Today’s correspondent says:

As I renew my paramedic registration I am reflecting on the multiple regulations, policies, moral and ethical considerations that I must adhere to as an individual. In light of deaths and harm occurring to individuals across Australian health systems, secondary to ambulance and emergency department delays, by what process are those individuals responsible for these system/structures (managers, executives, medical directors, boards, and govt ministers) held accountable? (NSW parliamentary enquiry, the sad case of Amrita Lanka, QLD – Courier Mail 18/9/22 “20 Queenslanders die”)

Policies of an ambulance service for example, could lead to greater harm, for a longer period, to more people than any individual healthcare professional could. How is this regulated and who is accountable? Could a medical director, or director, be held accountable through individual registration, for their decisions, lack of strategic planning that may have led to some factors contributing to these failures? Policies such as ‘all pediatric patients must be transported to hospital’ contributes to unnecessary health systems workload, which in turn generates delays in ambulance response and ability to manage multiple patients with limited resources.

I acknowledge the extremely complex, multifactorial causes of such failures, however concerns over system design and strategy have been raised for decades. I also acknowledge there are many individuals throughout the system doing their very best to ensure optimal care is provided. However, It seems individual health professionals are becoming increasingly regulated and accountable, however they are working in a seemingly unaccountable system that is failing its patients.

These are interesting questions, but I won’t attempt to answer each one. Rather I will discuss the principles, as I understand them, more generally.

Regulating ambulance services

First it is interesting to note, as my correspondent does, that individuals are required to be registered and to comply with codes of conduct, registration standards etc, yet ambulance services are not.  As my friend and fellow paramedic commentator, Ray Bange (who writes as ‘the Paramedic Observer’) has noted on many occasions, ambulance services are not subject to the same level of oversight as practitioners.  In his Submission to Department of Health and Human Services Victoria Review of the Ambulance Services Act 1986 (January 2017) he said:

While paramedics need appropriate regulation, so too should service providers be subject to an appropriate independent oversight regime as an integral element in delivering uniformly high quality care and accountability in the public interest.

… the author believes that all paramedic service providers in Australia should be subject to minimum standards of performance and operate under an independent accreditation and quality assurance regime…

(see also Ray Bange, Submission to the Rural Health Services Inquiry: Meeting the healthcare needs of rural Tasmanians (March 2021).  In another submission (Submission for Senate Inquiry into the high rates of mental health conditions experienced by first responders, emergency service workers and volunteers (June 2018)) he said:

Because paramedic services fulfil a key function in public health and safety and the health services are funded through the taxpayer, their accountability needs to be commensurate with that role. That mandates an appropriate level of independent oversight that is not provided by the RoGS [Report on Government Services] or limited transparency through an annual report or the lens of a health department.

It is interesting to repeat the observation that when it comes to health practitioners who are not registered under the health practitioner regulation national law, there is a Code of Conduct in place in NSW, Queensland, SA and Victoria. In NSW the newly revised code also applies to the practice that employs those practitioners (see Revised Code of Conduct for non-registered health practitioners in NSW (September 23, 2022)).  There is no equivalent of the AHPRA Code of Conduct that applies to ambulance or paramedic services in the same way the Code applies to individual practitioners.

Regulating individuals

With that background, the question that I understand I’m being asked is how individuals within those services are, in the absence of external quality control, held to account. The answer is that they may be held to account by professional paramedic standards, but it’s unlikely. 

Practising the profession.

The first part of the discussion will deal with managers and executives who are paramedics; and medical directors who are registered medical practitioners.  Those that are not cannot be held to account under the provisions of the Health Practitioner Regulation National Law and will be discussed later, below.

The first condition for the operation of the professional standards that come with registration is that a paramedic must be practising their profession.  The AHPRA Code of Conduct (29 June 2022), adopted by the Paramedicine Board, defines practice as:

… any role, whether remunerated or not, in which the individual uses their skills and knowledge as a practitioner in their regulated health profession. For the purposes of this code, practice is not restricted to the provision of direct clinical care. It also includes using professional knowledge in a direct non-clinical relationship with patients, working in management, administration, education, research, advisory, regulatory or policy development roles and any other roles that have an impact on safe, effective delivery of health services in the health profession.

There is no definition of practice in the Medical Board’s Good medical practice: a code of conduct for doctors in Australia (1 October 2020) but an approach similar to that quoted above is likely to apply. For the sake of this discussion, I will assume the definition set out in the shared code of conduct quoted above, will also apply to doctors such as an ambulance service medical director.

