Today’s correspondent was:

… recently been made aware of the provision contained in the Ambulance Service Regulation 2015 (Qld) r 3.

For reference, in other states, it can be common practice to attend to a patient and return them a short distance home either after treatment or assessment. Such cases could include an intoxicated person returned to a responsible person etc. This can avoid unnecessary hospital transportation, sometimes considerable distances, on busy Saturday night’s etc.

I am advised that this practice cannot occur in Queensland as the regulation does not allow the QAS to attend to a patient and then transport them home. I’m interested in your thoughts on this opinion. Particularly if someone calls for a low acuity issue that you wouldn’t think is ‘an accident or emergency’ as emergency is a vague term and can be different for everyone.

Do you think ‘accident or emergency’ applies to every job the QAS attends or only accidents and jobs that are deemed by a clinician as emergency cases?

If so, if every case we attend is an ‘emergency’ regardless of the actual acuity of the patient, according to the regulation, is it your interpretation that we cannot ever return a patient home without a doctor’s authority?

Rather they would have to go via taxi, private transport or be left in the care of others on scene as a non-transport (if appropriate), or transported to ED or transported to a doctor’s office or medical centre and the doctor determine that they can go back to a private residence and there is no other way to be taken home other than by ambulance?

Regulation 3 of the Ambulance Service Regulation 2015 is indeed an ‘odd’ regulation. It says:

(1) If a person is involved in an accident or emergency and is transported by ambulance, the person may be taken to—

(a) the nearest public hospital; or

(b) another public hospital that a health service chief executive of a Hospital and Health Service under the Hospital and Health Boards Act 2011 has decided is appropriate for the treatment of the person; or

(c) if transport to a hospital mentioned in paragraph (a) or (b) is not practicable—a private hospital; or

(d) if arrangements have been made with a doctor—the doctor’s surgery; or

(e) at the request of the person, or the person’s parent or guardian—

(i) the accident and emergency department of a local private hospital; or

(ii) if a local doctor’s surgery or office has the facilities to receive and treat the person—the surgery or office.

(2) If a person in need of ambulance transport has been seen by a doctor, the person may be taken to a place nominated by the doctor.

(3) Ambulance transport of a person from a hospital or doctor’s surgery to another place of medical care or a private residence may be provided only on the written request of a doctor.

(4) A doctor must not make a nomination under subsection (2), or a request under subsection (3), unless the doctor is satisfied the person can not safely, or reasonably, travel by an alternative form of transport.

(5) Despite subsections (1) and (2), an ambulance officer may transport a person to any place where medical treatment is provided if the officer believes the person needs urgent medical treatment.

 

A regulation in the same terms was in the earlier Ambulance Service Regulations 2003 (Qld).

This all begs the question of why is this regulation necessary? Regulations give effect to and provide the details to make an Act work, in this case the Ambulance Service Act 1991 (Qld).  Section 54 says:

(1) The Governor in Council may make regulations under this Act.

(2) A regulation may be made for or about—

(a) charges to be made for the use of ambulance services; and

(b) the entitlements of persons who use ambulance services; and

(c) all matters that arise in connection with the entitlements of and the conditions of employment, occupational superannuation, retrenchment or redundancy of service officers; and

(d) the procedures to be followed by an RCA [Root Cause Analysis] team in its conduct of an RCA of a reportable event.

On its face regulation 3 does not appear to be about any of those subject areas. Equally r 4 (Commissioner may decide conditions for transport by ambulance) does not appear to be supported by the regulation making power in s 54, ie r 4 is not a regulation about any of the subject matters listed in s 54.  Neither regulation 3 nor regulation 4 refer to any section that required the making of the regulation.

The regulation does not appear to be a limitation. It does not say patients ‘must’ be transported to those destinations and, with the exception of regulation 3(3), it does not say that a person may not be transported unless a given condition is met. If the regulation is a limitation on what the service can do that seems inconsistent with the Ambulance Services Act 1991 (Qld) s 3E(2)(a) which says

… the chief executive is responsible for— (a) defining the objectives, strategies and policies to be followed by the service.

