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Establishment of Inquiry into Ambulance Ramping

Dr Rosalie Woodruff MP

Dr Rosalie Woodruff MP  -  Wednesday, 9 August 2023

Tags: Ambulance Ramping, Health Crisis

Dr WOODRUFF (Franklin- Leader of the Greens) - Mr Speaker, I move -

That -

(1) A select committee be appointed with power to send for persons, papers and records to inquire into and report upon ambulance ramping in Tasmania, with the following terms of reference:

(a) the causes of the significant increase in ambulance ramping since 2015;

(b) the effect ambulance ramping has on:

(i) safety for ramped patients;

(ii) ambulance response times and availability, and any associated increased risks to the community;

(iii) wellbeing of healthcare staff;

(iv) emergency department and other hospital functions;

(c) the adequacy of the state Government's data collection and reporting for ambulance ramping;

(d) the state Government's response to ambulance ramping and its effects to date, and the efficacy of these measures;

(e) successful measures taken by other Australian and international jurisdictions to mitigate ambulance ramping and its effects;

(f) actions that can be taken by the state Government in the short, medium, and long term to address the causes and effects of ambulance ramping; and

(g) any other related matters incidental thereto.

(2) The number of members appointed by the House to serve on the committee be six: two nominated by the Leader of Government Business; two nominated by the Leader of Opposition Business; one nominated by the Leader of Tasmanian Greens Business; and Lara Alexander MP.

(3) The committee report by 28 March 2024. [OK]

Mr Speaker, ambulance ramping has spiralled out of control under nearly a decade of Liberal government. As ramping has rapidly increased, we have heard many desperate calls for action from healthcare staff and we have seen more examples of the tragic harm that ramping is causing to Tasmanians. There has been damning recent criticism from the Coroner and community outrage has grown. But rather than seeing a real response to this critical issue, we have seen the Government repeatedly saying that they are doing enough. Every year they have trumpeted their health spend and every year ramping has become worse. By their refusal to accept the worsening situation and to act to reverse it, the Liberals are putting the Tasmanian community at greater risk and healthcare staff under greater strain. Enough is enough. The Greens cannot stand by as the Liberals continue to normalise their increasingly dangerous hospital mismanagement. And we do not accept that nothing can be done to improve the situation. That is why today we are moving to establish an inquiry into ambulance ramping in Tasmania, to examine its causes and effects, and the changes that would make it better.

Before going further, I will provide a brief explanation of what we are talking about today for those who might be listening. Ambulance ramping, or 'ramping', is a term used for what happens when patients arrive at a hospital in an ambulance and remain in the care of paramedics for an extended period rather than being admitted to the hospital. The Government will often try to avoid the use of this term and instead talk about 'offload delay' or 'transfer-of-care delay'. These terms refer to the same situation and are their attempt to sanitise and euphemise what is happening.

A patient is recorded as being ramped when they remain in the care of paramedics at hospital for longer than 15 minutes. The term 'ramping' comes from ambulance vehicles being lined up on the ramp outside emergency departments because of a delay in transferring patients to hospital care.

Exactly where an ambulance patient is cared for while they wait to get admitted is different for each hospital. At the Royal Hobart Hospital, patients used to wait on stretchers in a corridor but, more recently, they are being taken to a room that was previously a dedicated emergency medical unit, the EMU. At the Launceston General Hospital, patients are stretchered in an entrance area between the ambulance bays and the emergency department.

Wherever patients are ramped, it is always the case that they remain in the care of paramedics. Despite their great skills, paramedics do not have the training or scope of practice to provide hospital care and they cannot provide testing or specialised medicines. It also means they are stuck, unable to respond to 000 calls.

Mr Speaker, the first part of the terms of reference for this inquiry relates to the causes of significant increase in ambulance ramping from 2015. And, wow, that increase has been significant. According to the Australian Medical Association collation of government data, in 2015 16 fewer than 8 per cent of patients arriving by ambulance to Tasmanian hospitals were ramped. The number now is close to 40 per cent. That means two in five patients who have to go to hospital in an ambulance are ramped.

From July to March in 2021-22, the total time patients were ramped at Tasmania's hospitals was just over 20 000 hours. Across the same period in the next year, that number had increased to over 31 000 hours. That is a 50 per cent uptick in one single year.

