Chapter 2


Chapter 2

Paramedics in context

2.1        This chapter describes paramedics in the context of related professions and compares regulatory frameworks and duties.

Contribution

2.2        The role of paramedics and their contribution to the healthcare system continues to evolve and expand. The level of education required of paramedics has similarly increased over time as their role has expanded.

2.3        The skill level and complexity of the work undertaken by paramedics has developed from a historical role as 'drivers' to highly skilled health professionals:

Historically paramedics (health treatment) services were inextricably linked to ambulance services (transport services). The training of staff was undertaken by state ambulance organisations as vocational training. On-road staff effectively only had to attend the scene of the patient, load them into the ambulance and go with them...('load and go') to definitive care.[1]

2.4        The procedures undertaken by paramedics are often complex and can involve high risk interventions, including:

  • putting a hand, instrument, finger into body cavity;
  • conducting procedures below the skin;
  • the administration of a scheduled drug by injection;
  • the supply of substances for ingestion;
  • managing labour or delivery of baby;
  • undertaking psychological intervention to treat serious disorders with potential for harm;
  • acting as primary care providers without referral from registered practitioner;
  • providing treatment commonly without other person present; and
  • providing care where the patient is commonly required to disrobe.[2]

2.5        Paramedics frequently work alone or in small teams, and interventions are regularly carried out in remote locations, without the resources of a hospital emergency department:

...unlike other health practitioners they do not have a team of allied professionals that they can easily call on at the scene of an emergency. Paramedics also work in a number of hazardous environments whether in a person's home or at the scene of an accident. Paramedics have to identify the nature of the patient’s complaint, illness or injury and then apply treatment without extensive diagnostic assistance.[3]

2.6        Paramedics are also trusted with sensitive health care information, including patients' medical history and current medications. When necessary, they also undertake advanced paramedic care, which can include 'triage and treatment where paramedics by-pass emergency departments to access acute care facilities, such as trauma, cardiac care, stroke services'.[4]

2.7        Due to the life-or-death situations with which paramedics are often confronted, they may be required to perform advanced procedures, such as 'surgical thoracostomies' (involving an incision in the side of a patient's chest), that would otherwise only be performed by doctors in a hospital setting.[5]

2.8        It should also be acknowledged that some paramedics are employed in positions which require a more diverse set of skills. These include health assessments, testing, and work health and safety roles.[6] There are an 'increasing number of Australian paramedics that participate in short term deployments to civil, humanitarian and government agency projects in overseas locations'.[7]

2.9        The size of the paramedic profession provides an indication of the significant contribution paramedics make to Australian society. In 2016, the National Council of Ambulance Unions estimated that 'there are currently in excess of 15,000 paramedics operating across Australia'.[8] In 2013/14 and 2014/15, New South Wales (NSW) Ambulance and the Queensland Ambulance Service each responded to approximately one million ambulance emergency calls.[9]

2.10      The Australian Medical Association (AMA) stated that paramedics are regarded as making a vital contribution to the Australian healthcare system:

in terms of acute care or emergent care, they are a vital part of the system because they provide the skills and expertise to stabilise people before they get to hospital, prioritise care for people so that they get to the right place at the right time and initiate treatment for patients who are out in the community and acutely unwell.[10]

Duties

2.11      The scope of work undertaken by a health practitioner is usually determined by factors such as relevant regulatory frameworks, the professional standards and policies of individual employers, their education and training, and current health treatment needs. The duties performed in a particular profession evolve due to factors such as changes in relevant professional standards, regulatory policies, and the development of new technology.

