This question relates to paramedic practice. My correspondent says:
I’m trying to clarify something about the law in regards to paramedics in Australia and I was wondering if you could help.
I know in South Australia that paramedics derive their authority to practice medical acts on members of the public directly from the corporate entity of the Ambulance Service. This is spelled out in the SA Health Care Act of 2008 (section 6, I believe, covering SAAS [The relevant provisions in the Health Care Act 2008 (SA) is Part 6, not section 6; part 6 contains sections 49-62]. My understanding is that this is true for all state-run ambulance services in Australia. This is in contrast to, for example, New Zealand and the United States where paramedics are delegated their authority to practice from a physician acting as the Medical Director of the Ambulance Service. Or, for example, the UK, The Republic of Ireland or South Africa where paramedics obtain their legal authority to practice from their own license as paramedics.
What I’m trying to get an answer to is this – does EVERY state in Australia delegate authority to practice paramedicine through the ambulance service? Is this a homogeneous national model? I’m also wondering if the private ambulance services in Australia work under the Medical Director model, wherein their paramedics derive their authority to practice from delegation from a physician.
Thanks for any insight you can offer.
Paramedicine is a largely unregulated profession. One does not need ‘authority to practice medical acts on members of the public’, one needs authority to do that which is regulated. In terms of paramedic practice the tasks that they need a licence for are to drive the ambulance and possess and administer scheduled drugs. We know they have a personal authority to drive in the form of their driver’s licence.
The term ‘authority to practice’ has moved into the lexicon but its really not appropriate in this context. The term does not appear in law. The South Eastern Sydney Local Health District defines ‘authority to practice’ as:
A license (this may be a certificate, notice, or other form of documentation) that is issued by the relevant National Registration Board on an annual basis certifying that the holder is eligible to practise in the profession and that the holders details are entered into the relevant Board register. That is, the person is authorised to call themselves a physiotherapist/ podiatrist / psychologist /pharmacist / occupational therapist. Once a name is removed from the register, it is then illegal for that person to call themselves a physiotherapist/ podiatrist / psychologist /pharmacist / occupational therapist.
You can see they’re using the term ‘authority to practice’ as a shorthand or ‘catch all’ phrase to cover the various documents that may be issued for registered health practitioners. The critical issue here is that paramedics are not registered health professionals.
So a paramedic’s authority to practice is, basically, their job description or the tasks that the employer determines that they are to do. In short the state run ambulance services determine what their members are authorised to do as part of their duties. They may issue a document called an ‘authority to practice’ but that is because they have adopted the term, not because the law uses the term. The idea of an ambulance ‘authority to practice’ is relevant when it comes to the use of drugs.
Using NSW law as an example, it is an offence to be in possession of or supply scheduled drugs. There are exemptions for paramedics, for example a person employed by the Ambulance Service of NSW as an ambulance officer and who is approved by the Director-General is ‘authorised to have possession of, and to supply, drugs of addiction’ (ie schedule 8 drugs) (Poisons and Therapeutic Goods Regulation 2008 (NSW) clause 101; see also clause 129 and Appendix C for similar authority relating to schedule 2, 3 and 4 drugs). So it’s up to the Director General to determine who is competent and then authorise them to carry and use these drugs. The Director-General may issue something that they call an ‘authority to practice’ to show that the particular paramedic is authorised under the regulations to use various drugs. (For another similar example see Drugs, Poisons and Controlled Substances Regulations 2006 (Vic) Reg 5, entry 11 relating to Ambulance Victoria and entry 12 relating to St John Ambulance (Victoria)).
