There has been moves to bring paramedics under the national health practitioner registration scheme. At a meeting of the Australian health Workforce Ministerial council on 10 October 2014 the decision on whether or not paramedics should join the ranks of nationally registered health professionals was deferred (see letter from Dr Kim Hames, Western Australia’s Deputy Premier and Minister for Health to Paramedics Australasia and reproduced on their Facebook page.
I, with my colleague Ruth Townsend, have argued elsewhere why paramedic registration is a desirable outcome (see Why National Registration of Paramedics is Best by Townsend and Eburn; see also Eburn, M and Bendall, J ‘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).
In the absence of a national scheme, Tasmania and South Australia have moved to limit who may call themselves a paramedic (see ‘Protecting the title of Paramedic (South Australia)’, October 2, 2014 and ‘Ambulance Service Amendment Act 2013 (Tas)’ January 24, 2014). Victoria has announced that it, too, will move to regulate paramedic practice with a state based registration scheme (Denis Napthine, Premier of Victoria, ‘Protecting paramedics and the public’ 29 October 2014). To that end the Department of Health has released an ‘exposure draft’ of the Paramedics Registration Bill 2014 (Vic). The Department is calling for submissions on the Bill to be received by 15 December 2014.
The Bill is long (252 sections; 188 pages) but does not appear to contain anything too surprising. It provides for the establishment of the Paramedics Board of Victoria that will set standards for paramedic registration; accredit education providers who are providing courses that are intended to lead to registration; maintain the register of paramedics and student paramedics, deal with issues of fitness to practice and professional standards, provide data for workforce planning and ‘regulate the advertising of paramedic services’ (s 7).
One of the functions of the Board will be ‘to facilitate the rigorous and responsive assessment of overseas-trained paramedics’ (s 4(2)(c); see also s 26(c) and (d) relating to accrediting overseas, but not interstate, education providers). There is no similar provision for the assessment of inter-state paramedics. It is possible that the Board will recognise qualifications and experience obtained interstate but there is in fact nothing in the Act that will, necessarily, assist interstate Paramedics to move to Victoria. In the absence of national registration, registration in Victoria will also not assist paramedics to move from Victoria.
The Board will be made up of between 7 and 12 members but no more than ½ of the board, and not less than 1/3 must be paramedics. Members are appointed by the Governor-in-Council on the recommendation of the Minister. There is no provision for members to be elected from the ranks of the practising profession (s 8).
The Minister may set the policy direction of the Board (s 9). The Board is to develop standards that must be met before a person can be registered as a paramedic but those standards must be approved by the Minister (ss 20-23). The Board can also set Codes and Guidelines that apply to paramedic practice. These Codes and Guidelines must be approved by the Minister if they relate to ‘qualifications, supervised practice, examinations for registration or the scope of practice of registered paramedics’ or ‘may have an adverse impact on the recruitment or supply of paramedics to the workforce’ (s 24). That last point is of note as Ambulance Victoria will be the largest employer of paramedics in that state.
Any registration requirement that may restrict the ‘recruitment or supply’ of paramedics, even if justified on clinical or community safety grounds, would have an impact on Victoria Ambulance (and others) to ensure that they have sufficient paramedics to meet their service needs and patient demand. It is up to the Minister to ensure that the Victoria health service is able to provide a service to Victorians but having a requirement that he or she must approve registration standards that may affect his or her ability to secure a supply of employees is problematic. These sections (ss 20-24) appear to mirror the provisions in the Health Practitioner Regulation National Law (Victoria) Act 2009 (Appendix; ss 11-15 and 38-40) which require health boards to refer standards, codes etc to the Ministerial council but those provisions, dealing with the registration of doctors, nurses and others, do not allow the Ministerial Council to reject the recommended standards or code if it would restrict the supply of registered professionals.
The Bill anticipates a number of types of registration. There will be
- General registration (s 33-36);
- Provisional registration (ss 37-39);
- Limited registration (ss 40-47):
- For postgraduate training or supervised practice (s 41);
- For an area of need (s 42);
- In the public interest (s 43);
- For teaching or research (s 44);
- Non-practising registration (ss 48-51); and
- Student registration (ss 61-68).
Limited registration for an area of need may be problematic if the Minister (s 43(1)) identifies an area in Victoria where it is hard to recruit enough paramedics and so allows the Board to register people to practice in those areas even though they would not be allowed to practice in Melbourne.
There’s no guidance when registration of a person who is not eligible for general registration would be in the public interest (s 43) but one case could be allowing overseas or interstate paramedics to travel as part of visiting sporting teams, or as part of visiting defence forces, to provide paramedic services to the members of their team or service.
The Board will have the necessary powers to verify peoples qualifications and identity and to check on their history to ensure they are appropriate candidates for registration and there are detailed provisions on the steps required to become registered including obligations upon the Board to give people a chance to be heard if the Board is intending to refuse the application or impose conditions on the person’s registration (ss 52-60). Apart from registration, the Minister may determine areas of practice that require special endorsement (s 21) and there are provision on how paramedics apply for that endorsement to engage in those areas of practice (ss 69-77).
