A new approach needed to help our emergency departments and ambulance service

November 10, 2022

Opinion editorial by Juan Paolo Legaspi, Deputy CEO of the Victorian Healthcare Association. This article was first published in the The Age.

It’s been a tough winter for our public health system. If you needed an ambulance or emergency department in recent months, chances are you witnessed our health workers under intense pressure.

Last week, new data revealed thousands of Victorians waited in emergency departments for longer than 24 hours during July, August and September because there weren’t enough resources to admit them sooner.

This had a knock-on effect for our ambulance service. Between July and September, 41 per cent of ambulance crews waited longer than 40 minutes to hand their patients over to hospital staff because there was not enough space for hospital staff to take over. This, in turn, tied up ambulance crews, potentially slowing them down to reach new patients.

These interconnected problems, known as “access block” for hospitals and “ambulance ramping” for paramedics, have been a perennial issue for decades. But the pandemic has exacerbated some of the key drivers of them, including unseasonal peaks in demand for emergency care due to COVID-19, and worsening shortages of healthcare workers due to illness and burnout.

Victoria is not alone with this. Recent data from England shows paramedics could not respond to about 4000 incidents a day in September (one in six calls) because they were delayed for at least 15 minutes with a patient outside a hospital. England’s ambulance service estimates 38,000 people are potentially harmed by this each month, with 4100 facing potentially “severe harm” from the delays.

The problem is complex because a lot of the contributing factors are outside the control of our hospitals and ambulance services. Drivers include a lack of prevention of health problems in the community, a shortage of resources in nursing homes and other supported accommodation to provide healthcare for people in their home, and a lack of disability, rehabilitation and mental health supports in the community so people can leave hospitals safely.

Some of these issues are difficult to tackle, partly because of different government funding streams, but with enough political will there are things that can help. A recent analysis by the Victorian Healthcare Association, which represents public health services in Victoria, identified 25 recommendations for governments to consider. In the lead-up to the Victorian election, all major parties have promised to adopt many of them, but the following stand out as “low-hanging fruit” yet to be picked:

The first of these is enabling seven-day-a-week discharge.

While emergency departments operate all day, every day, other hospital and community services slow down over weekends, making it harder for staff to discharge patients. This means patients can stay in hospital unnecessarily on weekends, making it harder for emergency departments to find beds for people who need them.

With additional funding, hospitals and other community care providers could deliver more comprehensive services over weekends to ensure patients can leave hospital when they’re ready to.

Another recommendation is community paramedics.

Helping people stay well and manage their health conditions reduces demand for ambulances and emergency departments. But this is hard in areas where there’s a shortage of GPs and other health services, or when people don’t reach out to health services due to cost and other barriers.

An alliance of regional and rural community health services is currently trialling a program that employs former paramedics to assist vulnerable people with their health in areas with a shortage of GPs.

Inspired by a model of healthcare created in Canada, community paramedics consult people about their health needs and give them advice on health assessments, disease prevention, and connect them with services they need including GPs, psychologists or other health and social services.

Research in Canada by McMaster University has found the model improved many people’s health while also reducing calls for emergency health services by up to 25 per cent and preventing some use of expensive hospital care. The alliance of community health services is seeking $16.6 million from the Victorian government to roll it out across the state. It’s a clever, cost-effective scheme worth backing to help people in rural and regional areas who experience worse health outcomes than their city counterparts.

There also needs to be more opportunities for nurses.

One of the fastest ways to increase the capability of our health workforce is to enable and encourage existing staff to work to the full extent of their ability. We saw this during some of the hardest days of the pandemic when we trained pharmacists to support the state’s vaccination rollout, so nurses and doctors could continue other work.

Supporting nurses to do additional training and become nurse practitioners has great potential to fill some of the gaps we currently have in all types of health services, including aged care facilities where staff frequently call on ambulance services due to a lack of visiting GPs.

A KPMG cost-benefit analysis found that an expansion of 10 nurse practitioner roles in aged care would cost approximately $1.5 million per year, but conservatively result in 5,000 avoided ED visits each year, an annual savings of over $5.7 million in reduced ED, hospitalisation and ambulance costs. It is just one example of how well nurse practitioners could work if we created more incentives for nurses to follow this path, including guaranteed employment in various public health services.

Victoria’s public health system will need a lot of help in coming years to overcome the current mix of challenges we face. While building new hospitals will always be welcome, there are many other policy options that can modernise and improve healthcare for all Victorians.