often difficult to implement new policies and practices in the face of customary and entrenched practices and existing silos of interest. At the same time, some issues lead to inescapable conclusions, and the integration of PS into the general ambit of healthcare is one of the more obvious and defining policy changes whose time has come - and which will reap long term and nationally significant healthcare benefits with minimal effort. Internationally, other jurisdictions have begun to realise the untapped resources within the paramedic workforce and the gaps that apply in the access and availability, safety and quality of PS delivery - which is often the start of the patient journey. 11 A recent Canadian study of patient safety in emergency medical services carries an observation that succinctly expresses the need for change in that country in relation to PS delivery: It s so horribly simplistic it doesn t involve technology, doesn t involve enormous capital investment, doesn t involve restructuring healthcare bottom to top, and doesn t involve government legislation. What it does involve is profoundly courageous and powerful leaders, compassionate caregivers, and the fearless humility to admit when one is wrong John Lewis The Canadian Patient Safety Institute, Patient Safety in Emergency Medical Services: Advancing and Aligning the Culture of Patient Safety in EMS, June 2010, ISBN PA believes that much the same situation applies in Australia, with the proviso that some legislative changes may be required to implement a new funding model. This may be separate from any other legislative changes needed to facilitate the flexibility and mobility of health professionals generally. 9 Australian Commission on Safety and Quality in Health Care, Developing a Safety and Quality framework for Australia, Australian Government, Canberra The Canadian Patient Safety Institute, Patient Safety in Emergency Medical Services: Advancing and Aligning the Culture of Patient Safety in EMS, June 2010, ISBN National EMS Advisory Council. EMS makes a difference: improved Clinical outcomes and downstream healthcare savings. accessed on 24 May 2011 at Page 11

12 The paramedic profession has examined the reach of the implementation domains and the scope of the original health reform process. Our assessment is that the necessary mechanisms already are largely in place and further progress simply requires a bold and forthright willingness to act. PA is disappointed by the apparent lack of attention given to date to primary health care and the reticence to embrace PS as part of the patient journey (especially in crisis or emergency conditions). Nonetheless, it is heartened by the growing realisation within government (as shown by the HWA), by other health professions and particularly by the public, that PS is in many respects the epitome of compassionate and responsive healthcare that treats people in their most vulnerable circumstances and makes a significant difference to patient outcomes. 12 PA believes there is nothing within the proposals advanced by the profession that cannot be achieved by enlightened application of the draft strategies and within the health reform process. Being feasible options they should be implemented promptly to begin reaping the potential benefits. 1b. If no, what might alternative outcomes be and why? This question is not considered applicable since the limited set of PA proposals advanced at this time is viewed as well within the capacity of government and the relevant stakeholders. Should these changes not be implemented, then in PA s view, there will continue to be underutilisation of available (and projected) human and physical resources that could be applied effectively to improving healthcare delivery throughout Australia. Perpetuation of the existing situation is considered likely to (relatively) disadvantage the servicing of the rural and regional population. Workforce mobility in the sector will continue to be stifled and innovation in practice developments restrained. That would be a sub-optimal outcome. 2. Do the intermediate outcomes focus on the most important health workforce issues from your perspective? The concerns of PA extend to the effectiveness of the healthcare system as a whole and are not limited to a narrow vision or sector of service delivery. However, in keeping with the request, the proposals advanced in this submission represent some of the more significant and immediate issues related to PS delivery. The National Health and Hospitals Network for Australia s Future identifies that A strong, responsive and cost effective primary health care system is central to equipping the Australian health system to meet future challenges. PS are integral to improved delivery of primary healthcare that will lead to better outcomes for all Australians regardless of their location in the city or the country. 12 Ibid Page 12

