Chapter 3


Chapter 3

National registration and accreditation

3.1        The vast majority of submitters and witnesses were strongly in favour of national registration of paramedics. For example, the Australian Paramedics Association (APA) Queensland emphasised the positive outcomes it believed would be gained through paramedic registration:

We sincerely believe that registration will make our profession stronger and ultimately we shall save more lives through being better equipped to handle emergencies. Registration will protect our industry and provide safer options for ambulance service providers and the public at large.[1]

3.2        Other health professions, such as doctors, were also supportive. According to the Australian Medical Association (AMA), the peak body representing doctors, 'there is a good case on the grounds of patient safety'.[2] According to the Victorian Department of Health and Human Services there are a number of reasons why national registration is necessary. These include:

  • the need to address avoidable risks of harm to the public;
  • changing models of paramedic care and expanding scope of practice, which may result in some higher risks to the public;
  • the potential for statutory registration to underpin more efficient quality assurance mechanisms and drive health system reform;
  • evidence from international jurisdictions, particularly the United Kingdom where a registration regime for paramedics has been in place for some years;
  • the expansion in first aid services provided by the private sector;
  • community expectations that paramedics should be subject to the same rigorous regulatory standards as similar professions; and
  • the continued need to address risks to paramedics (such as high suicide and WorkCover claim rates and reportedly higher rates of bullying compared with other health professions).[3]

3.3        There are several pertinent factors relevant to national registration and accreditation raised in the course of the inquiry and discussed in this chapter. These include public safety, workforce mobility, title protection, insurance, malpractice, state participation, and the accreditation process.

Public safety

3.4        A key point raised by witnesses at the public hearing was that members of the public who require a paramedic in an emergency situation do not have a choice in who provides that service. With this in mind, there is an expectation in the community that 'when someone turns up and says they are a paramedic, [they] can be reasonably assured that the person has undertaken the requisite training and has the capabilities to deliver the services that you would expect from a paramedic'.[4]

3.5        Paramedics Australia (PA) stated that the 'critical function of the national register is to ensure increased safety for the Australian public'.[5] In PA's view, national registration would offer greater safety in three key ways:

  • only people who meet approved and nationally consistent educational and practitioner standards would be able to call themselves a paramedic;
  • paramedics with fitness-to-practice issues would not be able to move freely across jurisdictions/employing bodies without disclosure; and
  • checks on qualifications, clinical currency, probity and criminal history would be a condition of practice.[6]

3.6        In addition to these more practical benefits, it was noted in the submissions that registration of paramedics would recognise their status as 'equal to those of other registered health practitioners', such as doctors, nurses and podiatrists; as opposed to other non-registered health practitioners, such as homeopaths. It was emphasised that paramedics share more in common with doctors and nurses than they do with other non-registered health practitioners.[7] According to PA:

The national registration of paramedics within the regulated structure of other health professions would create a professional safety net for both paramedics and the public. Under a national registration scheme, paramedics would be required to maintain professional registration through mandated continuing professional development and adhering to a National professional code of conduct.[8]

3.7        The Council of Ambulance Authorities (CAA) was of the view that national registration would serve to 'positively improve public safety, and increase community confidence in the paramedic profession and the broader provision of emergency health care in Australia'.[9]

Workforce mobility

3.8        Workforce mobility was a key point raised in support of national registration for paramedics. The AMA stated on the basis of its experience in the medical profession: 'One of the advantages of having a national registration scheme is transferability. If you are registered in one state, you can then go and work in another state, with a relatively minimal change of paperwork'.[10]

3.9        As stated in chapter 1, there is currently no national registration of paramedics. National registration would allow paramedics to move unrestricted within Australia for employment opportunities, and this would help to develop a 'more flexible, responsive, and sustainable paramedic workforce nationally'.[11] There would also be corresponding benefits for employers, who would save money that may have otherwise been spent on assessing the qualifications and suitability of applicants for positions as paramedics.[12]