Registered paramedics will have ongoing professional obligations, in particular there will be obligations to:
- Undertake continuing professional education (s 88);
- Hold professional indemnity insurance (s 89);
- Advise the Board of certain events such as being charged with a criminal offence (s 90);
- Advise the Board of any change in the paramedic’s principal place of practice (s 91);
- Report colleagues who have engaged in ‘reportable conduct’ (s 111).
Once the Act is in place it will be an offence for a person other than a registered paramedic to call themselves a paramedic or otherwise imply that they are a paramedic (s 96). This will not apply to ‘visiting interstate paramedics’ who are people entitled to call themselves a paramedic in another state and who have travelled to Victoria for the purposes of providing interstate transport for a patient. So a NSW or South Australian paramedic commits no offence if they drive their ambulance, marked with the word ‘paramedic’, into Victoria in order to collect or deliver a patient or as part of an interstate deployment to assist with an emergency in Victoria (s 96(4)).
There are then detailed provisions on receiving and dealing with complaints about a paramedics fitness to practice and allegations of unsatisfactory professional conduct. Most of these will be dealt with by the Board or disciplinary committees but they may be referred to the Victorian Civil and Administrative Tribunal (VCAT) where the allegation is one of professional misconduct or the paramedic asks that the matter be referred to VCAT.
As one would expect there are detailed provisions to allow the Board, on receipt of a notification to undertake a preliminary assessment, if necessary take urgent action to cancel or restrict a paramedic’s right to practice, arrange assessments as to the paramedics health or competence, to conduct investigations and to ultimately make decisions. There are also provisions to ensure the paramedic has the right ot be heard and represented during these proceedings (ss 109-189).
The remaining parts of the Bill deal with
- Finance (ss 190-193)
- Information and privacy (ss 194-211);
- General matters including protection from liability for members of the Board and investigators and the various powers of investigators (ss 212-246);
- Transitional provisions to allow the change from the current unregulated system to the new Act, eg to allow current paramedics to get registered (ss 247-249); and
- Amendments to other Acts such as the Ambulance Services Act 1986 (Vic) that will be necessary to allow the new Act to operate (ss 250-252).
A right to private practice?
The most interesting thing, in my view, is that the Bill infers a coming right to private practice. Under the current Ambulance Services Act 1986 (Vic) it is an offence to use the word ‘ambulance service’ so as to limply some connection with Ambulance Victoria or to use the word ‘ambulance’ on a vehicle that is not operated by Ambulance Victoria (s 39) (remembering that ‘Ambulance Victoria’ is a generic name that captures all the various ambulance services listed in Schedule 1 to the Act (ss 3 definition of ‘Ambulance Victoria’ and Schedule 1)). Under the Non-Emergency Patient Transport Act 2003 (Vic) there is a licensing scheme for the providers of non-emergency patient transport services. There is no scheme in place to licence private providers of emergency ambulance services.
Notwithstanding this there are suggestions in the Bill that private emergency ambulance services are intended. First registered paramedics must hold professional indemnity insurance. This is new as currently all paramedics must be employed in order to practice as it is their employer who determines their scope of practice and has the necessary authority to carry and use drugs. As they are employees it is their employer, and most often that will be Ambulance Victoria, that will be liable for any negligence. An obligation to carry personal insurance implies that they will be acting on their own, independent scope of practice.
Next the Bill deals wth the conduct of business that provide paramedic services; for example the Board may ‘prohibit [a] person from carrying on a business providing paramedic services’ (s 100). It is an offence to conduct that business during the period of any prohibition (s 102). It is an offence to advertise a business that provides paramedic services in a way that is false and misleading (s 98) but it is not an offence to provide that sort of business or to advertise it in a way that is not misleading and deceptive. As has been noted above a paramedic must report to the Board if certain events occur. These events include (at s 90(3)):
(iv) the paramedic’s right to practise at a hospital or another facility from which health services are provided is withdrawn or restricted because of the paramedic’s conduct, professional performance or health; or
(v) the paramedic’s billing privileges are withdrawn or restricted under the Human Services (Medicare) Act 1973 of the Commonwealth because of the paramedic’s conduct, professional performance or health;
Finally the paramedic must notify the Board if there ‘any change in the paramedic’s principal place of practice’ (s 91) not just in his or her employer.
To the best of my knowledge and belief, paramedics do not have ‘billing privileges’ under the Human Services (Medicare) Act 1973 (Cth) but it is clearly anticipated that this may happen. Equally if one can, unless prohibited, conduct and advertise a business that provides paramedic services and conduct practice from ‘another facility from which health services are provided’ (s 90(3)(iv); emphasis added) and that is not restricted to a government or public facility (see s 3, definition of ‘health service’). This is consistent with registration, if one is going to be registered then community safety is maintained through the registration and disciplinary provision and with professional indemnity insurance to provide redress in the case of negligence, the need to restrict paramedics to employment and in particular employment by Ambulance Victoria is lost. It is a surprise as the Bill is not put forward as a Bill to open the door to private emergency paramedic providers and it does not expressly do so, but in my view it does open the door, by implication, for private providers of paramedic services (provided they don’t suggest they’re part of Ambulance Victoria, so they can’t put ‘ambulance’ on their car, but they could be ‘Event Paramedics’ or the like). If the Bill (if passed) does not directly lead to a private industry in this area, it will certainly increase pressure to allow that industry to develop.
Who knows, perhaps Victoria see this a way to move from the provider of paramedic services to the industry regulator?