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Health – Ambulances and Paramedics

Dr Rosalie Woodruff MP

Dr Rosalie Woodruff MP  -  Monday, 6 June 2022

Tags: Ambulances, Paramedics, Health

Dr WOODRUFF - That is another question and I have the call.

About ambulances, you have added some more money in this Budget towards some additional full-time paramedics, which is welcome. But it is completely incommensurate with the scale of the need. I want to provide you with some information that you may or may not be aware of about the state of the standard Friday and Saturday nights that paramedics in many places in Tasmania are facing.

On 13 May, the state operational shift report from the communications centre shows that there were five stations that had no staff: Huonville, Dodges Ferry, Bridgewater, Kingston, and New Norfolk were all unstaffed. So, there was nothing south of Hobart.

Mr ROCKLIFF - What was that date, Dr Woodruff?

Dr WOODRUFF - That was 13 May, a Friday night shift. South of Hobart, there were no ambulances at all available. On the Saturday night, the day after, 14 May, there were no ambulances staffed at Huonville again, Dodges Ferry again and then at Glenorchy.

On another date, 7 April, there was no crew for Sorell again, Dodges Ferry, Bridgewater and also New Norfolk. Another date I have, 12 April, shows that there were vacant shifts in Hobart, Claremont and New Norfolk. This is just a sample but I am hearing that Friday and Saturday night in particular are very difficult to staff. There are multiple systemic reasons for this, there is no one reason but there has been a perfect storm of long-term weariness, the impact of COVID-19 and fundamentally and very importantly, the casualisation Ambulance Tasmania has taken to paramedic graduates, so that once they finish their three-month contract, it seems they now no longer go onto full-time permanent contracts. They are being moved around to plug gaps in the rosters and this is having a devastating effect on their own mental health and on team morale with people who are working in the hardest situations every day.

Will you make a commitment to end the casualisation of paramedic graduates, in particular, who are leaving Tasmania because they can't save to buy a house? They have no security and they are working without any sense of commitment from Ambulance Tasmania to them as an employee.

Mr ROCKLIFF - I would like to say that in 2019-20 we had 567.4 FTE at Ambulance Tasmania. As of 31 March 2022, we have 652.15 FTE employees. Through the 2021-22 financial year Ambulance Tasmania has also recruited key leadership roles to support the ongoing transformation of the organisation. The director of operations commenced in January 2022 to lead the operations directorate for the organisation. We have our commitment for 48 new paramedics, most of which have been filled, and 11 more with respect to Sorell and Huon.

In early 2021 Ambulance Tasmania introduced a graduate program for paramedics employed on a casual basis. Early monitoring of the program highlighted some concerns, particularly in relation to working hours and clinical support. This program has been discontinued and graduates of the program have been placed on 12 months full-time fixed-term contracts as per the conditions of other graduates in the organisation.

Dr WOODRUFF - Why are they still on 12-month contracts? Why aren't they permanent contracts? Why don't they become full-time employees?

Mr ROCKLIFF - I will invite the chief executive of Ambulance Tasmania, Mr Joe Acker, to the table to perhaps go through some of the more operational nature of your questions, Dr Woodruff.

Dr WOODRUFF - Mr Acker, why aren't graduate paramedics being put onto permanent full-time contracts instead of 12-month contracts?

Mr ACKER - Through you , Premier, we hire graduate paramedics to fill vacancies and we put them onto fixed-term contracts to get their what we call graduate year, which is their induction year. We can only move them into permanent positions when we have funded positions to move them to, so we put them into fixed-term positions as they are, the vacancies, and then if during their first year or after we can put them into permanent positions, we do so.

Dr WOODRUFF - Okay, thank you, you've answered my question. I have heard the reason young paramedic graduates are leaving Tasmania is because they have no confidence in a system that doesn't have confidence in employing them on a permanent basis and they are being moved around to fill gaps. Minister, I just point you to the Mingara review, which was very clear about the numbers of new paramedics that needed to be employed, which was 224. You talked about employing new paramedics and you mentioned 11 in the south. That is a drop in the ocean compared to what the independent Mingara review recommended is needed. In case you haven't seen it, your counterparts in New South Wales today have announced some extraordinary commitments to ambulances, the sort of stuff we should have had in Tasmania. If we don't have that, do you recognise that we are at grave risk of many paramedics leaving Tasmania permanently or leaving paramedicine altogether because of the stress they are under?