13 The importance of an integrated healthcare system that properly recognises out-of-facility care has been long known, but somehow forgotten, and its absence to date from the health reform process simply inexplicable. PA draws attention to the following statement made 15 years ago:...integration of health care services helps to ensure that the care provided by EMS does not occur in isolation, and that positive effects are enhanced by linkage with other community health resources and integration within the health care system. EMS provides out-of-facility medical care to those with perceived urgent needs. It is a component of the overall health care system. EMS delivers treatment as part of, or in combination with, systematic approaches intended to attenuate morbidity and mortality for specific patient subpopulations... U.S. Department of Transportation (NHTSA). Emergency Medical Services Agenda for the Future. TR Delbridge editor. NTS-42, Item No , Washington, DC. The PA proposals for change are founded on the basic principles of systems-based and holistic thinking; service integration and stakeholder/practitioner engagement; identifiable, consistent and accountable funding models; practitioner empowerment and registration; national quality and safety frameworks for both practitioners and provider entities; and appropriate data collation, monitoring and evaluation that informs best practice. While the proposals appear extensive, their main requirement is a visionary change in attitude towards PS, with each element a feasible and progressive move towards overall innovation in healthcare delivery. Whilst forming a cohesive whole and thus desirably implemented in a single coordinated manner, the various elements could be progressively implemented and phased in over a period of time within a detailed development program that embraced the long term objectives. 2a. If yes, are they achievable through implementation of the Domains/Objectives and Strategies listed in this Framework in conjunction with other major national health reforms? Yes see above. The most difficult aspects in implementation will not be feasibility, but to overcome ingrained attitudes and to break down silos of established practice and entrenched perceptions of PS delivery. (see later). 2b. If no, what might alternative outcomes be and why? Continued sub-optimal performance, resource imbalances, practitioner shortages and burn-out Restricted services to rural and remote areas Heightened public safety concerns as well as practitioner safety and welfare/ptsd issues Limited practitioner mobility and restricted career and professional development opportunities Inadequate research and data collection to inform best practice Lost opportunity costs through not developing & implementing other community healthcare delivery models such as community paramedics and enhanced triage and pathways to care. Page 13

14 SECTION 3 WHAT IS THE HEALTH WORKFORCE? 1. Does the Framework reflect the composition of the health workforce? If not, why not? The conceptualisation of the health workforce in the Draft Framework is exceptionally broad. It is considered appropriate since it extends even to the responsibilities of individuals to manage their own health. It recognises the legitimacy of emerging disciplines - and especially in the case of PS delivery, acknowledges the valuable contribution of volunteers. SECTION 4 CASE FOR CHANGE 1. Does the case for change adequately reflect the health workforce issues facing Australia? If not, why not? The Draft Framework case for change could almost be seen as taken from the many submissions made by PA to government and various Inquiry bodies in recent years 13 as well as independent Audit studies, 14 Committees of Inquiry 15 and Conference outcomes. 16,17 Focusing for the moment on PS delivery, the profession endorses the Draft Framework statement calling for a paradigm shift in ways of thinking about health system and workforce design and planning founded on achieving optimal outcomes for consumers. PA has consistently advocated the view that healthcare should begin with the patient wherever the need arises, and that it should be provided by the right person at the right time and place and for the right reasons. The rate of practice development in PS appears to have been more rapid than governments, administrators and related health professionals can readily absorb, with varying misconceptions remaining about the functions of PS and the breadth and depth of clinical interventions performed by paramedics. Even the occupational classifications under the Australian and New Zealand Standard Industry Classifications do not conform to current practices or international guidelines, making comparative performance evaluation less relevant. The disengagement of PS from broader healthcare policy is both counterproductive and difficult to reconcile with public perceptions that it forms a vital component of the healthcare system. For example, there is limited reporting under internationally recognised healthcare oriented Key Performance Indicators (KPIs) and a dearth of data on the real patient journey - given that a proportion of PS patients never enter the downstream hospital system to be recorded but are diverted or die. 13 Australian Institute for Primary Care, Factors in Ambulance demand: options for funding and forecasting, La Trobe University, April Queensland Treasury, Department of Premier and Cabinet and Queensland Health, Queensland Ambulance Service Audit Report, December New South Wales Parliament. Legislative Council. General Purpose Standing Committee No. 2 The management and operations of the NSW Ambulance Service, Report No 27 October 2008., NSW Parliament, Sydney NSW, ISBN accessed on 23 May 2011 at: 16 Government of Western Australia, St John Ambulance Inquiry: Report to the Minister for Health, Department of Health, October, 2009 (St John Ambulance Inquiry or Joyce Inquiry) 17 Government of New South Wales, Review of the Ambulance Service of NSW, Performance Review Unit, Department of Premier and Cabinet, Sydney, June 2008 accessed on 22 May 2011 at: Page 14