The idea that paramedics ‘are delegated their authority to practice from a physician acting as the Medical Director of the Ambulance Service’ makes no sense at all. Staying with NSW law medical practitioners may have authority to supply scheduled drugs (see Poisons and Therapeutic Goods Act 1966 (NSW) ss 10) but they need special authority to prescribe drugs of addiction (s 28A). There is nothing however that would allow a doctor, who is authorised to possess and/or supply a scheduled drug, to give that permission to someone else. A doctor may give an emergency prescription by telephone or radio (s 36 (restricted substances) and s 81 (drugs of addiction)) but that would depend someone who is with the patient to communicate the relevant signs and symptoms and the medical practitioner to make an informed decision on the treatment. It would not allow a medical practitioner to give some general permission – if you find a person in this condition you can administer this drug – nor does it give permission for that person to be in possession of that drug. Medical practitioners just can’t authorise someone else to do things that are otherwise illegal but would not be illegal if a medical practitioner did it; nor can a medical practitioner empower someone to practice medicine on his or her behalf, and make decisions in his or her name for a patient the doctor has never seen, and if they did they would be likely to find themselves ‘struck off’.
In New Zealand a person needs the Minister’s consent to deal with restricted medicines (Medicines Act 1981 (NZ) s 20). I can’t easily locate any approval but it may be that there is some authority to allow paramedics who are working with St John Ambulance or the Wellington Free Ambulance or any other NZ ambulance authority and who has been authorised by the services’ Medical Director in the same way that a NSW ambulance officer is authorised by the Director General, but I can’t confirm that.
It should be apparent that the authority to use drugs is set out in the relevant poisons or drugs Act, not the relevant ambulance service legislation. It should also be noted that there is no relevant ambulance legislation in either the Northern Territory or Western Australia. Further authorities may be given but they are not publically available so finding out the exact terms upon which provider is authorised to carry and use drugs is not something that is easily done and would presumably require freedom of information type applications.
So, ‘does EVERY state in Australia delegate authority to practice paramedicine through the ambulance service?’ The answer is “No” as you don’t need an authority to practice paramedicine as paramedicine is not a registered health profession. A paramedic’s employer determines what is, or is not, in their scope of practice, that is what they are employed to do. A paramedic does need an authority to carry and use scheduled drugs. The state health authorities issue the relevant authorities so, for example, NSW Ambulance can authorise its employees to carry and use drugs. , so paramedics employed by the state services are authorised by the state services but that does not extend to paramedics working in the private sector. Private providers must also be granted approval subject to whatever terms the relevant department choses to impose (see Poisons and Therapeutic Goods Act 1966 (NSW) ss 11 and 29). That would be how private providers get authority to carry and use drugs but it does not explain how they get authority to operate in those states and territories where there is a prohibition on private ambulance services (see for example Health Services Act 1997 (NSW) s 67E; Ambulance Service Act 1982 (Tas) s 37). (I have argued elsewhere that it appears, on the face of it, some of these operators must be acting in breach of these laws (see Michael Eburn and Jason Bendall ‘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 (previously (2010) 8(4) Australian Journal of Emergency Primary Health Care, Article 990414).)
Australian Emergency Law 
Hi Michael, Thank you for responding to this query. Unfortunately, I couldn’t make it all the way through your post before feeling compelled to send you a little article I wrote for ambos after the ASNSW corrupted Queensland’s term ‘Certificate Of Practice’ into our ‘Certificate To Practice’. Cheers, Malcolm.
Malcolm, I’m concerned – was it unfortunate that you couldn’t make it through the post because you disagreed with it? On the other hand your comment that ‘ASNSW corrupted Queensland’s term ‘Certificate Of Practice’ into our ‘Certificate To Practice’’ may mean you agree? I look forward to receiving your article but perhaps you can sum up your conclusions here?
Informative, factual and pithy as usual Michael – thanks.
Of course registration is a critical pathway to independent practise for practitioners of Paramedicine and is vital to ensure a permanent fracturing of the rather inflexible tenure that is almost omnipresent to state/territory based Ambulance Services through respective governments.
A national approach to the regulation of practice is this that will promulgate the emancipation of Paramedics.
This comment, from my original correspondent, was received by email:
The idea that doctors can delegate permission to do things to a person that the doctor hasn’t seen or diagnosed is an anathema to me. I can understand how that developed when the art of paramedicine was new and had to be fitted into then current regulatory rules but today it is out of touch with reality. Firstly it reinforces the notion that doctors are the only true health professionals and the purveyor of all wisdom and knowledge in the field and as the controllers or gate keepers for all access to health care. Paramedics (or nurses or other health professionals) who act solely at the direction of, and as the extension of the doctor, are not truly professional and could not claim to be part of a profession. It does nothing to enhance patient safety by ensuring that the person with the doctor’s delegation is competent or a fit and proper person to be conducting that practice and it puts the doctor’s professional registration at risk for actions taken by others. It may have made sense in the 1970s, it makes no sense today.