Mr ROCKLIFF - I would like to highlight, however, that we have recruited 48 paramedic positions that we committed to as a government at the last election. This includes an additional 24 paramedics for the urban communities, with 12 based in Hobart and 12 based in Launceston; 24 paramedics have been recruited to support regional stations across the state, including Sheffield, Strahan, Campbelltown, Ouse, Swansea, Miena, Alonnah and Bridport, and this commitment has also seen the upgrade of the New Norfolk station to a paramedic-only station in recognition of the growth of the community. Bridport, as I mentioned the other day, began operations as a single branch station on 31 May 2022 with one paramedic on duty during the day and on call at night, supported by a volunteer ambulance officer.

The election commitment of 24 paramedics for rural communities was to be staggered over two years and these positions were brought forward to support the state border reopening and the response to COVID-19. The secondary triage model is currently being resourced to a sustainable 24-hour, 7 days a week operation, supporting more people in the community who call triple zero and are assessed as not requiring an emergency ambulance response to be referred to telehealth and other alternative referral pathways. Recruitment is underway for nine community paramedic positions across the state, with a new training program commencing in June this year, and these community paramedics will be able to support more Tasmanians to receive care in the community and reduce pressure on our hospital emergency departments for patients with non life-threatening medical care needs.

The recent commitment to convert Sorell and Huonville stations to career paramedic-only ambulance stations from July 2022 will see a further 11 paramedics recruited to these locations and we are working very closely with volunteers from both stations to identify new models of service delivery. A 10 year master plan is being commissioned by Ambulance Tasmania to assess the future needs of communities in Tasmania and to determine, using evidence, where best to expand and deploy new ambulance services around the state. The report from the consultant Operational Research in Health is expected to be complete in November 2022.

From the RoGS data I'm looking at, in terms of dollars spent per person in the population for ambulances, if we go across, Tasmania is the highest of that, and if we look at New South Wales at 136.68, we are at 201.7 per person, so any announcement in New South Wales would most certainly be welcomed based on those figures, but we are 201.7.

Dr WOODRUFF - How many new paramedics have graduated in the past 12 months and how many of them have been given permanent full-time positions?

Mr ROCKLIFF - Well we can comment perhaps, and I'll refer to Mr Acker on the graduates we've taken on in Ambulance Tasmania, perhaps, Joe do you have that information, I'm not sure -

Dr WOODRUFF - I thought graduates had to have 18 months for training. I thought there was an 18 month period for on-the-job training required after they graduated.

Mr ACKER - Through you Premier, Dr Woodruff, paramedics are unlike other health professions in APRA, so when paramedics graduate they are essentially 'fit-for-service.' Our internal process is that they have to accomplish a number of competencies in 12 months after we've hired them and if they need more support we provide that ongoing, but it is to ensure that they're safety and clinically competent, but there is no requirement under APRA like there is for other health professions.

Dr WOODRUFF - 12 months, not 18 months, you said.

Mr ACKER - 12 months is the minimum, in some cases we go to 18 months, depending on the needs of the individual.

Ms O'CONNOR - On 24 April the ABC reported that Ambulance Tasmania last year concluded a resilience scan of employees to collect confidential anonymous feedback. The scan was conducted by Frontline Mind and participants were asked to share experiences from their work with Ambulance Tasmania. The ABC reported that a Frontline Mind employee emailed Mr Acker with the line:

After a bit of trickery, I have managed to format the full data set as attached and hopefully this works for the purposes required. I think it is important to note that this could be taken out context quite easily so I advise some discretion as to who has access.

Minister, how was the full data set of a confidential and anonymous survey able to be fully reconstituted after 'a bit of trickery' by Frontline Mind?

Mr ROCKLIFF - First, we have done the resilience scan for Ambulance Tasmania and it is an important step in assessing the health and wellbeing of our workforce. I commend the leadership of the chief executive in terms of listening to our employees. I must say there was some challenging data presented. I think shortly we are undertaking another resilience scan to see if there has been improvement and how further we can support our workforce. Mr Acker, would you like to respond to Ms O'Connor.

Ms O'CONNOR - That was not the question.

Mr ROCKLIFF - I am talking more broadly about the resilience scan.

Ms O'CONNOR - I am talking about how data which contained private information was able to be fully reconstituted after a bit of trickery.

