Non-Emergency Patient Transport Amendment Bill 2021

The Non-Emergency Patient Transport Amendment Bill 2021 amends the Non-Emergency Patient Transport Act 2003 to provide for the licensing and regulation of commercial first aid services, to further provide for the licensing and regulation of non-emergency patient transport services, to abolish the accreditation scheme for licence holders who operate stand-by services, to increase penalties for certain offences and to introduce new offences.

The following is a speech by Dr Tim Read, Greens MP for Brunswick, in the legislative assembly, on the 6th of May, 2021. 

I am addressing the Non-Emergency Patient Transport Amendment Bill 2021. This is a bill that probably would not have been needed had non-emergency patient transport not been privatised about 28 years ago.

I will not venture into the territory already covered extensively by the members for South Gippsland, Melton and Ringwood—and I thank them for dissecting it so well. The bill does regulate and provide additional measures, setting minimum standards for staff and equipment. I will take this opportunity to talk about some of the current challenges faced by emergency departments and the ambulance service, which relate at least in part to ambulances being held up at hospitals because there is not space in the emergency department for their patient.

This then takes ambulances out of circulation as they cannot leave until hospital staff are able to assume care of the patient. This is not a problem that is new, nor is it unique to Victoria, but it has got worse around Australia this year. For example, in Perth all three hospitals were on code yellow a few weeks ago and patients were being treated in corridors. There was an episode about five or six weeks ago in Melbourne, reported in the Age, where 120 ambulances at one point were ramped—so-called—waiting to unload patients, and that is approaching a third of the ambulances available.

So what is the cause of this problem? The emergency departments are full of patients, obviously, and the emergency departments are under pressure from two directions. First, more patients are coming in for care, often with more complicated or difficult conditions, and secondly, the hospital wards where the emergency departments want to send the patients they are admitting are also full—and they are full because they cannot discharge patients, an issue known as bed block or access block. The first of these issues may also be contributing to an increase in ambulance call-outs.

The increased demand on hospitals and ambulances this year has related to several factors. First, many GPs are still not seeing patients with acute respiratory symptoms as a precaution to try and keep COVID out of their clinics. Then some viral infections have reappeared since the long lockdown and quite unseasonal epidemics over our summer and autumn months, when in fact we might be expecting to see them in winter. There are also medical conditions that were either neglected or not diagnosed because people were staying away from clinics during the lockdown. These medical conditions have worsened and are forcing people into hospital with more serious illnesses. These could be cancers that have become more aggressive or complications of neglected chronic disease or complications of delayed or deferred elective surgery, but they also include psychiatric presentations.

Other factors contributing to bed block include a shortage of nurses, which may in turn be due to a fall in the number of overseas nurses in Melbourne. It could also be due to insufficient rehabilitation beds for some wards to discharge patients to and likewise insufficient aged-care services, both residential and in-home care, for patients who are already unwell to be discharged to. On top of that you have got inadequate services for the chronically ill in the community, which mean that flare-ups in physical and mental illness are too hard to manage without hospital admission. I should point out that this contributes to more patients needing to either have ambulances called for them or take themselves into hospital, but it also means it is hard to discharge patients who are incompletely healed. So hospital presentations have therefore increased and stays are prolonged.

Now, much but not all of the above has been exacerbated by the pandemic. Hospitals were always running at pretty close to 99 per cent capacity, if not over 100 per cent capacity, during winter months pre-pandemic, but then, as described, all of these other factors have conspired to make the situation worse. Putting more ambulances into service will not fix any of those points. Some of the temporary pandemic-related factors, such as unseasonal viral infections at the moment, will improve in the spring. Mental health care in the community is expected to improve as funding starts to flow in the wake of the royal commission. But other factors will not improve without attention from the state government, and others simply cannot be fixed by the state government alone because they sit on the other side of the divide separating the state health system from the Medicare-subsidised private practitioner businesses.

There are things that the state can do to speed the flow of patients through and out of hospitals to relieve access block and allow ambulances to move on to the next job. Two initiatives worth attention in the short term are increasing the services for discharged geriatric patients and providing more rehabilitation beds. Further, I would add that we need to use advance care directives better to prevent unnecessary ambulance trips from aged care.

Hospital bed management is something that can always be improved to improve the flow of patients in and out of hospital. I highly recommend to people interested in this to have a look at an article by Simon Judkins published about 10 days ago in InSight+, which is a companion publication to the Medical Journal of Australia. Among his suggestions are that hospitals need to start moving more towards a 24/7 model, and I quote:

We need more senior clinicians in more substantive roles spending more time in the acute areas, making senior decisions and facilitating patient care, improving care and decreasing the growing risks.

The point is that often the decision to discharge a patient is made when a senior consultant comes onto the ward the next morning, when that decision could have been made many hours earlier. That does not mean kicking the patient onto the street at 3.00 am, but it means that if the decision is made in the middle of the night, then the phone calls can be made and the patient can leave at first light. It means these decisions can be made right through until midnight, seven days of the week. It means that patients can exit the hospital sooner, and if you can just get people moving out several hours sooner on average, that opens up emergency department beds. That will not be cheap, though. It means paying specialists to be on the premises for 24 hours as well.

The bigger challenge of course is working across the federal-state divide to support primary care to manage more patients in the community and in aged care so that they do not need to call an ambulance or so that they can be discharged earlier, freeing up hospital beds. That is a bigger problem and it requires, obviously, a contribution from the federal government as well as the state, and all of this must be done while bearing in mind that health care consumes an ever-increasing proportion of both state and federal total budgets.

I really think that if we can get primary care in the community to call ambulances less often and to be able to accept discharged patients when they are still more fragile and look after more complicated patients, we can reduce the demand on hospital care. One thing is for sure: to care for a patient for an additional day in hospital is vastly more expensive than caring for that patient for a day in the community, even if additional money is spent in the community to enhance its ability to cope with those patients. The problem is that we have got two different governments paying for that money, and so saving money for the state requires federal investment. There are other areas where a state investment will save the feds money. That is particularly in the area of preventive health care. The savings in the first case might be felt within months, the savings in the latter case typically within years or decades. But spending money on reducing junk food and alcohol consumption, for example, will take the pressure off emergency departments. It is just that the benefits are more likely to be felt by the federal health budget in reduced Medicare and pharmaceutical benefits scheme expenditure.

It is easy for me to outline the challenges, and I wish the Minister for Health every bit of luck and encouragement in tackling some of these bigger issues. But that is really what is causing a lot of the ambulance problems that we have been hearing about at a somewhat oversimplified level this week.