3.10      There would be further practical benefits of implementing a national registration system for paramedics. Registration would unlock:

the benefits of a national approach to regulation that minimises the wasteful duplication of functions that would be present under other forms of regulation or independent and piecemeal jurisdictional regulation. From practical, economic and human resource viewpoints a single, uniform and independent accreditation process is required for paramedic education.[13]

3.11      The enhanced workforce mobility that would be provided by national registration would be of benefit to employers, paramedics themselves, and to the general public. Under such a system, the employer could look up an applicant's:

registration and see if there are any conditions or extra endorsements on your registration. It is all there and it is all very public, rather than having to ask: 'What certificate have you got? Where did you get that? What have you done with your previous employer?[14]

Rural Australia

3.12      The committee heard that the role of Australian paramedics in rural areas is growing due to the limited availability of healthcare services: 'There is an extending care paramedic structure that is coming in that will be very important for regional and remote communities in being a first point of contact'.[15]

3.13      The Royal Flying Doctor Service (RFDS), which provides aeromedicine services in rural Australia and employs doctors, nurses and paramedics to undertake patient retrievals,  explained:

When a tasking of an incident occurs, a clinical decision is made as to whether it warrants a doctor, a doctor and a flight nurse, a paramedic. In response to the clinical circumstance, the right health professional is dispatched.[16]

3.14      The RFDS employs paramedics and 'value[s] the professional skill that paramedics acquire', utilising their skills 'in varying roles within our organisation'.[17] The RFDS currently employs paramedics in a new service providing 'ambulance-like transport on the ground',[18] and foresees further employment opportunities for suitably qualified paramedics as its range of services continues to grow:

Non-emergency patient transport is one of our areas of expansion in Victoria in particular, where there is not the same call for aircraft to transport patients across what is mostly a regional state. We are now providing non-emergency patient transport on ground, and that is involving the employment of paramedics in growing numbers. But we do think that, if we had a national system of professional oversight, there would be new opportunity for us as the Royal Flying Doctor Service to engage paramedics in the evolving work that we do.[19]

3.15      There are particular issues recruiting paramedics to work in rural and regional Australia, and this is particularly acute due to the higher competency required to work in isolated locations. The RFDS believed that national registration would make recruitment decisions easier: 'we would have great confidence in the pool of national paramedics because they are overseen by this national system of safeguards'.[20] The RFDS emphasised the importance of national registration from the perspective of employers:

the RFDS regularly faces challenges in seeking to employ paramedics, as it can be difficult to ascertain their experience, currency and scope of practice owing to the variable requirements in different States and Territories. The RFDS therefore strongly supports national registration for paramedics and is of the view that national registration, including the recognised minimum standards of practice that will necessarily be implemented, will only serve to advance the profession and benefit the health sector in Australia more broadly.[21]

3.16      The importance of 'preventing avoidable accidents and injuries from occurring' in rural Australia was also discussed in the context of the expiry of the national 10-year accident and injury prevention strategy in 2014, and further investment by the Commonwealth encouraged.[22]

Professional standards

The title 'paramedic'

3.17      It was discussed in plain terms at the hearing that in most Australian jurisdictions 'there are simply no laws that say who or what is a paramedic or who can call themselves a paramedic'.[23] This can cause confusion in relation to paramedics' services, skill levels, and capacity to treat certain conditions. It was argued that it can  confuse the general public when the term 'paramedic' can include 'people who are volunteers who do not really have paramedic skills, and have not been trained to the same level as paramedics'.[24] For example, 'if you go to a first aid post at a public event and there is someone there with a badge that says "paramedic", you have no idea who they are or what their qualifications are'.[25]

3.18      The committee was told that paramedics are concerned about a lack of professional recognition for the important skills and university qualifications that many hold, especially in the context of the complex and important work they undertake:

We receive feedback from our members...working, especially the private sphere, with someone who has completed a diploma through a private organisation that has required very little placement work, very little on-the-job training. They have someone with them with years of experience with a degree. They are both sitting next to each other. One has substantial skills and is able to perform the multitude of roles required of a paramedic and the other one is actually unqualified and inexperienced in that environment and they are called the same thing. That is a perfect example of comparing someone who might have a three-week course or a three-month course and minimal training and experience outside of that with someone who has 10 years of experience and they are called the same. They are not the same.[26]

