Pearls and Irritations

In a country with well-publicised shortages in the health workforce, it’s perplexing and perverse that policymakers don’t use paramedics better. It’s an anomalous situation that the Strengthening Medicare Taskforce can help to overcome.

In his recent article on demarcations and restrictive workforce practices in health, John Menadue has correctly identified the significance of health care and the benefits that might arise from improvements in the delivery of health services. As he noted, reform of the health workforce structure, work practices, multi-skilling, teamwork and flexible training are key micro-reform issues.

The role of allied health professionals in primary health is not always well defined or understood. This situation is not surprising given that the committees responsible for health policy development are commonly not well populated with relevant personnel.

Health workforce reforms are needed to make better use of nurses, midwives, practice nurses, nurse practitioners, allied health and community health workers. A glaring omission from many workforce discussions is the consideration of paramedics who already practice at an advanced clinical level and care for people with problems of varying complexity.

Every day across Australia, thousands of paramedics working for public and private ambulance services undertake patient assessments, administer powerful drugs and perform diagnostic tests ranging from ECGs to ultrasonography and other interventions that would qualify for a Medicare rebate if performed within a clinic or GP setting.

But these services are not reimbursed under Medicare since the ambulance sector is the responsibility of state and territory governments, and paramedics have not been included among the health professional providers recognised by Medicare.

Indeed, it was disconcerting to see that the National Rural Health Commissioner Final Report omitted paramedicine from consideration as part of the available health workforce despite having more than 23,000 registered practitioners in June 2022. That omission needs to be resolved, with paramedicine mobilised as a key stakeholder profession.

The UK is ahead of Australia in the use of paramedics in primary and other areas of care – with the express recognition of paramedics as part of the allied health workforce. This includes the use of paramedics with prescribing rights.

The UK’s development of innovative models of care is a good example of how the paramedic workforce can be mobilised across a variety of settings and in integrated and inter-professional practice.

Significant support for primary care practice is provided through the funding of allied health practitioners (AHPs) under the Additional Roles Reimbursement Scheme (ARRS). The ARRS facilitates the addition of AHPs to make up the multidisciplinary practice workforce needed.

The arrangement provides 100% reimbursement to create additional capacity across the five roles of clinical pharmacists, social prescribing link workers, physician associates, first contact physiotherapists and first contact community paramedics. By 2024, paramedics are expected to have become an integral part of the core general practice model.

A feature of the ARRS is the explicit recognition of AHPs as a valuable part of the primary care team, while the nomination of paramedics acknowledges the perceived benefits of paramedics in primary care and multidisciplinary teams.

This sustainable practice regime is consistent with the move towards supporting an aging population and caring for increasingly complex patients with chronic conditions by providing care close to home. It’s an approach that should be considered for Australia.

An existing Australian model that partly reflects the ARRS framework for GPs is the Australian Government Workforce Incentive Program – Practice Stream (WIP). This provides financial incentives to help general practices with the cost of engaging nurses, AHPs and/or Aboriginal and Torres Strait Islander health workers and health practitioners.

The WIP Guidelines lists 15 eligible professions. That said, the Guidelines do not include paramedicine among the listed professions.

While the WIP offers promise as a mechanism to foster a multidisciplinary health system, it is limited in scope and complex. Moreover, by not nominating paramedicine as an eligible profession it omits one of the most complementary professions available for a GP practice, especially for people in rural Australia.

Paramedics are renowned for being able to rapidly and independently assess patients and situations, diagnose, make decisions, intervene, manage and develop operational plans. The evidence from many pilot studies locally and overseas is that community paramedic programs have been highly successful and cost effective.

Omission of paramedicine from the WIP has significant ramifications, including the loss of benefits that could flow from the strategic mobilisation of an expert available workforce. It’s an omission that dramatically reflects the forgotten status of the profession when it comes to workforce planning and utilisation.

It’s a situation that must change through direct action to formally recognise paramedicine both for Medicare purposes and through other other practice support mechanisms.

Governments are currently pledging to recruit hundreds of additional paramedics across Australia to work within the ambulance services. Paradoxically, they have been slow to remove obsolete barriers to paramedic practice that inhibit the use of paramedics in primary care, hospitals and other settings that would potentially improve service levels

Dr Meg McKeown put the funding situation well in her appearance before the Tasmanian Rural Health Services Inquiry on Friday 26 November 2021:

“The people I have with me are not funded through Medicare. I have a paramedic practitioner who works as my physician assistant. She can’t bill through Medicare, so all of my earnings are important. If I allow her to see a patient, and I don’t see them, they get seen for free.

I either have to see all of my patients and all of her patients, or we find another model where we can fund her, and we make legislative change where we can do that.”

The Strengthening Medicare Taskforce at its inaugural July meeting committed to developing recommendations to achieve (inter alia):

• a reliable training and development pipeline, to build a strong and vibrant primary healthcare workforce
• increased access to multidisciplinary care, harnessing the full skills of nurses, pharmacists and allied health professionals.