Mr ACKER - The quote that was used by the ABC came from an RTI request. 'A bit of trickery', as Frontline Mind referred to it, was specific to how they were able to convert what is an online database, which is a survey database, into a PDF document so that it could be reviewed by the executive committee. The Frontline Mind survey, the resilience scan, specifically said that the information was to be anonymous and we were not collecting any identifiable information. There are no fields to collect any identifiable information and the confidentiality was assured by maintaining the results within the executive team.

It was also made clear at the time of the survey that the executives would have access to all of the data. The only way that we can solve the issues and the challenges at Ambulance Tasmania is to know what our people think. There was full expectation that what they put in the survey the executive would read. The only people who have had access to the data results are the executives.

Ms O'CONNOR - The public response by Ambulance Tasmania stated that Ambulance Tasmania cannot control where the people include identifying information in the responses they choose to share in the survey and that a confidentiality framework and an agreed Chatham House rule extended to, 'the executive team who are looking at the patterns identified'. How many people saw the full data set and are now operating under this Chatham House rule? And why was it necessary to de identify the information prior to being shared with Ambulance Tasmania instead of simply redacting identifying information from the responses and sharing the thematics of the content identified?

Mr ACKER - When we worked with Frontline Mind they were very specific that they would not themselves do the thematic work or do any redacting. The way that this resilience scan is delivered - and it is delivered across many other organisations internationally - is that all of the richness needs to be presented so that the feelings of the staff can be clearly articulated. The information was not redacted; it was provided as entered. There were some cases where people's names were used, individuals who specifically put in there, 'My name is so and so and here is how I feel'. Those were the names that came out into the survey. There was very few of those. It was only the executive team that had access to the results and it has not been shared beyond that.

Ms O'CONNOR - Can I ask what Ambulance Tasmania and the Government's response has been to the results of the survey? First of all, can I ask if there is an understanding that for some Ambulance Tasmania staff it has been a confronting and intrusive reality that their personal information could identify them? Secondly, what has been Ambulance Tasmania's response and therefore the Government's to the views of Ambulance Tasmania staff that were identified in the survey?

Mr ACKER - Through you, Premier. When the ABC news came out we responded immediately to our staff in an all-staff email and we follow that up with a Teams meeting with all of our staff and we do every month. The message that we shared with them is that your information is confidential and assured, but also a reminder that they did not have to provide identifiable information. It was not requested and only those who provided that did so under their own situation. The survey was completed by 323 staff members. The survey, as I said, has had a significant impact on the organisation in terms of allowing us to understand how our staff feel about the organisation and has given us a road map to do things better.

Mr ROCKLIFF - Can I say, further to your question, Ms O'Connor, in response to the resilience scan, Ambulance Tasmania leadership committed to three immediate actions to commence the journey of cultural improvement for Ambulance Tasmania, including - 1.

A program of monthly all-staff forums conducted via Microsoft Teams, to communicate with staff and volunteers and share information from the Ambulance Tasmania executive team. 2.

Face-to-face workshops in each region to identify ways the organisation can take ownership and make a positive change in culture, processes and leadership, and 3.

Filling vacancies and stabilising the senior leadership team by the end of 2021.

In October 2021 Frontline Mind facilitated four workshops, I'm advised, across the state to provide an opportunity for employees and volunteers to identify issues at Ambulance Tasmania and to seek suggestions from staff as to how these can be addressed. A further 11 consultation sessions were held across the state, facilitated by the chief executive. Employees and volunteers were provided with many opportunities to contribute to the consultation process including online via Microsoft Teams, at face-to-face workshops and sessions and via email to a general inbox. All feedback has been considered by the senior leadership team with actions now being finalised and prioritised to inform Ambulance Tasmania's cultural improvement action plan and a follow-up resilience scan, as I believe I mentioned before, will be conducted shortly after the plan is released in June 2022 to enable organisational cultural improvement to be measured.

Ms O'CONNOR - New ambulance stations have been desperately needed in a number of regions for years. The data probably shows this but our understanding is that the eastern shore has had a significant uptick in calls, but it is basically only serviced through Mornington and Sorell. Tasmania's largest subdivision is proposed at Droughty Point with more than 2000 dwellings planned. I understand a station site has been mooted for the Police Academy at Rokeby. Is this true? And will you be funding a new ambulance station to service the eastern shore? Will it be on this site or somewhere else?

Mr ROCKLIFF - Mr Acker, would you like to answer Ms O'Connor's question regarding the eastern shore?