15 PA strongly believes that reporting of PS incidents should cover not only emergency service indicators such as response times but also other indicators 18 that deliver appropriate measures of quality and cost-effectiveness in healthcare terms. The deficiencies in performance-related data have been identified on several occasions, and in the recent Performance Audit Report of the ACT Ambulance Services (ACTAS) it was noted: ACTAS did not have a sufficiently comprehensive performance management framework by which to manage and monitor performance of service delivery. This makes it difficult for management to fully assess, monitor and report on performance... The delivery of community-based PS (aka public ambulance services) is a symbiotic relationship between the infrastructure service provider and the paramedic practitioner. They are inextricably bound together in providing emergency and other forms of out-of-hospital care. Performance factors thus have a great influence on workforce issues including the availability of properly qualified and experienced personnel. Similarly PS infrastructure providers comprise one of several service platforms and do not operate in isolation. There is a major interface with the hospital system that too often sees lengthy and unacceptable ramping of patients (since each ambulance carries a patient). The situation demands a more strategic and national vision that properly integrates PS with the healthcare system and engages paramedic practitioners in the task of optimising the pathways of care. Through suitable interactions and expert advice the healthcare system may move towards (hopefully) achieving an effortless interface between service platforms and treatment by relevant health professionals with timely transfers and accurate information crucial to patient outcomes. Particular efforts therefore should be made to ensure an holistic approach to healthcare delivery. Engagement should be sought from knowledgeable persons drawn from the practising members of the professions that form the healthcare team (not just physicians) as well as educational and research institutions and professional groups such as PA in the determination of broader healthcare policy. 2. Are the priority areas stated appropriate? If not, what should they be? The suggested priority areas are considered appropriate so far as they go. The principal concern held by the profession is the omission of PS from the priority settings where investments might be made to foster innovation and productivity improvement. It is not enough to say that PS will be captured within the ambit of primary care or that the descriptor of allied health professionals adequately covers the professional paramedic cohort. On the contrary, government in the past has specifically excluded paramedics from the description of health or allied health professionals despite the undoubted clinical roles and interventions they perform. These would generally be eligible for a Medicare rebate if performed in other healthcare settings or by someone with a provider number. 18 Myers, J. B., C. M. Slovis, et al. (2008). Evidence-Based Performance Measurements for Emergency Medical Services Systems: A Model for Expanded EMS Benchmarking, Prehospital Emergency Care 12(2): ACT Auditor-General s Office, Performance Audit Report: Delivery of Ambulance Services to the ACT Community, ACT Ambulance Services (ACTAS), Emergency Services Agency, Canberra, June 2009 Page 15

16 The inescapable evidence is that PS and the contribution of paramedics to patient care have not been considered as part of the national healthcare policy agenda in the past and will continue to be overlooked without overt action. The current innovation and reform strategy being driven by the HWA is one of the few areas where PS has been afforded more than cursory attention at national policy levels. The previous situation of neglect (which ultimately affects patient care) must change through affirmative action and leadership from HWA and governments. PA therefore proposes that an important additional area to be included in the priority areas for investment should be the provision of PS in both conventional and extended care and community paramedic care modes. Such developments would be facilitated by paramedic registration and different models of practitioner engagement that took advantage of the repository of human resources and skills represented by thousands of paramedics Australia-wide. There are several reasons for proposing this additional priority area. They include the complementary outcomes and benefits that can be realised by the better utilisation of paramedics in initial triage and extended care and community paramedic roles. These are feasible and natural outcomes from implementing the PA proposals. Their adoption will have an impact across the three nominated areas of community based care, provide better servicing of Australia s rural and remote communities and have the potential to restrain the growth in costs of health care delivery. SECTION 5 DOMAIN 1 Health Workforce reform for more effective and accessible service delivery. Reforming health workforce roles for more effective and accessible service delivery models to better address health promotion, prevention, population and demographic needs and improve productivity. 