A general practitioner has written to me about the role of GPs in emergency response.  The story has also been raised with the ABC – see Patrick Wood ‘Local GPs who were sidelined at evacuation centres want to be added to bushfire plans’ ABC News (Online) (7 January 2020).

The issue is largely identified in the ABC story.  In essence, general practitioners responded to evacuation centres in the areas where they practise.  The doctor who wrote to me said:

I expected someone from the medical coordination team or Red Cross or hospital in [a NSW country centre], 30 km away to get in touch with us. We have a large elderly population with many complex medical needs.  But no one did.

As the situation worsened as the day progressed, we raided our practices and our pharmacists to try to at least provide some basic care.  And it was needed.  We gave adrenaline to a severe asthmatic, we nebulised those who were struggling in the smoke.  The ambulances took at least an hour to arrive.  Would we have had increased fatalities if we had not been here, I think yes. As the fire situation worsened, our evacuee population rose to 1000 over 3 sites. …

As I write this we still have no St John cover.  And we don’t know how long we will need to provide this care…

I don’t understand why there would not be better coordination of care. If not for the dedication of our lovely group of local GPS and evacuated nurses, who have and continue to share the provision of 24 hr care, these people were abandoned with not even any access to basic first aid. Given they are elderly, given that the nearest hospital is 30 km away, why would you not send down a team or at least support or liaise with the local GPs their care?

The critical issue here is pre-planning. Once the emergency starts its very hard for those who, under the local emergency plan, have been given responsibility to act, or react, to do anything other than apply the plan.

Because a NSW town gets a mention, I’ll look at NSW.

The State Emergency and Rescue Management Act 1989 (NSW) (the SERM Act) provides for planning at the local, regional and state level.  At the local level the plan is written by the Local Emergency Management Committee (ss 28 and 29).  The Committee is made up of

(a) the General Manager of the council of the relevant local government area, who is to be the Chairperson of the Committee, and

(b) a senior representative of each emergency services organisation operating in the relevant local government area, and

(c) a representative of each organisation that:

(i) provides services in a functional area or areas in the relevant local government area, and

(ii) the council of that area determines from time to time is to be represented on the Committee, and

(d) the Local Emergency Operations Controller for the relevant local government area.

The NSW Emergency Management Plan (the EM Plan) and supporting sub-plans, including the Health Services (HEALTHPLAN) Supporting Plan provide roles for ‘Participating and Supporting Organisations’

Participating organisations are (EM Plan [435]):

The Government Departments, statutory authorities, volunteer organisations and other agencies listed as Participating Organisations have either given formal notice to Agency Controllers or Functional Area Coordinators, or have acknowledged to the SEMC, that they are willing to participate in emergency response and recovery operations under the direction of the Controller of a Combat Agency, or Coordinator of a Functional Area, or an EOCON, and with levels of resources or support as appropriate to the emergency operation.

Supporting Organisations are (EM Plan [437]) organisations that

… have indicated a willingness to participate and provide specialist support resources. Where such coordination arrangements are required for the conduct of emergency response and recovery operations, the agreed roles, tasks and responsibilities of the Supporting Organisations should be recorded in Combat Agency or Functional Area Plans.

In the Health Plan the participating organisations are listed at [251] as:

a) Australian Red Cross Blood Service (NSW)

b) Department of Health and Ageing, NSW & ACT State Office (DoHA-NSW/ACT Office)

c) Peak bodies of Residential Aged Care Services

d) Ageing Disability and Home Care (ADHC), Department of Family and Community Services

e) St John Ambulance Australia (NSW)

Under supporting organisations [252]) it says:

NSW Health may request the provision of support and resources from the following organisations. Resource commitment agreements are to be negotiated at the LHD level [see Annex 7].

a) Residential Aged Care Services

b) Private Health Facilities

c) Local Governments

f) Medicare Locals

Annex 7 says:

Medicare locals are primary health care organisations with the principal role of working with general practitioners, nurses, allied health professionals, Aboriginal Medical Services and LHDs to identify and respond to gaps in local health services.

There is a role for local health districts (at [241]):

All Local Health Districts and Networks through the LHD/Network HEALTHPLANs will develop control/coordination management infrastructures and arrangements for health emergencies/emergencies. When LHD/Network-based services are mobilised for State- and LHD-level responses, they will be coordinated through the LHD/Network HSFAC [Health Services Functional Area Coordinator].

With respect to pre-hospital care, the plan says (at [218]):

The State Ambulance Services Controller is responsible under the NSW HEALTHPLAN for controlling and coordinating pre-hospital emergency and ambulance services during an emergency.

This includes ‘Activating and coordinating pre-hospital supporting services including St John Ambulance Australia (NSW)’.

Discussion

GPs can be involved in their local emergency response and as a part of the State HEALTHPLAN but this has to be done in advance of an emergency and without waiting for ‘someone from the medical coordination team or Red Cross or hospital …away to get in touch with us’ because those people won’t know who to contact, who is available or who is willing to do what.

Rather, when there is no emergency present, interest GPs need to form an organisation, or through an existing organisation (eg the Royal Australian College of General Practitioners, the Australian College of Rural and Remote Medicine, the Rural Doctors Association of Australia or the like)  approach the local emergency management committee and State Health Services Functional Area Coordinator and advocate for a role in the plan.  They need to demonstrate to those that write the plan that they have a role to play and be part of the planning process to say what they will do, how they will be activated and what services they can provide.

Failing that the GP that arrives at the evacuation centre is another spontaneous volunteer, that is ‘an individual who is not affiliated with an existing incident response organisation or voluntary organisation but who, without extensive preplanning, offers support to the response to, and recovery from, an incident’ (International Organisation of Standardisation, cited in Blythe McLennan, ‘Understanding Models For Spontaneous Volunteering’ (September 2019) 64 Hazard Note (Bushfire and Natural Hazards CRC). Whilst agencies should plan for spontaneous volunteers (Australian Institute for Disaster Resilience, Communities Responding to Disasters: Planning for Spontaneous Volunteers (Australian Disaster Resilience Handbook Collection, Handbook 12, Commonwealth of Australia, 2017) not everyone does and the planning and incorporation of spontaneous volunteers can be difficult.  Often its easier to ask them to leave as their presence may interfere with the plan.

Some organisations and leaders will be better prepared and more open to recognising people who turn up, with special skills, than others. Some evacuation centre operators may say ‘great, there’s a space, set up a clinic, what do you need?’ Others might say ‘we’ve got this covered, the ambulance service manage this, thanks for your help but we’re good’.  And others may be anywhere in between.    And some doctors will say ‘ok, we’re out of here’ and others will say ‘I don’t need your permission to treat patient’s I’ll do what I need to do’ and others will be somewhere in between.

The quote in the ABC story, attributed to the CEO of Victoria’s Rural Workforce Agency, Trevor Carr is apposite.  He:

… said he understood the concerns of local doctors wanting to help when emergencies happened, but it had to be done in a co-ordinated way.

“We need to have a command structure, because otherwise things just turn to chaos,” he said.

“I think one of the challenges is when the emergency is actually in play, the emergency command structures don’t necessarily take into account private individuals. And of course a lot of general practitioners are in private business.

Conclusion

If GPs are not part of the plan, they don’t have a predefined role.

If they don’t want to be spontaneous volunteers – if they want to be involved in pre-planning – they cannot just wait and assume someone will call.  They need to be getting involved via their peak organisations during the non-emergency times.  They need to be advocating for a place on the Local, Regional and State Emergency Management Committees and making sure that they have a defined role for the next emergency.