Words by Shell Piercy
In 2020, a group of pioneering paramedics in New Zealand began establishing opportunities to support better patient outcomes in areas outside of ambulance services. Specifically they set to work in district health board emergency departments, urgent care clinics, general practice, and rural and remote clinics. However, the transition for paramedics from ambulance services to any of these areas is not without its challenges. Fighting for recognition and equal funding is one of the many barrier’s paramedics face. Currently in New Zealand, the Accident Compensation Corporation (ACC) funds ambulance services via bulk funding. Within urgent care, general practice and rural general practice, funding is given per patient based on time and services rendered. In the ACC legislation, paramedics are not specified as providers, hence cannot access this funding. From the aforementioned areas of health, providers in the ACC schedules are listed as medical practitioners, nurse practitioners, registered nurses and enrolled nurses. The same applies for general medical services funding from the Ministry of Health. Typically, an enrolled patient will be funded for non-accident illness through bulk funding called capitation. Non enrolled patients will be funded for the visit. Paramedics cannot currently claim for this funding either. The GMS funding is for medical practitioners and Nurse practitioners only. In saying this, nurse practitioners had to overcome their own obstacles to access this funding as well.
Ironically, paramedics are perfectly suited to acute, chronic and urgent care. For example, urgent care patients and acute patients presenting to general practice and rural general practice are often not enrolled patients. The small group of advanced and extended care paramedics that currently work in these areas are working together with the support of two, physician-based colleges in these areas. This bridges the gaps and allows access to funding.
As many are not willing to admit, we have a health work force crisis. On the ground, nursing staff are light, there are not enough doctors, and patients are waiting for extended periods of time to access appropriate healthcare. It is important to remember that we are here for the patients. Our focus must be on patient care and the best outcomes for them.
Other challenges facing paramedics that are stepping away from ambulance services, are understanding the standards and legislation for the specific area they are working in. Some of these standards and legislations include: ‘The standard for Urgent care 2015 and the quality programmes of ‘Foundation’ and ‘Cornerstone’ for General Practice. Within this legislation and industry standards there are also education and training requirements that are different to current requirements for Paramedics within ambulance services such asACLS qualifications, ATS triage qualifications and standing order qualifications etc.
Understanding the standards for each of the healthcare sectors is vital to ensure paramedics and registered nurses are working safely within them. ‘The standard 2015’,for example, stipulates the type of triage assessment needed within urgent care and what qualification the person conducting triage needs. Education platforms like Ace Hub are working hard to ensure this type of education is accessible and affordable for all.
Utilising Paramedics outside of the comfort and security of ambulance services in New Zealand requires a robust set of standing orders. The MoH provides guidance on the specific details of how Registered Nurses and Registered Paramedics can utilize these orders. These orders explain in detail, the skills, medication for administration and supply. Competence is proven as per the MoH guideline. This constitutes the paramedics Authority To Practice (ATP). Unlike the robust ATP and CPG systems within ambulance services in NZ, it is hard to imagine that every clinic’s medical director will want to establish their own standing orders and manage the extent of assessment of competence required. Therefore, collaboration is going to be key. The risk is health care professionals not understanding each other’s scope of practice, not having an understanding of audit processes, and unclear competence assessments. We must work together to raise the profession of paramedicine outside of ambulance services and ensure our new frontier does not become the wild west.
The goal here is to reduce patients needing ambulance services, reduce emergency department admissions, offload overly stretched medical colleagues, while supporting better outcomes for patients.
I have worked for several years in both ambulance services and emergency departments. No matter how hard I worked, I could never improve anything other than the experience of my individual patients. So I stepped aside , took a broader view of the situation and dove head first into health work force change management. My current role is to support healthcare providers improve patient outcomes by changing the way the health work force is utilized. This includes supporting healthcare practices with education, CPG’s, policies, procedures, standing orders, procedures for assessment of competence, and utilizing extended scopes in both nursing and paramedicine. I also aid the transition from ambulance services into the world of primary health care acute service. This is done with educational support for extended scope paramedics and nurses.
So how do we change the current paradigm?
Now, I am not an authority on this subject, I am just a one-woman crusade to ensure health work force management is given a broader view within New Zealand. So, let’s take off the blinkers, lets understand the scopes and limitations of our multi-disciplinary team, let’s work together to be the best evidenced based clinicians we can be, and let’s aim to work at the top of our scopes with currency and competence and without ego. Reflect and develop with excellent professional practice to ensure equity in health care and better patient outcomes are available for all patients.
Shell Piercy BN, PGDipNS, BSc (Paramedic), RN, ECP, NPI