EMS Around the World: Australia`s Tyranny of Distance

Stereotypical images of Australia include vast, open bush landscapes with bounding kangaroos and sleepy koalas, sandy beaches, Foster’s beer, and shrimp “on the barbie.” These images may be a tourist marketing dream, but Australia’s “tyranny of distance” is a formidable challenge for delivering emergency medical services. 

Australian ambulance services have been in operation since the late 1880s, when the then-British colony was becoming more industrialized.¹ With the reemergence of St. John (more correctly the Most Venerable Order of the Hospital of St. John of Jerusalem) in England, the charitable order commenced both brigade transport operations and first aid training in its colonial outposts. A number of states relied upon St. John for the provision of ambulance services for some years, alongside funeral homes and railway and police ambulances, until state governments took over. 

State-Based Services 

Today ambulance provision remains organized as state or territory-based services, principally through health departments. Only the Western Australia and Northern Territory ambulance services remain coordinated by St. John. Each state and territory now manages its own jurisdiction, legislation, funding, and insurance scheme. Nationally there are 1,520 locations with 1,367 first responder vehicles, 3,599 general transport and patient transport vehicles, and 94 ambulance aircraft.² 

The funding of each service is based on a mixed model. Funds are sourced from state government grants/contributions, fees from interhospital transfer services, charges to motor vehicle insurers, fees from uninsured patients, and subscription fees. Australian ambulance services’ total revenue for 2015–2016 was approximately $3 billion AUD ($2.14 billion USD). 

The national universal healthcare scheme (Medicare) does not fund or provide ambulance insurance. This means users pay for ambulance services, with transport charges and insurance coverage varying across Australia. Nearly 25% of the Australian public assumes that Medicare does in fact cover ambulance services.³ If Medicare were to fund ambulance services, the base-level taxation would need to increase by 0.3% to cover the costs.⁴ As a user-pay system, insurance is purchased directly from the ambulance service or as part of individual private health insurance. Those not insured may be charged a callout fee as well as mileage. Only two states offer free service, Queensland and Tasmania.²

State-based ambulance services are organized based on activity: emergency and nonemergency patient transport as well as specialized teams such as rescue and special operations, aeromedical retrieval, and mental health.

Employment

To be employed as a paramedic in most states of Australia, you need to obtain an undergraduate bachelor’s degree from an approved university. The “pre-employment model” for paramedic recruitment was part of industrial and education reforms that commenced in the 1980s. The primary ambulance employer body, the Council of Ambulance Authorities (CAA), supported the move from competency-based on-the-job diploma training to university education in the mid 1990s. There are now 19 approved universities in Australia and New Zealand providing paramedic education to nearly 7,000 enrolled students.² Ambulance services offer certificate-level training for volunteer officers. 

The scope of practice for paramedics also varies across states. The main representation body, Paramedics Australasia (PA), has published role descriptors that overview various competencies. These include entry and advanced levels and specializations such as retrieval, community, and communications.⁵  

Further training and upskilling of paramedics has seen the development of intensive care and extended care roles. These specialized paramedics can be educated to graduate diploma level to provide advanced treatments for patients with complex healthcare needs (e.g., severe trauma or acute medical conditions).

Further upskilling of the intensive care paramedic has led to the introduction of extended care paramedics who can treat patients in their homes and reduce congestion in EDs. Western Australia, South Australia, and New South Wales introduced ECPs as a strategy to reduce presentations initially as trials, but made them permanent when they were successful (as did New Zealand).^6–8 

While in the main Australian ambulance services are public health services, private-sector providers deliver specialized occupational, industrial, patient transport, and first aid attendance at public events. 

The commencing graduate paramedic salary ranges from AUD $66,500–$105,900 (USD $47,270–$75,300) depending on location and shift configuration.⁹ 

Workforce and Workload 

The workforce profile of Australia paramedics encompasses both paid and volunteer. To cover the breadth of the continent requires a large workforce, with many services relying on volunteers. Volunteer ambulance personnel principally are located in rural and remote regions, with urban areas being trained and supported by paid training staff in regional centers.

In Australia there are 16,087 full-time salaried and 6,182 volunteer personnel, with 2,620 community first responders (personnel trained for response but without transport capacity before ambulance arrival).^2,6 Nearly a third (32%) are female, and more than three-quarters (77.3%) are under age 50. The turnover rate is 3.3%. 