Mr ACKER - As we have discussed previously, we are engaging all our [inaudible] to use evidence and data to determine where we build stations. That is the most accurate way to identify where the trends are going, not only in terms of our call volumes but also in the demographics of the population of Tasmania.

At this point in time, beyond the current established or agreed-upon stations, we have not identified that list in terms of priorities. We do not have any stations on the list in terms of priorities beyond what we are currently building.

Ms O'CONNOR - So, there is no planning for an extra eastern shore ambulance station despite the fact that the population is increasing and the number of calls from that area are increasing?

Mr ACKER - That is the purpose of the ORH review, to look at our call volumes, the locations using GPS coordinates, the volumes, the severity of the patients, the scale of the paramedics required and also the demographics. That data will now inform our masterplan in terms of where we are going to build stations going forward and where we are going to staff ambulances and what level of service we will provide to the paramedics on the ambulance.

Ms O'CONNOR - Thank you. For people who are asking these questions, and these come from constituents, what is the time frame on that body of work and when is it likely to lead to the delivery of new ambulance stations?

Mr ACKER - We intend to have the report back from ORH by November this year. Then we will come forward with budget submissions with our top-priority stations in terms of where they have identified we need to invest in infrastructure around the state. That will then depend on funding from the Government in terms of stations, ambulances and staffing for those stations.

Ms O'CONNOR - Final question on this line of questioning: is this likely to lead to the closure, and I was listening to what Ms Morgan Wicks said earlier, to the closure of some ambulance stations and the opening of new ambulance stations? Are we likely to see a rationalisation in some areas?

Mr ACKER - We have asked for the scope of the whole system, identifying where we need resources and how resources are being utilised right now. That may result in us making an assessment on where vehicles are used. For example, in some places we have volunteer-only services. They may be upgraded or they may be downgraded in terms of places where we have put ambulance stations very close to those communities.

Ms O'CONNOR - So there could be closures of ambulance stations?

Ms MORGAN-WICKS - I did not suggest there was going to be any rationalisation of ambulance stations, but what I -

Ms O'CONNOR - I am sorry if I have misspoken you. I understood that there was a looking at the whole system and where you needed more resources and where you might need less.

Ms MORGAN-WICKS - Yes, and certainly we look at every station. But it is usually around an upgrade of that station so, for example, if we move from a single branch to a double branch station, or from a volunteer to a manned station. The work being undertaken will consider existing stations to determine whether they are sufficient in terms of resourcing or whether they need an upgrade. It is not to suggest that we would close particular stations.

Ms O'CONNOR - Thank you, finally. Minister, I am glad to hear that the data on ramping and wait-times is available. Are you able to provide the committee with the current figures for this financial year for the percentage of patients arriving by ambulance at each of the state's major hospitals who are transferred within 15 minutes of arrival and within 30 minutes of arrival?

Mr ROCKLIFF - So, if you look at statewide and at major hospitals, in 2021 we had 68 per cent -

Ms O'CONNOR - At which hospital?

Mr ROCKLIFF - This is statewide - transferred within 15 minutes. For July 2021 March 2022 it was 64.4 per cent. In 2020-21, transferred within 30 minutes, 75.5 per cent. And July 2021 March 2022,71.9 per cent. And then if you want to go hospital by hospital -

Ms O'CONNOR - Yes, thanks.

Mr ROCKLIFF - 2020 21 transferred within 15 minutes, 66.2 per cent

Ms O'CONNOR - Which hospital is that?

Mr ROCKLIFF - Sorry, my apologies. The Royal Hobart Hospital.

Ms O'CONNOR - 66, yes.

Mr ROCKLIFF - July 21 to March 22, 58 per cent within 30 minutes; 2020 21, 74.3 per cent; and then in the nine months, July 21 to March 22, 66.6 per cent.

I will now go to the LGH: 2020 2, within 15 minutes, 61.4 per cent; July 21 to March 22, 60.2 per cent transferred within 30 minutes; 2020 21, 68.1 per cent; and July 21 to March 2022, 66.2 per cent.

In the North West Regional Hospital: 2020 21, transferred within 15 minutes, 77.5 per cent; July 21 to March 22, 78.7 per cent; transferred within 30 minutes, 85.7 per cent; and July 21 to March 22, 86.9 per cent. That was the North West Regional Hospital.