Not specifically mentioned by the Taskforce communique was the paramedicine workforce which one assumes must be considered under the ambit of allied health, since it is neither medicine nor is it nursing or midwifery.

Therein lies the danger that this valuable generalist health workforce once again will be the forgotten profession and remain overlooked in terms of Medicare provider status.

Among the many contributions that paramedics can make to primary care and which might reasonably attract a direct Medicare rebate are services under various categories of consultation, health education and preventive care, ATSI health assessment, pathology and woundcare and other minor procedures.

The procedures include but are not limited to:

• ECG evaluation and decision-making in the context of chest pain
• Resuscitation support including anaphylaxis response
• Seven point collection and interpretation of vital signs (HR, BP, SpO2, RR, BGL, Temp, AVPU) – with serial assessment potentially attracting a higher fee
• Status assessment of body systems (i.e. respiratory status, cardiovascular status, neurological status) in the context of concern for compromise – and different fee structure for home/prehospital/mobile assessment
• Emergency ultrasonography
• Referral for specialist diagnostic services and collection of blood and other samples
• Telehealth liaison with ambulance service for triage assessment
• Creation of an emergency or prehospital management plan for patients at higher risk of deterioration in the community
• Provision of vaccination on an enduring basis as an authorised vaccinator
• Intramuscular injection of medications
• IV cannulation and drug/fluid administration within scope of practice – with potentially different fee if warranted under medical direction/outside scope
• Suturing, wound care and other minor procedures
• evaluation and preparation of patient care plans.

Other areas of practice support include mental health, aged and palliative care for which various programs of micro-credentialling might apply to attract a specific MBS item payment. They are also areas where the ambulance services and private paramedic services may play a bigger role.

The question is not that paramedics can’t add value to a multidisciplinary primary care team but that the range of competencies that paramedics bring to the table has not been recognised by the Commonwealth within the Medicare framework.

Every paramedic in Australia must be registered under the same national regulatory system as medical practitioners, nurses and other health practitioners, and must meet continuing professional development and other standards designed to protect the public.

Australia is an acknowledged international leader in the provision of paramedicine education and research. Paramedicine is a popular university program with more than 9000 students across Australia – in many cases being educated alongside nurses and doctors.

In recent years graduate numbers have been greater than the number recruited by the ambulance services. The result has been understaffed services and varying levels of practitioner under-employment given the present restrictive funding and other policies that inhibit their general practice.

Some of our brightest and most passionate practitioners who have spent tens of thousands of dollars and many years to be qualified are being denied the opportunity to support our communities in need. From both economic and human perspectives it’s inexplicable.

It’s thus not surprising that Australia is being targeted for recruitment internationally with graduates and experienced paramedics being sought by health services from the UK, Ireland, Canada, and the United States. More than 500 paramedics from Australia and New Zealand work for London Ambulance Service alone.

While highly proficient in emergency response and resuscitation, paramedics increasingly have training in primary care and related fields through micro-credentialling and a growing array of postgraduate programs.

The limited workforce data on paramedicine is unreliable and consistently conflates professional paramedics with ambulance officers. Better data and a wider understanding of the integration of paramedics into local clinical teams are needed to enhance their engagement in primary care.

Innovative solutions are required to improve access to AHPs and integration of these practitioners with primary care networks, hospital and health services, mental health, palliative, aged care services, disability, and other community services.

An example is the introduction of palliative care services to overcome deficiencies in the availability of palliative and end-of-life care. In Canada, there is formalised training for paramedics in palliative care through funding provided by the Canadian Partnership Against Cancer and Healthcare Excellence Canada.

Paramedics have demonstrated their capacity to provide high-level clinically focused and autonomous care and their competencies in the assessment, diagnosis, and treatment of patients in diverse environments. Their capacity to respond to the demanding roles of the ambulance services is legendary.

We should use that existing workforce better. As John Menadue opines, there is not so much a workforce shortage. The issue is more often how we use the workforce.

The Commonwealth and jurisdictional governments must acknowledge that paramedics are part of the national health workforce and not pigeonhole them as employees of ambulance services, however valuable that role may be. The perception that paramedics work only for ambulance services needs to be overcome.

As registered health professionals, the capacity of paramedics to work in multidisciplinary roles and diverse settings should be mobilised to provide cost-effective care and patient-focused solutions.

We need a National Health Commission to drive change that spans jurisdictions and the life cycle of governments. The former Health Workforce Australia did excellent work with the health and higher education sectors to identify and break down barriers to innovation and reimagine the roles of the health workforce. That level of innovation largely disappeared with its defunding in 2014 but could be re-established.

It’s a perplexing and perverse situation that in a country with well-publicised shortages in the health workforce in every jurisdiction; whose paramedics are among the most highly educated in the world; where there has been a past surplus of practitioners; whose registered practitioners are being actively recruited overseas; and whose research activities are recognised as among the most advanced in the world; policymakers don’t use paramedics better.

It’s an anomalous situation that the Strengthening Medicare Taskforce can help to overcome by recognising paramedicine as an eligible health workforce for a range of service items well within the paramedic scope of practice.