The critical part of the definition is that it is not related to direct patient care.  As it says ‘using professional knowledge … [whilst] working in management, administration … or policy development roles and any other roles that have an impact on safe, effective delivery of health services in the health profession’ is professional practice as a paramedic or doctor.

That means that those practitioners must have regard to the various professional standards that focus on delivering patient centred care. A key issue in management and policy development should be Principle 6 that is ‘Practitioners have a responsibility to contribute to the effectiveness and efficiency of the healthcare system and use resources wisely.’  Those charged with developing ambulance policy must ‘understand that your use of resources can affect the access other patients have to healthcare resources’ ([6.1]). 

That does not mean, however, that every policy that has an adverse effect is a bad policy. In most, if not all, policy choices there are costs and benefits; pros and cons; winners and losers. A policy that ‘all pediatric patients must be transported to hospital’ may contribute to unnecessary health systems workload but it may also decrease the risk of missed diagnosis or rapid decline in child health with adverse consequences. 

Health policy decision making is necessarily complex and it’s not as simple as asking ‘what would be best in the best of all possible worlds?’  Managers, executives, medical directors, boards, and government ministers must make decisions that are necessarily always a compromise. Resources are limited, demands on those resources are not. Where the service is a government service they are established by government and subject to government policy directives.  Those charged with managing the service must do so within that context.  Individual paramedics faced with the consequence of policy choices and their impact on particular patients will have a different perspective to those charged with managing the service as a whole – whether that is the Ambulance Service or the entire health service or the range of government services.

When seeking judicial review of a decision by a government appointed decision maker, the test is to ask whether the decision was so ‘so unreasonable that no reasonable person acting reasonably could have made it (Associated Provincial Picture Houses Ltd v Wednesbury Corporation (1948) 1 KB 223).  That may not be the relevant test in professional discipline but it is, perhaps, a good guide.

The test, I would suggest, to hold an individual registered health professional ‘accountable through individual registration, for their decisions [or] lack of strategic planning’ would be to ask whether their decisions were ‘Wednesbury unreasonable’ and whether that paramedic or doctor proved by their actions, or inaction, that they were not a fit and proper person to be a paramedic, or doctor.  There may be obvious examples where that is the case – a  person that develops a policy where they have a clear conflict of interest so that they are trying to advance their own private interests; a person that makes decisions based on bribes or ‘kick backs’ etc.  A paramedic or doctor who engaged in corrupt, malicious or criminal conduct in their managerial role may well compromise their registration.

That’s not impossible but one can see the difficulty given the factors that the decision maker must consider and because decisions are not usually made by individuals. Where there are multiple minds brought to bear on a problem it would be hard to say the policy outcome was ‘so unreasonable that no reasonable person acting reasonably could have made it’ if multiple people agreed that it was indeed a reasonable outcome.

People other than registered health professionals

Other people are involved in the management of ambulance services.  Where there is a Board one would hope it had a cross section of expertise including legal and accounting experts as well as health professionals. Where it is a government service the Chief Officer should, ideally, ensure that he or she has access to advice, but they are all subject to direction and control from their Minister who in turn should adopt policies approved by Cabinet which effect all of government.

Where a government establishes a service, like an ambulance service, it appoints people to the chief role and then expects them to manage the service. As noted by the Bange the services are not independently regulated or subject to independent quality assurance. That means accountability is mostly political.  If we do not like the way state governments are running hospital and health systems, we get to vote for someone else. 

Civil litigation

Another route to hold agencies (rather than individuals) accountable may be through civil litigation but again that is unlikely to succeed.  If someone wanted to sue the ambulance service, or the Minister, for adverse consequences that resulted from the implementation of a policy choice they would find it a very difficult legal road.  Legislation, for example the Civil Liability Act 2002 (NSW) is enacted to limit government liability.

First, that in deciding whether a public authority (such as a jurisdictional ambulance service) has been negligent, the service is limited by the financial and other resources available to it and the allocation of those resources cannot be challenged (s 42).  This means you cannot sue a government service for not having equipment or resources that would have lead to a different outcome nor how they allocate the resources they have. The service has to share the budget between recruiting, capital expenditure, training, maintenance, on-road staff etc.  They could have more paramedics if they had less of something else but that sort of decision-making is ‘non-justiciable’. You cannot sue because you think the Ambulance Service, or the government, should have had different priorities or had more resources.