In 2020-21, one in five patients arriving at hospitals by ambulance across the state were ramped for longer than 30 minutes. Two years on, in 2022-23, this has grown to one in three of all ambulance patients. The Government's own stated target for this measure is that zero patients should be ramped for more than 30 minutes.

All up, nearly 16 000 patients were ramped in the first nine months of the 2022-23 year. That is over 1700 patients ramped every month.

In the Government's suggested amendments to this motion, they are seeking to remove the reference to 'significant increase in ambulance ramping since 2015'. We reject this entirely. The increase since 2015 is a fact. If the Government were serious about this issue, they would not try to deny it.

There has been significant community conversation on the causes of ramping. The lack of bed space in hospitals is obviously a massive issue. There are a range of underlying matters contributing to that, including the increase in demand, lack of allied care staff and the rate of readmissions due to a lack of community health services. It is important for an inquiry to look at these issues.

The second part of our terms of reference relates to the effect of ambulance ramping. A Victorian study released last year showed that once patients are ramped for longer than 17 minutes, they are at increased risk of harm or death. This is not an issue the Government has shown any interest in examining in Tasmania.

In considering the impact of ramping on patients, I want, at this point, to give a voice to some of the people who have very bravely spoken to the media about the real effects of ramping and their firsthand experience.

Last year at the Launceston General Hospital, there was a terrible situation where a woman called Anne Pedler died after being ramped for eight hours. The Coroner released a scathing report on the situation, saying that if Mrs Pedler had received treatment in a timely manner, 'her chances of survival would have been significantly increased'.

Speaking to media, her daughter, Stella Jennings, said: [OK]

People are dying because they don't have the staff, and because they don't have the staff their morale is so low that they make mistakes, they have more sick leave.

It all snowballs until you have one night like when my mother went to hospital and there was no-one there for her.

Ms Jennings also said:

I don't want to be doing this interview. I don't want my mum to be gone. I just don't want this to keep on happening.

Thank you so much for speaking up about your terrible circumstances, Stella.

In another tragic situation last year, a woman named Kathleen Schramm died in agony at the Royal Hobart Hospital after being ramped for two hours. I note that two hours is now the average time that patients are ramped at the Royal Hobart Hospital. The circumstances around Mrs Schramm's death are harrowing. Her daughter Rebecca courageously spoke about the pain she suffered and her shock at what happened just days after it occurred.

Nine months later, Rebecca spoke again on ABC Radio last week, saying:

Nothing has changed in the nine months since my mother died in a lot of pain. There has only been talk and that is all. There is nothing. Nothing has happened except the public are putting faces to the numbers and saying, 'This has to stop', because it affects everyone. It could be anyone this happens to. It is very upsetting because it can affect any of us. It is not just because my mother was old. She may have been 80 but she lived a very happy and independent life, looking after other people as well.

Rebecca, we know it must be difficult for you to keep talking about this but we want you to know that we have been listening and that you are making a difference.

We have also heard in recent days from two paramedics, Sophie and Cam, who spoke to the ABC. Sophie said:

It's awful and my condolences go out to the families who have been affected by this. They are not alone in their experiences. There have been a lot of near-misses that just don't get reported and they get swept away. Even as a student being on the road there was very little ramping. Fast forward to now, it's not uncommon to be ramped for several hours with the one patient and take no other patient, so crew isn't clear and can't get back out on the road.

Cam said:

The equipment of the paramedics and the hospital doesn't match up. We've got ambulance equipment inside a hospital and then we have a significant patient adverse event and then the hospital bring their trolley. We don't know what we're doing. It's messy.

Asked about a Government comment on ramping being related to the availability of GP access and a high demand on services, Cam's response was:

I wrote down that quote of 'high demand on services'. I find that a little but offensive, to be honest. It's the state Government. The Government and the Department of Health could step in tomorrow and say enough is enough.

Mr Speaker, our motion also refers to the effect ramping has on ambulance response times and availability and any associated increased risks. This is a crucial part of the terms of reference as it relates to one of the most serious effects of ramping. As Robbie Moore, the industrial manager at the Health and Community Services Union said earlier this week:

This situation has gone on for far too long. We're seeing lives being put at risk because of ramping every single day. When ambulance and the paramedics are with patients in hospital corridors, that means they're not responding to emergencies in the community. That's putting lives at risk. It's leading to increase response times and it's time the Government and all politicians took this seriously.