Interestingly the sort of practices that you say are regulated in those other countries give support to the claim for paramedic registration. The Options Paper on Paramedic Registration prepared by the Department of Health, Western Australia, on behalf of the Health Workforce Principal Committee for the Australian Health Ministers’ Advisory Council says, at p 35:
It is not the case that one needs a licence to do these things but the policy is that if one is going to do some or all of those things on a regular basis that is good evidence that one should be registered. I agree with David Burns (see his comment, above) that professional registration is essential. A registered professional such as a doctor, nurse, lawyer etc is recognised as being able to make judgments in their professional practice, is subject to review by professional peers and owes duties to their patient/client and profession as well as, and in some cases above, their duties to their employer. At the moment paramedicine is not a profession (which is not to say paramedics are not very professional). That is the case when their scope of practice is determined solely by their employers and the states’ enjoy an effective monopoly on paramedic practice. It is even more true if they are acting only as a doctor’s delegate as described above.
In the United States way back in the late 60’s a trial was done to see if emergency medicine could be effective using low payed low skilled workers. trained up by Dr’ to be their hands in the field. They were in direct contact with the Dr’s via two way. This was in Philadelphia around 1968. The trial proved effective and thus the beginning of ‘paramedicine’. Protocol, guidelines, standing orders replaced the need for Dr’s direct contact but in some places direct Dr input still exists.
In the same way RFDS operates their Dr’s boxes in remote stations, mining, seismic and communities. Its all about cost and providing a cost effective solution to manning an ambulance for 12 hour plus shifts, 7 days a week, 365 days a year.
Lets say paramedics become registered practitioners; in the way you described in your blog, the cost for providing ambulance services, would blow out.
Dr’s factor into their incomes, cost of insurances, equipment, knowledge/ expertise etc. professional paramedics would have to do the same therefore becoming unemployable. The services would just adopt lower levels and employ only a handful for peak times.
In the private industry they wont have a job. Cost is ultimately the determining factor also the area of operations.
First a definition of paramedic is needed without that registration is fruitless. Then tackling the levels from first aid to beyond ICP and ECP levels.
We have to accept that its going to take a long long time and all these concepts must be tested in court.
We need to crawl before we walk talking about ‘ a lower level of emergency GP’ is going for a sprint.
Doctors rule the medical roost and that will never change. They’re having convulsions with nursing practitioner models in remote Australia let alone the idea of paramedic practitioners in cities.
I’m not sure that all of the conclusions are true; but taking it one step at a time – anyone who saw ‘Emergency‘ back in the 1970s will have seen US fire fighter paramedics responding and making radio contact with the hospital, but I’m sure their practice and the permission to carry and use drugs was organised with the regulators and not just working on the doctor’s say so.
As for expense many health professionals continue to work as employees and don’t need their own tools of trade or insurance. Nurses and doctors remain employed as I’m sure paramedics will be though yes, different skill levels will come at different costs, just as they do now. I’m not sure why the concepts will be ‘tested in court’, issues of who or what is an RN or EN have not been?
Hi Michael,
Great blog as usual!
I would only add – and you have really already covered it – that regardless of whether employees (public or private) are acting under the instruction of a Medical practitioner or not, the individual employees are responsible for the treatment they give. The liability for negligent treatment rests with the paramedic practitioner quite separately from the liability that rests with the medical practitioner who may have established the protocols on which the practitioner relies ie a nurse can’t defend a negligent action that they have taken on the basis that they were following a doctor’s orders. (Strictly legally speaking if liability were established it would most likely be deemed to be vicarious ie employer held responsible, but this would not relieve the individual practitioner who may be subject to the negligence action from the stress of having to defend such an action).
