This question relates to paramedic practice.  My correspondent says:

I’m trying to clarify something about the law in regards to paramedics in Australia and I was wondering if you could help.

I know in South Australia that paramedics derive their authority to practice medical acts on members of the public directly from the corporate entity of the Ambulance Service.  This is spelled out in the SA Health Care Act of 2008 (section 6, I believe, covering SAAS [The relevant provisions in the Health Care Act 2008 (SA) is Part 6, not section 6; part 6 contains sections 49-62].  My understanding is that this is true for all state-run ambulance services in Australia.  This is in contrast to, for example, New Zealand and the United States where paramedics are delegated their authority to practice from a physician acting as the Medical Director of the Ambulance Service.  Or, for example, the UK, The Republic of Ireland or South Africa where paramedics obtain their legal authority to practice from their own license as paramedics.

What I’m trying to get an answer to is this – does EVERY state in Australia delegate authority to practice paramedicine through the ambulance service?  Is this a homogeneous national model?  I’m also wondering if the private ambulance services in Australia work under the Medical Director model, wherein their paramedics derive their authority to practice from delegation from a physician.

Thanks for any insight you can offer.

Paramedicine is a largely unregulated profession.  One does not need ‘authority to practice medical acts on members of the public’, one needs authority to do that which is regulated.  In terms of paramedic practice the tasks that they need a licence for are to drive the ambulance and possess and administer scheduled drugs.  We know they have a personal authority to drive in the form of their driver’s licence.

The term ‘authority to practice’ has moved into the lexicon but its really not appropriate in this context.  The term does not appear in law.  The South Eastern Sydney Local Health District defines ‘authority to practice’ as:

A license (this may be a certificate, notice, or other form of documentation) that is issued by the relevant National Registration Board on an annual basis certifying that the holder is eligible to practise in the profession and that the holders details are entered into the relevant Board register. That is, the person is authorised to call themselves a physiotherapist/ podiatrist / psychologist /pharmacist / occupational therapist. Once a name is removed from the register, it is then illegal for that person to call themselves a physiotherapist/ podiatrist / psychologist /pharmacist / occupational therapist.

You can see they’re using the term ‘authority to practice’ as a shorthand or ‘catch all’ phrase to cover the various documents that may be issued for registered health practitioners.  The critical issue here is that paramedics are not registered health professionals.

So a paramedic’s authority to practice is, basically, their job description or the tasks that the employer determines that they are to do.  In short the state run ambulance services determine what their members are authorised to do as part of their duties.  They may issue a document called an ‘authority to practice’ but that is because they have adopted the term, not because the law uses the term.   The idea of an ambulance ‘authority to practice’ is relevant when it comes to the use of drugs.

Using NSW law as an example, it is an offence to be in possession of or supply scheduled drugs.  There are exemptions for paramedics, for example a person employed by the Ambulance Service of NSW as an ambulance officer and who is approved by the Director-General is ‘authorised to have possession of, and to supply, drugs of addiction’ (ie schedule 8 drugs) (Poisons and Therapeutic Goods Regulation 2008 (NSW) clause 101; see also clause 129 and Appendix C for similar authority relating to schedule 2, 3 and 4 drugs).  So it’s up to the Director General to determine who is competent and then authorise them to carry and use these drugs. The Director-General may issue something that they call an ‘authority to practice’ to show that the particular paramedic is authorised under the regulations to use various drugs.   (For another similar example see Drugs, Poisons and Controlled Substances Regulations 2006 (Vic) Reg 5, entry 11 relating to Ambulance Victoria and entry 12 relating to St John Ambulance (Victoria)).

The idea that paramedics ‘are delegated their authority to practice from a physician acting as the Medical Director of the Ambulance Service’ makes no sense at all.  Staying with NSW law medical practitioners may have authority to supply scheduled drugs (see Poisons and Therapeutic Goods Act 1966 (NSW) ss 10) but they need special authority to prescribe drugs of addiction (s 28A).  There is nothing however that would allow a doctor, who is authorised to possess and/or supply a scheduled drug, to give that permission to someone else.   A doctor may give an emergency prescription by telephone or radio (s 36 (restricted substances) and s 81 (drugs of addiction)) but that would depend someone who is with the patient to communicate the relevant signs and symptoms and the medical practitioner to make an informed decision on the treatment. It would not allow a medical practitioner to give some general permission – if you find a person in this condition you can administer this drug – nor does it give permission for that person to be in possession of that drug.  Medical practitioners just can’t authorise someone else to do things that are otherwise illegal but would not be illegal if a medical practitioner did it; nor can a medical practitioner empower someone to practice medicine on his or her behalf, and make decisions in his or her name for a patient the doctor has never seen, and if they did they would be likely to find themselves ‘struck off’.

In New Zealand a person needs the Minister’s consent to deal with restricted medicines (Medicines Act 1981 (NZ) s 20).  I can’t easily locate any approval but it may be that there is some authority to allow paramedics who are working with St John Ambulance or the Wellington Free Ambulance or any other NZ ambulance authority and who has been authorised by the services’ Medical Director in the same way that a NSW ambulance officer is authorised by the Director General, but I can’t confirm that.

It should be apparent that the authority to use drugs is set out in the relevant poisons or drugs Act, not the relevant ambulance service legislation.  It should also be noted that there is no relevant ambulance legislation in either the Northern Territory or Western Australia.   Further authorities may be given but they are not publically available so finding out the exact terms upon which provider is authorised to carry and use drugs is not something that is easily done and would presumably require freedom of information type applications.

So, ‘does EVERY state in Australia delegate authority to practice paramedicine through the ambulance service?’ The answer is “No” as you don’t need an authority to practice paramedicine as paramedicine is not a registered health profession. A paramedic’s employer determines what is, or is not, in their scope of practice, that is what they are employed to do.  A paramedic does need an authority to carry and use scheduled drugs.  The state health authorities issue the relevant authorities so, for example, NSW Ambulance can authorise its employees to carry and use drugs.  , so paramedics employed by the state services are authorised by the state services but that does not extend to paramedics working in the private sector.  Private providers must also be granted approval subject to whatever terms the relevant department choses to impose (see Poisons and Therapeutic Goods Act 1966 (NSW) ss 11 and 29).  That would be how private providers get authority to carry and use drugs but it does not explain how they get authority to operate in those states and territories where there is a prohibition on private ambulance services (see for example Health Services Act 1997 (NSW) s 67E; Ambulance Service Act 1982 (Tas) s 37).  (I have argued elsewhere that it appears, on the face of it, some of these operators must be acting in breach of these laws (see Michael Eburn and Jason Bendall ‘The provision of Ambulance Services in Australia: a legal argument for the national registration of paramedics’ (2010) 8(4) Australasian Journal of Paramedicine Article 4 (previously (2010) 8(4) Australian Journal of Emergency Primary Health Care, Article 990414).)