2.12      Submitters to the inquiry explained the role of doctors and nurses in the healthcare system:

Doctors have the broadest scope of practice and are authorised to prescribe medications, refer patients, undertake the widest array of medical interventions (depending on their specialisation) and are recognised by the health care system and private health care insurers for access to funding arrangements such as Medicare and the Pharmaceutical Benefits Scheme.[11]

2.13      Nurses work in similar settings as doctors, but have comparatively less autonomy and responsibility in the tasks that they undertake and 'work at a somewhat lower level of intervention than doctors. Their autonomy is restricted and they generally act in accordance with instructions or under advice from medical practitioners'.[12]

2.14      The Australian & New Zealand College of Paramedicine (ANZCP) noted that both doctors and nurses work in 'structured, highly regulated environments where clinical governance, oversight, consultation and supervision systems exists for patient safety...Registered Nurses generally only administer medications ordered by a Doctor for that patient, unless they are working in remote emergency departments and have authority to do so'.[13]

2.15      The duties undertaken by paramedics are similar to many of those performed by doctors and nurses in hospital emergency departments and are often high risk and include 'significantly complex clinical interventions as independent decision makers'.[14] An important difference is that the work of paramedics is usually undertaken in an unstructured environment, where they are often the first, and sometimes the only health professional, to have contact with patients.

2.16      For example, paramedics may be required to treat 'patients at a single or multiple-vehicle road accident on a country road at night surrounded by several inebriated or substance-affected patients of different ages and nationalities and uncertain medical histories'.[15] This demonstrates the range of factors that can contribute to a complex and highly stressful work environment for paramedics where they must make time critical decisions that can have a significant impact on patients' lives.

2.17      In terms of professional standards, the current avenues for complaints vary around the country and lack transparency:

... at the moment, if you want to complain about a paramedic, with the exception of New South Wales, the person you would complain to is the employer. Whether they make any of that information public or not would be a matter for them. You can imagine that many employers, if you were complaining about their staff, may deal with the complaint, but they would not want to ruin their own reputations. There simply is not a public register where people can go to complain about subservice standards by paramedics.[16]

Regulation

2.18      The Australian Health Practitioner Regulation Agency (AHPRA) is a Commonwealth government agency that regulates health professions in Australia through its administration of the National Registration and Accreditation Scheme (NRAS). [17] Both doctors and registered nurses have been regulated under the National Registration and Accreditation Scheme (NRAS) since it was implemented in 2010.[18]

2.19      The NRAS was established by state and territory governments through the introduction of consistent legislation in all jurisdictions: the Health Practitioner Regulation National Law (the National Law). The NRAS is designed to protect the public, facilitate employment mobility, and enable the development of the health workforce.[19] It currently regulates the following professions:

  • Aboriginal and Torres Strait Islander health practice,
  • Chinese medicine,
  • Chiropractic,
  • dental practice,
  • medicine,
  • medical radiation practice,
  • nursing and midwifery,
  • occupational therapy,
  • optometry,
  • osteopathy,
  • pharmacy,
  • physiotherapy,
  • podiatry, and
  • psychology.[20]

2.20      Each of these professions has a national board to register practitioners and develop standards and guidelines. For doctors, the Australian Medical Council (AMC) accredits education providers and their programs; whilst for nurses, the Australian Nursing and Midwifery Accreditation Council (ANMAC) is the accreditation body. Doctors and registered nurses must have completed an approved and accredited course of study. The Medical Board of Australia and the Nursing and Midwifery Board of Australia provide registration standards for these professions. These standards include criminal history checks, English language skills, recency of practice requirements, ongoing professional development, and professional indemnity insurance registration.

2.21      Witnesses, such as the Royal Flying Doctor Service of Australia (RFDS), provided evidence to the committee that paramedicine should be added to the list of professions regulated by NRAS:

it is time that paramedicine was properly respected in Australia as a profession on par with that of medicine and that of nursing...As an employer, we want to know that across the nation there is a standard of care that we can expect, demonstrated through prequalification and through continuous professional development, but, most importantly, we also want to know that there is a system of monitoring a nationally consistent standard'.[21]

2.22      The reasons that were provided to the committee supporting the introduction of a national registration to regulate paramedics in Australia are explored in greater detail in the next chapter.   

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