This is all the more reason why becoming part of the national registration system is necessary. Not only does the national law make provision for registration of practitioners and oversight of their practice via disciplinary bodies etc, it also mandates the education standards required for those practising in a particular profession. It is via this route that there could be clearer and more uniform requirements for knowledge and practice skills across paramedic practitioners both publicly and privately and across jurisdictions.
Regards
Ruth
Hi Michael
This is a very informative post. I would be appreciative if you could confirm a doctor’s ability to legally delegate permission to carry and dispense S4 – S8 drugs to Registered Nurses outside of a hospital environment or government sanctioned medical centre for the purposes of providing first aid.
Jeremy, I have answered this question in a separate post – see Doctors delegating authority to carry drugs
Michael this is a very in-depth and informative post. Having said that, the NSW Ministry of Health has licensed through some avenues several of the private paramedical or private first aid providers out there to carry and supply scheduled poisons, this includes St John Ambulance. To the best of my knowledge, these licenses will be given if one or more registered medical practitioners sign off on the organisation’s clinical policies as well as obviously the application forms for the license. The medical practitioners are then responsible for clinical review and review of the clinical policies used by that organisation.
Hence why I have to ask you – isn’t that exactly what you meant by Doctors delegating authority to carry drugs?
Here is a list that includes some of the private operators out there, I believe there is a second such list under another category as well as with the TGA: http://www.health.nsw.gov.au/Hospitals/privatehealth/Documents/List-of-wholesale-licence-holders-as-at-1Sep14.pdf
No, that’s not ‘exactly what [I] meant by Doctors delegating authority to carry drugs’. What I meant was some general right in any doctor, because they are a doctor to authorise to carry drugs. In the examples you’ve given it’s not because they are doctors, it’s because there is someone who holds a relevant position and it is that position holder who can authorise someone to carry drugs. Whether or not they need to be a doctor depends on the various permissions. So it’s not because they are a medical practitioner but because they occupy the office of ‘clinical director’ or some other such title. Take for example NSW Ambulance, an employee approved by the Ambulance Service can carry various drugs. There is no doubt that approval has been given in the expectation that the service has a system to ensure that only appropriate people are approved by the Director General, but the DG’s ability to approve is only because it says he or she has that authority in the Poisons and Therapeutic Goods Regulation 2008. So if there is a licence that says people employed by private provider A can carry drugs if approved by the medical director, then the medical director’s authority comes from that licence not from the fact that he or she is a doctor. And that was my point, a doctor qua doctor (ie just because he or she is a doctor) cannot authorise a person to carry drugs.
Hey,
Maybe you could help us settle a debate on station the other day. Lots of paramedics carry a cheeky bag of fluids to give to themselves or others with a hangover. Is that legal? I am under the understanding that sodium chloride is unscheduled and your post suggests there is no law against cannulating someone.
Thanks, Wil
Provided that: your correct that sodium chloride is not scheduled (I haven’t checked that); the person receiving the fluid is consenting or it’s being self administered, and assuming the equipment has been purchased, not stolen from the employer, then there is nothing illegal going on here.
I called paramedics because I dislocated my pinky finger and asked operator on call do the services reset the injury she replied I’ll send them over I responded if they don’t then no need to come. They arrived at my home and did not assist me but said let me educate you what an emergency is in a rude manner so I asked them if you didn’t come to assist me then leave my home now. The neighbors and all witness this misbehaved conducted by them to me. My finger is still broke.
The issue here is surely that the operator should have listened to your questions and advised that an ambulance wasn’t required. If ambulance services want to only respond to an emergency then they need to allow people to ring and ask ‘is this appropriate’ and operators need to answer ‘yes’ or ‘no’ rather than despatch an ambulance to make the assessment. The alternative, a campaign to encourage people not to ring, keeps the service ‘off the hook’ as people make the triage decisions for them. I suspect it comes down to unwarranted fears of legal liability that is also reflected in policies that require paramedics to transport everyone – see
https://emergencylaw.wordpress.com/2013/05/06/transport-everyone-or-act-as-a-professional/
and
https://emergencylaw.wordpress.com/2014/02/03/do-paramedics-have-to-transport-everyone/