Workload varies across jurisdictions. Nationally, 3.5 million incidents were reported to ambulance services, in which 4.4 million ambulances responded and assessed 3.3 million patients.²

The increase in demand for ambulance services is because of an aging population, changes in social support, accessibility of services, and increased awareness.^11–14 

“Ramping,” whereby no suitable ED bed is available for a patient who arrives by ambulance at a hospital, preventing them from being admitted, remains an issue for many services across Australia.^11,12,15 The ambulance, with the paramedic and patient on board, is forced to wait outside the ED until the patient can be accommodated. 

Continued research shows the workplace of Australian paramedics is hazardous, with higher-than-average injury rates and even fatalities.¹⁶  

New Developments 

At the time of this writing, Australian paramedics have just become eligible for national registration through the Australian Health Practitioner Regulatory Authority (AHPRA). Previously they were regulated through their employer, and the title of paramedic was not protected.   

References

1. Howie-Willis I. A Century for Australia: St. John Ambulance in Australia, 1883–1983. Canberra: Priory of the Order of St. John in Australia, 1983.

2. Australian Government Productivity Commission. Report on Government Services 2018, Part E, Chapter 11, www.pc.gov.au/research/ongoing/report-on-government-services/2018/health/ambulance-services.

3. Finder. Australians misusing ambulance service, www.finder.com.au/australians-misusing-ambulance-service.

4. Livingstone CH, Condron J, Dennekamp M, et al. Factors in Ambulance Demand: Options for Funding and Forecasting. Bundoora, Victoria: Australian Institute for Primary Care, 2007.

5. Paramedics Australasia. Paramedicine Role Descriptors, www.paramedics.org/paramedicine-role-descriptors/.

6. Paramedics Australasia. Paramedics in the 2011 Census, www.paramedics.org/content/2012/11/Paramedics-in-the-2011-census-final.pdf.

7. Finn JC, Fatovich DM, Arendts G, et al. Evidence-based paramedic models of care to reduce unnecessary emergency department attendance—feasibility and safety. BMC Emerg Med, 2013 Jul 15; 13: 13.

8. SA Ambulance Service. Extended Care Paramedics, www.saambulance.com.au/Whoweare/Emergency/Singleresponders/ExtendedCareParamedics.aspx.

9. Grantham H, Hein C, Elliott R. South Australian Ambulance Service (SAAS) Extended Care Paramedic (ECP) Pilot Project. J Emerg Prim Health Care, 2010; 8(3): 32.

10. SA Ambulance Service. Paramedic—Qualified–Frequently Asked Questions, www.sahealthcareers.com.au/_userfiles/Paramedics_Qualified_FAQs_16052017.pdf.

11. Gaughan J, Kasteridis P, Mason A, Street A. Waits in A&E departments of the English NHS. International Health Congress, 2018.

12. Honeyford K, Bottle A, Aylin P. ED attendances: an overlooked performance metric? A statistician’s perspective. International Health Congress, 2018.

13. Lowthian JA, Jolley DJ, Curtis AJ, et al. The challenges of population ageing: Accelerating demand for emergency ambulance services by older patients, 1995–2015. Med J Aust, 2011; 194(11): 574–8.

14. Schierholtz T, Carter D, Kane A, et al. Impact of lift assist calls on paramedic services: A descriptive study. Prehosp Emerg Care, 2018 Aug; 17: 1–8.

15. Hammond E, Shaban RZ, Holzhauser K, et al. An Exploratory Study to Examine the Phenomenon and Practice of Ambulance Ramping at Hospitals Within the Queensland Health Southern Districts and the Queensland Ambulance Service. Griffith University, https://research-repository.griffith.edu.au/bitstream/handle/10072/49997/74885_1.pdf?sequence=1.

16. Maguire BJ, O’Meara P, O’Neill BJ, Brightwell R. Violence against emergency medical services personnel: A systematic review of the literature. Am J Industrial Med, 2018; 61(2): 167–80.

Louise Reynolds, PhD,  is a senior lecturer with the Faculty of Medical Science at Anglia Ruskin University in Chelmsford, England.