1. Are there other strategies that would better support national effort in this domain? (p 20) The strategies outlined in this domain are couched in general terms and to that end appear to meet the broad outcome objectives. The devil lies in the detail of determining which developments are feasible and appropriate to best meet the needs of the community (the user) rather than the seller (the service provider / practitioner). The ability to identify and evaluate potential innovative approaches within this broad framework will be the key to success. The challenges facing any form of change that alters the status quo can be seen in the political arena with the proposed Mineral Resources Rent Tax or the Carbon Tax - and closer to home in healthcare - with the sometimes acrid debate about the role of Nurse Practitioners, Midwives and Physician Assistants. Evidence -based practice alone may not enable innovation without a struggle, as witness the unwillingness of some jurisdictions and educational institutions to engage 20 and train Physician Assistants. 21 Enlightened leadership is hard to find and requires unswerving commitment. 20 Brisbane Times, Queensland won't use physician assistants without public consensus, 23 Sept 2010, accessed on 23 May 2011 at Page 16

17 There are likely to be objections raised to nearly any form of change. One may well find the truth in Galbraith s observation that:... Faced with the choice between changing one's mind and proving that there is no need to do so, almost everyone gets busy on the proof... John Kenneth Galbraith ( ) There are several ways in which the expertise of paramedics could be better utilised to make a positive impact on the immediacy of access, efficacy of care and optimal use of resources that will also minimise overall healthcare costs. These innovations do not rely on creating a new profession but on dispelling one-dimensional role perceptions that tend to focus on transport and emergency responses to life-threatening events, rather than the much broader healthcare services that lie within the competencies of paramedic practitioners. Change in this context can come through better recognition and extension of role of the existing workforce with organic growth in scope of practice. Paramedic practice has evolved swiftly and today paramedics are the primary practitioners in the delivery of advanced extra-facility emergency care, providing emergency room support 22 and holding the capacity to triage effectively and provide alternative pathways of care. In rural settings there is often a dearth of other resources to which patients might attend or be appropriately referred and paramedics may be the healthcare providers most likely to be called on for a variety of more routine health needs. Not surprisingly, professional paramedic-delivered services may be the more useful, the more remote the community. Remoteness has other consequences including the use of volunteers in first responder roles which may result in widely variable standards of care. Volunteerism is vital and welcomed but may marginalise and stratify the perceptions of PS. This arises from the challenges in gaining qualifications and maintaining competencies as a volunteer, the difficulties in ensuring adequate quality control, the problems in developing sustainable career structures or establishing a professional identity, and mentoring and professional development issues. The result is the present focus on emergency patients and a simplistic care regime at a time when community paramedics could be available to fulfill a more widely defined role as local hospitals, GPs, primary care providers and other health services are disappearing or are being overwhelmed. Those undesirable developments may be offset by the greater use of existing paramedic resources in an interdisciplinary care mode and as community practitioners able to supplement other primary care services and healthcare personnel. The use of paramedics in an extended care mode in clinics, hospitals, and elsewhere thus can fill gaps in community healthcare needs while allowing paramedics to maintain their skills and being available to respond to emergencies for which they are uniquely qualified. 21 University of Queensland, Closure of the Physician Assistant Program at The University of Queensland, May 2011, accessed on 24 May 2011 at 22 College of Emergency Nursing Australia, Mechanical Ventilation, accessed on 25 May 2011 at: Page 17