Tasmania has the slowest emergency response times for ambulances in the nation and this is being made worse by ramping. Just this morning a woman named Julie called in to ABC radio to talk about calling an ambulance and being told she needed to go to hospital but would have to take a taxi there because there were no crews available.

In July last year, a Hobart woman had to take her teenaged son to hospital because no ambulance was available and ended up performing CPR on the side of the road. Even though this 13-year-old boy was in such a dangerous situation it took a full 19 minutes for paramedics to get there - and I say again, this was in Hobart. That is what we are seeing more of now in Tasmania as more paramedics are stuck in hospitals.

I note the Government's amendment to our motion wants to move a reference to the increased risks posed to the community by ambulance response times, but with situations like this occurring that is why we feel it is so important to include that in the terms of reference.

The impact of ramping on healthcare staff is significant. In 2019 paramedics in the state's south wrote to Ambulance Tasmania's CEO to tell him ambulance ramping was causing 'widespread and undeniable psychological injury'. Since 2019-20 the percentage of patients ramped at the Royal Hobart Hospital has increased substantially. Rather than highlighting this issue in general terms I want to read into the Hansard a submission made to us by an anonymous paramedic specifically supporting the inquiry and providing his experience. I will read a small part of it:

The practice of ramping has had a profound effect on myself to the point I have considered resigning from the organisation and even sought employment in areas not related to health or emergency services.

I am a paramedic of 22 years' experience, having worked for three different ambulance services, and whilst ramping did occur at one other service and not at all at the other, this practice in Tasmania is by far the worst I have experienced and is getting worse over time.

It has resulted in me seeking out help and attending regular psychologist sessions to manage the effects it has on my mental health, other physical symptoms and impact on family relationships.

He goes on to say:

As demand has increased on ambulance services from the community, now the ramped paramedic is required to look after two or three or more patients at once, so a complete ambulance crew can be released from the corridor or ramp ward to respond to the caller in the community.

Not only are we nursing but we are also acting as nurses' aides and medical orderlies, pushing patients around the emergency department to X-ray or CT or other hospital areas for diagnostics and interventions. That adds the extra pressure on leaving ramped patients unattended while we're away from them.

Despite requesting the storage of our own scheduled medication in these ramped wards, nothing has been actioned, so we are reliant on hospital staff to attend the patient and administer their supply. This often comes with considerable delay once you make the phone call to the ED nurse in charge, wait for the doctor to come and review the patient and then wait further for another nurse to attend and administer the medication and chart it.

This is stressful and can result in patients in being in pain for longer and time is of the essence with conditions such as seizures, which happened, and result in a prolonged period of no treatment that would normally be rectified immediately by a paramedic inside their home or the ambulance from our supply.

You can see from that testimony that ambulance paramedics are in a nowhere zone when they are in a ramped situation. They do not have access to the normal recourse for treatment that they would when they are in a person's home and neither do they properly have access to the emergency department supplies. That was exactly the situation for Rebecca Schramm's mother when she died in pain without proper palliative care while she was on the ramp.

We have included a clause in the terms of reference on data collection and reporting because this is a really important issue. The Government collects ramping data on a monthly basis for internal use and does not release this information on their health stats dashboard. The only published location for ramping-related information is in the Department of Health's annual report, which only has basic information about the rate of ramping at each hospital.

The Greens have sought to understand the true extent of ramping through questions at annual budget Estimates, and I will note here that I had to ask nine or 10 times for some basic information in this process this year and was told by a senior bureaucrat that the information I sought was publicly available when it was not. It is a real concern to see senior management of the Tasmanian Health Service not understanding such basic details.

While we did get some basic information in Estimates, we have also been left to piece bits and pieces of it together ourselves in order to get a true picture of what is happening. I pay tribute to my staff and one in particular, who has done this incredible body of work that should have been available to us as members of parliament and to all Tasmanians. Meanwhile, we have seen the Government try to mislead the public by using information that is two years out of date to defend the state of ramping in Tasmania's hospitals in the present day.