Second if one were to argue that a statute imposed a duty on a service then a plaintiff can only successfully sue if the actions of the service are ‘so unreasonable that no authority having the functions of the authority in question could properly consider the act or omission to be a reasonable exercise of its functions’ (s 43 and adopting words from Wednesbury’s case, above). To put that into context, the Health Services Act 1997 (NSW) s 67B(1)(a) says that the Health Secretary is to provide ambulance services and:

… (c) in connection with ambulance services referred to in paragraph (a), to protect persons from injury or death, whether or not those persons are sick or injured,

(d) to adopt and implement all necessary measures (including systems of planning, management and quality control) as will best ensure the efficient and economic operation and use of resources in the provision of ambulance services,…

The family of a person who dies waiting for an ambulance may want to argue that the Health Secretary has failed to do what s 67B(1)(c) requires as they did not ‘protect’ their loved one from death.  And they may argue that a different policy approach would have been better so that the health secretary did not ‘ best ensure the efficient and economic operation and use of resources’.

The effect of s 43 is that sort of litigation could only succeed if the plaintiff could show the decisions of the health secretary were ‘so unreasonable’ that no-one in that position would consider the choices they made ‘to be a reasonable exercise of its functions’.  Given the health secretary would no doubt be able to point to the advice received and the processes in place to make decisions that test is almost insurmountable.  And I say ‘almost’ because there is perhaps some factual situation that is not far-fetched and fanciful that might exist where that could be proved, but I cannot think of it – but never say never.

Again, the way agencies like government ambulance services are held accountable for these sort of policy decisions is via the ballot box.

Private services

Private ambulance services are not in quite the same position. First private ambulance services generally need permission to operate. They are regulated by conditions imposed on their licence to operate (Emergencies Act 2004 (ACT) s 61; Health Services Act 1997 (NSW) s 67E; Ambulance Service Act 1991 (Qld) s 43; Health Care Act 2008 (SA) ss 57 and 58; Ambulance Service Act 1982 (Tas) ss 37 and 37A; Non-Emergency Patient Transport and First Aid Services Act 2003 (Vic)) and/or by any conditions imposed upon them under relevant drugs or poisons legislation.

Where a private entity contracts to provide ambulance services (either to individuals, to the private sector or to government) they can determine their level of service in their contract negotiations and they have to deliver the service they promise to deliver. Unlike a government service, a private service is not required to provide a particular service so if it fails to deliver what it promised, it can be liable as a breach of contract.

As a non-government entity, they do not get the benefit of sections like ss 42 and 43 of the Civil Liability Act 2002 (NSW) discussed above, but even so they will not be liable for the adverse outcome of ‘reasonable’ policy decisions.

The other relevance of private ambulance services is that they can hold government agencies ‘to account’ via competition.  If people are sufficiently unhappy with jurisdictional ambulance services it will continue to open the door to private ambulance services. In an article I wrote with Ruth Townsend ‘Paramedicine in 10 years: What will it look like?’ (2019) 46 Response 18-20 we argued that registration could lead to the growth of private ambulance services and this would be hard for governments to resist given their commitment to competitive neutrality that is (NSW Policy Statement on the Application of Competitive Neutrality (2002), p. 23) ‘Government businesses should not enjoy any net competitive advantage simply as a result of their public sector ownership’. 

If private services can provide high quality services, they should be able to enter the market and compete with public services. There may not be sufficient interest in private emergency ambulance services but if demand arises because of perceived failures by the public services, that pressure may be hard to resist and that would be another way of holding ‘managers, executives, medical directors, boards, and govt ministers’ to account for their management decisions.


The question I was asked began:

As I renew my paramedic registration I am reflecting on the multiple regulations, policies, moral and ethical considerations that I must adhere to as an individual. In light of deaths and harm occurring to individuals across Australian health systems, secondary to ambulance and emergency department delays, by what process are those individuals responsible for these system/structures (managers, executives, medical directors, boards, and govt ministers) held accountable?

The answer is that individuals are largely not responsible for the system/structures, teams are.  Individuals could, in rare circumstances, ‘be held accountable through individual registration, for their decisions [or] lack of strategic planning’ but these would be very rare and most likely in cases of criminal or corrupt conduct. 

The way ‘managers, executives, medical directors, boards, and govt ministers’, particularly where there are state operated ambulance services (everyone but the NT and WA) will be held accountable for the performance of the ambulance service will be via the ballot box and the Parliament.

This blog is made possible with generous financial support from the Australasian College of Paramedicine, the Australian Paramedics Association (NSW), Natural Hazards Research Australia, NSW Rural Fire Service Association and the NSW SES Volunteers Association. I am responsible for the content in this post including any errors or omissions. Any opinions expressed are mine, and do not necessarily reflect the opinion or understanding of the donors.