3.19      Witnesses at the public hearing stated that registration of paramedics would address this issue, by applying 'a legislative restraint on the holding out of a person to be a paramedic'.[27] It was emphasised that this is a significant benefit that would be realised as a result of national registration for paramedics in Australia and would address current public safety issues that arise in the absence of any protection of title. The committee heard evidence that it is a 'situation of high risk' for the public if anyone 'can buy and wear uniforms which hold you out or make you appear to be a paramedic without any control'.[28] Protecting the title 'paramedic' is a key aspect of national registration that is described as likely to have significant benefits for both paramedics and the community.

Education

3.20      Most major ambulance employers in Australia have moved to only employing new paramedics with a university degree. The committee heard that this has been driven by changes in paramedic practice over the past 10 years:

If I reflect back 20 or 25 years, there was very little invasive therapy and very few invasive techniques provided by ambulance officers then. Paramedicine today is quite different. It involves a lot of critical thinking and critical reasoning. A lot of judgement is required in very short time frames and there is a high level of invasive procedures and techniques required to deliver competent paramedic practice in the current environment.[29]

3.21      The large number of students currently studying towards a relevant degree qualification demonstrates the shift in education for paramedics:

There is no doubt that with some 7000 or more students undertaking university courses in paramedicine across many campuses in Australia, a robust process of accreditation is needed to ensure consistent and acceptable course standards that will provide a level of confidence that graduates are competent to practice safely and effectively as beginning level professionals.[30]

3.22      This investment in 'educational facilities, human resources, course development and the expenditure of hundreds of millions of dollars by students' was submitted as a further reason that these courses should be accredited as part of a national registration system for paramedics.[31]

3.23      Australia was the first country to offer a degree in the field of paramedicine, and the education system in Australia is among the best in the world.[32] Australian graduates in paramedicine are sought worldwide, and a significant number have been recruited to work in ambulance services in the United Kingdom in recent years:

I have to say that the London Ambulance Service is looking at taking about 300 paramedics a year out of Australia to meet its current shortfall. The way that they have been recruiting them and the way they have been targeting Australian and New Zealand graduate paramedics, again, highlights the quality of those graduates.[33]

3.24      Approximately 40 percent of paramedics hold a bachelor's degree or higher, and there are over 6000 students currently enrolled in relevant university courses in Australia. Paramedics may also undertake ongoing training and professional development to maintain their skills and enhance their competence. However, 'there is currently no [minimum] qualification for the role of paramedic, nor is there a nationally consistent restriction on the use of the term paramedic'.[34]

3.25      In relation to existing paramedics, the range of qualifications they currently hold, and how those who do not presently hold tertiary qualifications would be affected, was discussed during the course of the inquiry. It was suggested that this could be addressed through 'grandparenting':

The transition period and procedures for grandparenting ensure that current practitioners are not disadvantaged by the introduction of registration which may bring new or changed qualifications...It allows individuals who have been practising at a relevant level during the preceding period (commonly 5 years) to apply for and be granted registration. It facilitates change in an emerging profession and would be appropriate to apply in the registration of paramedics.[35]

Ongoing professional development

3.26      Regulated health professions in Australia are required to continue their education to ensure that they remain up-to-date with respect to new developments in their field. Currently in Australia, there is 'no requirement for paramedics to do any continuing professional development or education, except for what their employer requires them to do'.[36]

3.27      The Queensland Ambulance Service has been establishing a 'yearly or biannual certificate of practice...with CQI points—which are clinical quality improvement points' to provide ongoing professional development training for [its] staff'.[37] It was proposed that this type of system should be incorporated into registration requirements for paramedics, and that a small number of professional development training days each year could be provided by employers for this purpose, as is currently the case in the nursing profession.[38]