18 Pilot studies 23 in Nova Scotia, Alaska, Australia, United Kingdom 24 and New Zealand have conclusively demonstrated improved quality of life and enhanced community health care with paramedics delivering a range of services including Primary care, Emergency care, Public health, Disease management, Prevention, Wellness and Mental Health. There is now an International Roundtable of Community Paramedicine which recognises a variety of such practices and systems around the world. 25 There are moves to formalise the roles of community paramedics by establishing specific training programs to suit. This is one option to mobilise existing paramedic skills that implementation of the PA proposals would facilitate. Another option that has demonstrated substantial benefits is advanced triage and referral pathways that can reduce the inward load and costs on the hospital system. 26 This is shown conceptually below. Figure 1 Advanced Paramedic Triage and Pathways of Care 2. Can you foresee any unintended negative consequences of the suggested strategies? How could these consequences be avoided? PA sees no significant negative consequences in the proposals it has put forward. That is not to say that objections might not be raised on the grounds of feasibility or for specious reasons or simply arising from cultural attitudes and inertia. Resistance to change is common, and that resistance manifests itself in various ways based on the perceptions of the sponsor s motivation, efficacy of the proposal and even self interest of the objecting party. 23 Joyce CM, Wainer J, Piterman L, Wyatt A, Archer F, Trends in the paramedic workforce: a profession in transition, Australian Health Review November 2009 Vol 33(No 4): Mason S, Knowles E, Freeeman J, Snooks H, Safety of Paramedics with Extended Skills, Academic Emergency Medicine 2008; Vol 15(7): International Roundtable of Community Paramedicine; About Us, accessed 23 February 2011 at: 26 Turner, J., Lattimer, V. and Snooks, H., An evaluation of the accuracy and safety of NHS Pathways. London: The UK Department of Health accessed on 23 May 2011 at: Page 18

19 Views opposing an innovation or policy change might be advanced as a protectionist move by another professional group or by agencies and service providers who have a vested interest in maintaining the status quo. This may take the form of active opposition, benign neutrality or indifference (with the likelihood of realising a zero change outcome either purposely or through natural risk aversion). For example, a degree of negativism has been observed in relation to a number of recent healthcare change proposals including the introduction of nurse practitioners and physician assistants, and earlier moves to introduce registration of paramedic practitioners. The introduction of community paramedics may alter the relative balance of care delivery with a reduction of medical practitioner load for lower acuity work - but that outcome is an intentional development in the public interest and not perceived as a negative consequence. Similarly, registration of paramedics and fostering their ability to practice in independent and interprofessional settings does not detract from the operational provision of community emergency services, but benefits the community by enhancing access to a wider range of available care. The early triage and referral pathways option, either as part of community practice or in conjunction with an emergency service, is intended to minimise the load on more expensive hospital and medical care and is perceived to be beneficial on an outcomes / costing basis. Given the overall positive results envisaged by implementation of the PA proposals, there are no particular measures suggested to avoid negative consequences. Innovation without some form of change is not possible, although the disruption may be minimised and the best measures to promote change and minimise objections and take-up resistance are often specific to the affected parties. They need to be developed and implemented as the potential innovations are identified. 3. Are there potential barriers to achieving change in this domain? What are they? How could they be overcome? Barriers to change are legion and may be human, physical, technological, financial or any combination thereof. While the outcomes of an innovation may be positive and hold strong evidence-based support, the acceptance of change may be poor. The result is that there may be antipathy towards new developments proposed by PA and other groups. Adaptive challenges can only be addressed through modifying people s priorities, beliefs, loyalties and habits. Disruptive change driven by (say) external events (war, pandemic, economic crisis) can often introduce sweeping changes more easily and rapidly because of their impact on such factors. It will be important to offset any manifestations of risk aversion and change antipathy, for which the suggested countervailing measures are adequate consultation, transparency and time - sufficient for participants and stakeholders to embrace the change, place it into context and own the process. This careful change management strategyneeds to apply for all significant new developments 27 regardless of the source or sponsor of the innovation. 27 Pronovost P, BMJ Quality & Safety 2011 [epub], Navigating adaptive challenges in quality improvement, accessed on 24 May 2011 at: Page 19