Ambulance services attended 2.88 million incidents nationally in 2007-08 (and that’s not including figures from the NT), according to the Report on Government Services 2009.

One therefore might imagine that the provision of out-of-hospital Emergency Medical Services (EMS) and the role of paramedic practitioners would figure prominently in any debate on national health care reform.

That has not been the case, and the background papers and reports prepared by the National Health and Hospitals Reform Commission (NHHRC) and the National Health Workforce Taskforce (NHWT) are notable for the manner in which they have ignored this vital element of primary health care.

Nationally, emergency medical services provision is administered and funded in a myriad of ways. In WA and NT the principal community provider is a private charitable organisation operating under contract, while in the other States it is a government agency under the health portfolio (except in the ACT and Queensland where it sits with the emergency services and police portfolios as a Division of the Department of Community Safety).

Funding of EMS ranges from government grants, lottery donations and electricity levies, to subscription and insurance schemes, public donations and cost recovery from fees for services such as transportation. Volunteers play a significant role in some states (most significantly in WA and NT) and there are considerable disparities in equity and access, with the urban-rural divide strongly evident.

This complexity and fragmentation stems from many causes including jurisdictional issues, and the convenient argument in the past when discussing health care policy appears to have been to brush off EMS as “a State matter “.

That argument no longer holds water in the face of a health care reform agenda under the NHHRC or the work being done by the NHWT and its several project teams that are supposed to develop initiatives to ensure more equitable and accessible health care.

Yet out-of-hospital EMS doesn’t register in any significant way in Commonwealth health policy discussions or receive direct funding from the Federal health budget. There is no national regulatory scheme for the independent accreditation of statutory and private contract service providers. Paramedics aren’t even listed as allied health professionals by the Commonwealth, apparently in part as a result of the jurisdictional divide!

So one looks in vain for a national practitioner registration scheme like other health professionals (eg nursing, medicine, dentistry, pharmacy etc) such as one finds in the UK, Ireland, or South Africa and which is proposed for New Zealand. 

The regulation of EMS and the paramedic profession in Australia thus raises legitimate questions regarding transparency, public accountability and performance management, which would appear to mandate an independent regulatory and national registration regime.

The analogy of a hospital emergency department provides a good example. It would be unthinkable for an emergency department in any hospital to have 150,000 patients or more a year come through its doors and be staffed by unregistered clinical staff.

Other health care workers have independent regulatory bodies, and you can’t practice as a nurse or medical practitioner unless you hold registration within the relevant jurisdiction. Emergency departments Australia-wide answer to clinical governance processes that are laid down by health departments and monitored by their safety and quality sections and accreditation under defined performance frameworks.

Yet the NHHRC and NHWT appear oblivious to the role of out-of-hospital EMS providers and paramedics who deal with far more patients than that. Much is said about hospitals and emergency care, but the reality is that emergency health care starts with the patient and not at the hospital or clinic door – and the clinical interventions performed by paramedics often are what keeps patients alive until they can receive more definitive care.

Today’s paramedic deals with life and death decisions on a daily basis, administers restricted medications, applies CPR and defibrillation, intubates, cannulates and saves lives without (often) knowing the medical history of his or her patient, and in many cases having to triage with unconscious, incoherent and often rebellious patients.

It’s also instructive to note that many of these clinical and related procedures would fall within the scope of Medicare if they were performed in a hospital or by someone with a provider number. If that’s not clinical care and professional responsibility then there is something sadly amiss within the system.

So the critical role of out-of-hospital emergency medical services needs to be acknowledged in funding a health system that delivers seamless and high quality patient care as part of the government’s broad commitment to the community.

Reform proposals that do not include appropriate recognition of emergency medical services as a discrete and significant field of health care and the role of paramedics as the professionals qualified and working in that field are unlikely to realize optimal health outcomes.

If the NHHRC’s final report, due to be handed to Health Minister Nicola Roxon today, does not address this important issue, it will be a major oversight.

Ray Bange is the Principal of Probity Consultants International, and has provided advice to the Australian College of Ambulance Professionals. These are his personal views.

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