3.28      The importance of a board overseeing paramedicine was emphasised by witnesses as it provides a process for clinical experts to agree on the professional standards that should be established, how these should be developed, and the scope to approve and expand professional development:

They provide a very important oversight of the development of the profession as clinical and research changes come along. I would like to see a similar board overseeing the paramedic profession that regularly attests as to what are the requirements for entry—what is the basic requirement of university qualification first—and to keep that monitoring of changes in clinical practice to ensure that the standards reflect the time.[39]

Accountability

3.29      National registration and accreditation of the paramedic profession would increase accountability and ensure appropriate standards are upheld. Evidence provided to the committee highlighted that paramedics:

...largely work independently. My partner and I work by ourselves in the community, so what is happening is only witnessed by the two of us. There is a lack of accountability and there is a...lack of transparency. We need to raise the bar higher so we are all working to the same standards.[40]

3.30      There are also issues with the process for managing complaints about unprofessional behaviour and incompetence, and there is no public register of complaints. Currently, a complaint about a paramedic must be lodged with their employer. The employer may deal with it themselves, 'but they would not want to ruin their own reputation'.[41] A paramedic who was causing harm and should not be employed could simply find a job in another state. This is an unsatisfactory situation for employers:

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 of ethics—not only monitoring but providing that safeguard for both employers and patients alike so that, when those circumstances unfortunately arise where a call on the code of ethics is necessary, we actually have in place a robust national understanding of monitoring and enforcing that standard of ethics where it is appropriate.[42]

3.31      A national register would ensure that both employers and 'the public can access any paramedic's status: whether I have been suspended, whether there is discipline against me or whether I am current. It is completely transparent'.[43] There is a firmly held and seemingly well founded belief within the profession that registration would increase accountability:

national registration of paramedics will provide strengthened, consistent and increased accountability and transparency for those practicing in the profession and will ensure that the public can continue to have high levels of confidence in the qualifications, skill and level of care provided by highly trained paramedic professionals.[44]

Insurance

3.32      As paramedics predominantly operate as employees, according to the legal doctrine of vicarious liability, their employer is liable for any negligent conduct that occurs in the course of their duties. Generally, it is:

a requirement for registered health professionals that they hold personal professional indemnity insurance, but the rules of vicarious liability still apply. So even if I am a registered medical practitioner, if my practice is entirely as an employee for New South Wales Health or any health department or public hospital it will be my employer that will be liable for my negligent conduct.[45]

3.33        In the case of businesses in the private sector providing ambulance services:

They would wear the liability for their employees and, hopefully, they would have insurance, but there would be no requirement on them to do so. It would just be mindlessly foolish of them to be out there without it...[46]

3.34        A paramedic board could take a similar approach to the Nursing and Midwifery Board, which states that insurance by their employer can be sufficient: 'Just as nurses that are employed in public hospitals are covered by the state, the same approach for paramedics could also apply.[47] There does not appear to be any need for current insurance requirements to change under a system of national registration: 'we do all fall under the vicarious liability of our employer. I do not foresee that changing'.[48]

3.35      This position was supported by Associate Professor Michael Eburn, a legal expert on paramedics and the law in Australia. He also considered there would be no need for individual paramedics to obtain insurance following the introduction of national registration:

The current position is that paramedics do not carry private indemnity insurance. I think they would never be able to find it, even if they wanted it. No-one is offering it. Private ambulance companies should certainly be ensuring that they have insurance to cover their staff, but there is no legal requirement on them to do so...There is some fear that if we had national registration, then paramedics would have to go and get personal indemnity insurance. I do not think that is necessary. It would be up to the paramedic board.[49]

Governance

3.36      Submitters considered that the Australian Health Practitioners Regulation Agency (AHPRA) is the appropriate agency to administer paramedic registration, and that the process should be integrated with the existing approach taken to the other health professions. The AHPRA already maintains the register for 14 other health professions, and has experience supporting professional boards and disciplinary processes.[50] The AMA noted that:

Paramedics' registration under NRAS will result in the development of national accreditation standards for the education and training of paramedics, the national accreditation of programs of study, and national standards for the practice of paramedics.[51]

3.37      Submitters believed such a scheme would ensure minimum standards across the country, leading to improved patient outcomes:

The availability of legally enforceable instruments which impose mandatory practice requirements onto the profession are considered essential clinical quality and patient safety elements to ensure community confidence in paramedics as health care professional practitioners. A nationally standardised model of professional registration such as the NRAS, fundamentally provides an efficient and effective means of assuring the quality of service delivery, which cannot be delivered as successfully through other less unified systems of regulation.[52]

3.38      The Victorian government stated that further benefits of this approach include that it would 'underpin the development of more flexible models of out-of-hospital primary care, and enable better quality control of the emerging private sector, thereby reducing pressure on the public hospital system'.[53]

3.39      As discussed elsewhere in this report, there are inconsistent standards throughout Australia in relation to paramedics, including the use of the title 'paramedic' itself:

...as demand has grown for better health care (especially in more remote settings) the absence of a strong national regulatory framework raises the prospect of some operators being employed with significantly less experience, lower qualifications and uncertain competence. Comprehensive and consistent regulation is required to protect the public by ensuring appropriate standards of education, training and continuing competency.[54]

3.40      PA advised the committee that the AHPRA has the necessary infrastructure to administer a national registration system, and integration with other health professions would reduce duplication across the healthcare system.[55]

Participation in a national registration scheme

3.41      It was made clear during the course of the inquiry that an 'opt-out' system would 'undermine the integrity and purpose of national registration'.[56] As the NCAU stated, a national registration system would enable the:

public to have confidence that that safety is being preserved. With an opt out system, unfortunately you cannot guarantee that and, by having one jurisdiction not involved in a so-called national scheme, there is a glaring gap that people can take advantage of.[57]

3.42      As raised earlier, New South Wales (NSW) considers the current regulatory approach to be effective:

In determining whether or not registration should proceed, it is necessary to consider both the benefits and the costs, and whether the benefits outweigh the costs. In NSW, where there is already a high level of regulation of paramedics, many of the benefits of national registration have already been achieved through other regulatory mechanisms...The question of the benefits versus the costs of national registration is a matter under continuing consideration by NSW.[58]

3.43      Witnesses stated that if NSW does not participate in national registration, this may undermine the process that other states and territories are working towards:

A regulatory scheme should provide as much consistency across jurisdictions as possible...However under the federal system of government the different jurisdictions have the power to make different laws. This has often proved an impediment to change and carries economic costs unless there is uniformity...If NSW continues to remain apart and does not participate in the NRAS model, the regulations addressing issues such as minimum required qualifications, competency standards and exemptions will not be consistent and will create additional regulatory compliance and administrative costs by practitioners and service providers.[59]

3.44      The AHPRA submitted that it is important for all states to participate in national registration through the NRAS:

If in the future, a jurisdiction decides that regulation of paramedics under NRAS will not apply in that state, then the register of paramedics will not be a fully national register. Careful consideration will be needed to assess the full implications that an opt-out model will have on the effectiveness of the national register including clearly communicating how and why there is a potential difference in the national register for paramedics, and whether mutual recognition arrangements may be put in place to assure the public and employers that if action is taken to restrict, suspend, or cancel a paramedic's registration due to disciplinary action, this is communicated effectively in a non-participating jurisdiction to protect the public.[60]

3.45      As was discussed in chapter 1, there is already progress towards establishing a national registration system for paramedics in Australia. It is currently being progressed through the COAG Health Council. The Victorian Department of Human Services is leading the necessary policy changes, and Queensland Health is leading the legislative development and establishment of a paramedic board. It is likely that national registration 'will come into effect around September 2018'.[61]

3.46      The common view shared by those that gave evidence to the inquiry was well articulated by the RFDS: 'We think there is only benefit from the proposition that your inquiry is considering. I will be honest and say that I struggle to see the detriment. The time has come: why would you not move to this system of national recognition?'[62]

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