Accident and emergency are two different things.  An intoxicated person who has fallen and grazed their arm has had an accident, but it’s not an emergency.  If an ambulance is called and examines the patient or provides treatment they have attended an accident and can charge for that assessment and treatment (Sch 1 cll 2 and 3).

It cannot be the case, however, that ‘accident or emergency’ applies to every job the QAS attends as regulation 3(2) and (3) don’t refer to an ‘accident or emergency’.  The service can also charge for ‘emergency transport’ and ‘transport, other than emergency transport’ (Ambulance Service Regulation 2015 (Qld) r 5 and Schedule 1. Arguably r 3 defines what is emergency transport’ and ‘transport, other than emergency transport’ for the purposes of the fee schedule such that the ambulance service can only charge for transport that falls within r 3. That would be consistent with the power of the Governor to make regulations with respect to ‘charges to be made for the use of ambulance services’.

Discussion

Doing the best I can, I would read r 3 as defining transport for the purposes of charging. If an ambulance was called ‘to attend to a patient and return them a short distance home either after treatment or assessment…’ the service could charge the greater of 139.80 fee units or 0.19 fee units per km to and from the nearest ambulance station (to a maximum of 1376.50) fee units, but could not charge the fixed 1376.50 fee units for emergency transport or the 509.90 fee units for the first 50k of non-emergency transport then 2.07 fee units for each kilometre thereafter, even if they did drive the patient home. Clearly if it’s a short trip being able to charge for the transport would earn the QAS much more than the fee only for assessment and/or treatment. (From 1 July 2023, a ‘fee unit’ is $1.060 (Acts Interpretation Act 1954 (Qld) s 48B; Acts Interpretation (Fee Unit) Regulation 2022 (Qld) r 2).

The other interpretation is that r 3 is indeed a limitation based on the rule of thumb that a natural person (you and I) can do whatever we like unless there’s a law that says we cannot, and governments cannot do anything unless there is a law that says they can – but that is just a guide rather than a rule of law and we can test it by some thought experiments. Consider an ambulance crew find a lost child on the street, do we really think that because of r 3 they could not take the child and drive them to the nearest police station?  Assume an ambulance on a remote country road and a person whose car has broken down, do we really think the ambulance crew could not pick up the stranded driver and drive them into town to get help but would have to leave them by the side of the road?  Or take a young ‘tween-ager’ whose come off a scooter. A bit scratched and bruised but doesn’t need hospital but upset and when asked ‘can we call mum or dad?’ says “I just live around that corner’. Surely no one would criticise a paramedic who said ‘we’ll drive you home’ and who then knocks on the door, delivers the child to its parent with advice of what they have done and what to look out for to make sure it’s nothing more serious than a few scratches.

These examples are not ‘core’ activities of the ambulance service, but it would be perverse if it was thought the ambulance officers were prohibited from doing that sort of community service particular where the risk to the people if they are not helped is a risk to health and safety. 

Conclusion

I don’t see that r 3 means that an ambulance crew ‘cannot ever return a patient home without a doctor’s authority’. If an ambulance is called, or comes across a scene, and the paramedics determine that in their mind the patient doesn’t need to go to hospital and it’s appropriate in the patient’s and the community’s interest, then I don’t see that r 3 says that they cannot deliver the person, but they could not charge for that transport. It’s not ‘core’ business and the ambulance service certainly doesn’t want to get in the situation where people ring it rather than a taxi or a friend or relative but it’s not actually a prohibition.

On the other hand, regulation 3 would give clear authority to paramedics to refuse a request to drive someone home. Someone who insisted on being driven home could be told ‘we don’t do that’ and they could have no grounds to critique the service or complain about the officers. It would certainly provide a shield against demands to use the ambulance as a taxi; but I cannot see it is a prohibition that must be universally applied.

But to be honest, why r 3 is there and what it’s meant to achieve is not at all clear.

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.