I have Mersey Hospital as well, Ms O'Connor. For 2020 21, 85.1 per cent transferred within 15 minutes; July 21 to March 22, 86 per cent; transferred within 30 minutes, 89.8 per cent and July 21 to March 22, 91.3 per cent.

Ms O'CONNOR - Thank you. So, once a patient is subject to offload delay of more than 30 minutes, what is the average amount of time they have to wait? We would like the data for the Royal, the LGH and the North West Regional Hospital, if possible.

Mr ROCKLIFF - All right. We don't have it with us today, Ms O'Connor, but if you'd like to put that question on notice, we'll see if we can find that data and if it is reported somewhere internally and if we are able to access that for you.

Ms O'CONNOR - Thank you. And minister, how many triple zero calls have been referred to Ambulance Tasmania's secondary triage service since it commenced in February 2021? And I am happy to put this on notice, but are you able to provide a monthly breakdown?

Mr ROCKLIFF - Okay. As at 22 May 2022, approximately 2140 patients who had rung triple zero since the commencement of secondary triage on 22 February 2021 were diverted from an emergency ambulance response. Did you want the monthly data as well?

Ms O'CONNOR - Yes.

Mr ROCKLIFF - Which I don't have in front of me.

Ms O'CONNOR - Is that okay to put on notice?

Mr ROCKLIFF - Sorry, Mr Acker, would you like to comment on that?

Mr ACKER - Secondary triage doesn't get referred calls any longer. We started in the initial phases of taking specific triple zero calls and sending them to secondary triage. Now, the secondary triage clinicians have access to all the cases, so they will look at appropriate cases that they can apply their methodology to, to find referrals and apply the referrals where necessary. So, any case that is identified as a low acuity sits in a queue and the secondary triage clinicians will look at the queue and take cases out of it that can be appropriately referred. We don't specifically take triple zero calls and send them to secondary triage any longer because we [indistinct].

Ms O'CONNOR - We all have heard the terrible story of the man who called an ambulance, and waited seven hours and died alone. What is the secondary triage process? How does a tragedy like that happen? This is no reflection on Ambulance Tasmania staff. How does a tragedy like that happen, and what sort of investigation has there been into that tragic situation, and is it possible that through that secondary triage process some people are being misdiagnosed in terms of their urgency for help?

Mr ROCKLIFF - I agree with you on the tragedy, Ms O'Connor, and there is a root cause analysis which is currently underway. I am not sure if Mr Acker can provide any further information to that, at this particular point in time?

Mr ACKER - We do have serious cases that require investigations; this is one of them. Any case that results in a poor outcome from a delayed ambulance respond we take very seriously and we look into it. We set up a panel to review that case with an external expert from New South Wales who is joining the panel to identify opportunities for us to do better. The cases like this are not a result of secondary triage. Cases like this could be a result of some challenges to our primary triage and that is the initial 000 call and how it is initially triaged - whether it's high acuity requiring an ambulance immediately or whether it's lower acuity. Those are the cases where secondary triage would pick them up.

Secondary triage is essentially a very safe system in that they try to find referral pathways, and if those safe referral pathways are not available then those patients will always get an ambulance at some point in time. Secondary triage is not likely a failure in this particular case, but we are investigating our primary triage system to identify where we can make improvements.

Ms O'CONNOR - Can I ask, finally, when that investigation into that man's death will be completed, and will there be a public announcement about it or an explanation?

Mr ACKER - Importantly, our Director of Operations has done an open disclosure with that family to express our condolences and to also commit to following up with them to let them know what happened in that particular case. As I mentioned, we do have an external person that is joining our panel and we hope that commences very shortly. Once the results of that are available to be released we will be using those internally, of course, in terms of making our process improvements.

Ms O'CONNOR - You would foresee it will be available this year?

Mr ACKER - Yes, I would hope that it is done this year. We have a number of cases to investigate and a very small team investigating cases. This is a priority case for us, because there is a system issue that we need to understand better. We will work this as quickly as possible - recognising that doing a complete and thorough process is incredibly important.

Mr ROCKLIFF - Ms O'Connor, there is the coroner's review as well and we can' interfere in that process.

Mr WEBSTER - Yes, it is subject to a coroner's inquiry so that may delay the release of our information because we do need to provide it to the coroner, and the coroner may not wish us to release it. A note of caution on that. Your first question around secondary triage and would it delay a case - in fact, there is a percentage of cases that go to secondary triage that result in an upgrading in acuity level and results in a 000 ambulance responding, so it actually works the other way.