Despite years of questioning by the Greens, the Government still will not collect or report information about the number of medical emergencies that occur among ramped patients or the number of deaths that occur on the ramp. Some of these cases make it into the media but so many others would occur without public awareness whatsoever. We understand other jurisdictions collect this information and make it publicly available. Tasmania does not, under the Liberals. This is not good enough and we hope this inquiry could make some real changes around that specific issue as well.

I do not feel the need to go into further detail on the remaining clauses as they speak for themselves. However, before I finish I refer again to the minister's intended amendments. What the Government is putting forward in the amendments I have seen would erase any mention of the term 'ambulance ramping' from this motion and from the name of the inquiry. In our view, that is ludicrous and is a desperate attempt to try to fix a political problem that the Government believes they now have. The fact is, ambulance ramping is the commonly used term in the community and in the media and it is also the language that is used by health staff. Although it might not be the preferred language of the minister and senior bureaucracy, we believe that trying to change it from what everyone understands is simply trying to muddy the waters and we do not accept it and cannot support it.

I will finish today by reading the words of a paramedic called Jan who spoke to the media on Monday. Jan told the media -

Ramping is an insidious problem that affects everyone. No-one is immune to it but it's the weakest members of our community that are really affected by it. This kind of inquiry is going to give them a voice, it's going to give a voice to paramedics, to ambulance staff, to all the staff affected by this, and hopefully provide us with a positive outcome and an excellent direction for a health service that is struggling. I sincerely hope all members of this place can agree on that and will vote in support of this motion.

Dr WOODRUFF (Franklin - Leader of the Greens) - Mr Speaker, I am very glad that the Government has realised it is politically untenable not to support this inquiry into ramping. I have listened very closely to the minister's comments about the amendments he is proposing and the Greens will not be supporting them. He has made his own argument in relation to (1)(b)(ii) where he is trying to strike out the words 'any associated increased risks to the community'. He said in relation to another matter he was trying to change that 'any other matters related incidental thereto' will cover all the things he is concerned are not covered properly, like federal responsibilities which he is concerned to raise. The Government, I expect, would make a submission in that regard but as Health Consumers Tasmania's Mr Bruce Levett has indicated very strong support for the inquiry, he is very keen to have rural and regional issues focused on and obviously there are increased risks to the community. The point that Ms Dow made before is really important as well.

The issues outside the narrow frame of the hospital response time and availability, the burden, the stress, the burnout of paramedics as well as the difference across Tasmania is a very strong motivation for why we put that into the inquiry focus in the first place.

We disagree with your interpretation about changing the words in paragraph (1)(b)(i) to 'patient care and outcomes'. We believe safety for ramped patients is important. We do not believe removing the word 'ramped' is appropriate. You can say whatever you like about it being the formal language of Ambulance Tasmania. That is okay but we do not have to speak in bureaucratic jargon. It is there as a term at the top of a spreadsheet for recording data. That is not the way Tasmanians understand what is really going on. They know it is ambulance ramping. On a small fact, Tasmania is committed to trying to use 26Ten simple plain language. Let us do simple plain speaking to Tasmanians. It is a 'ramping' inquiry because that is what people understand.

Minister, on the matter of the role of the federal government, of course, we accept, as you said, that it is a multifaceted issue. We know it is complex and we know that for the whole health system and funding in the health system federal and state governments have a role to play in what happens in any individual hospital. However, it is a bit rich to lecture the Labor Party that they should be energetically encouraging their federal colleagues to take a more active part in this space when you have been in government for eight of nine-and-a-half years and over that time it was a Liberal federal government under Scott Morrison, who did absolutely nothing in this space, and I never once in eight years heard any Health minister - Michael Ferguson, Sarah Courtney, Jeremy Rockliff - talk about pointing the finger at the federal government. Now, all of a sudden, with a change of federal government, all of the finger pointing is happening up north instead of at yourself.

This is a ramping inquiry on a very critical state health issue. We would expect that some of the recommendations might include that the state Government should advocate with the federal government to make changes to federal funding for hospitals and changes to federal funding for Medicare support rebates to GPs. That is the appropriate role for you as the Health minister to be advocating on these issues. We do not support the amendments and we hope that the rest of the House goes with the simple terms of reference as have been tabled.