This section will provide background information specific to ambulance services in Australia and New Zealand to highlight the key issues impacting on ambulance services and therefore the interface with volunteers. The background context for the study involves the role of ambulance services; policy impacts on ambulance services; other general trends affecting ambulance services; and the rurality of volunteer delivered ambulance services because these contextual matters are pivotal.
Ambulance services
Volunteers have always played a role in health and social services in Australia and New Zealand, and have been particularly important in ambulance services, which rely on a large population of volunteers to deliver rural services. There are around 5000 operational ambulance volunteers within Australia (Australian Government
Productivity Commission 2006), and around 2000 volunteer ambulance officers within New Zealand (St John New Zealand 2006). Ambulance services are no exception in experiencing volunteer troubles and I saw some of these problems first-hand through involvement in a study of ambulance volunteers (Fahey, and Walker 2002). Despite a volunteer shortage there was evidence of inadequate training, communication, and organisational support for volunteers across all of the ambulance services studied (Fahey, and Walker 2001a, 2002).
Ambulance services are responsible for providing pre-hospital medical emergency care, retrieval of acutely ill patients, and transportation for people who require
intervention due to accident or illness. Australia and New Zealand have a range of key service providers using volunteers in delivery of ambulance services: St John New Zealand (NZ), Tasmanian Ambulance Service (TAS), St John Ambulance WA Ambulance Service Inc (WA), St John Ambulance (NT) Inc, Queensland Ambulance Service (QAS), The Rural Ambulance Victoria (RAV), Victorian Metropolitan Ambulance Service, SA Ambulance Service (SAAS), Australian Capital Territory (ACT) Ambulance Service, and NSW Ambulance Service. The small urban ACT Ambulance Service and Victorian Metropolitan Ambulance Service do not employ ambulance volunteers (Fahey, and Walker 2002), and therefore were not part of the study, while in NSW a volunteer workforce is the exception not the rule and this service was therefore excluded as well.
Ambulance service models vary because of different funding models, the diversity of rural and urban environments needing services, and because services have evolved from small local organisations. The ambulance services deliver largely state-wide prehospital and emergency services in Australia, but national level services in New Zealand. There are some small variations, such as the use of the Royal Flying Doctor Service in Australia for remote emergency cases, and some rescue and emergency work undertaken by fire departments or state emergency services (Australian Government Productivity Commission 2006: 8.35), but on the whole ten services provide pre-hospital emergency care in Australia and New Zealand, eight of which use volunteers, seven of which formed part of this study.
While ambulance services stand at a nexus between acute and chronic health care their most recognised role is in the provision of emergency health services which, depending on how they are defined, makes up between 60-80% of the incidents they attend (Australian Government Productivity Commission 2006: Table 8A.20). Confusion over whether ambulance services are an emergency health service or a health focused emergency service has left a legacy of poor linkages between
ambulance services and the rest of the health system (McGrath 2003: 10). However, Australia and New Zealand have less confusion in this area than for example the United States, and ambulance services are increasingly being recognised as part of the broader health system (O'Meara 2002: 36-38).
Health Service Trends
Ambulance services are affected by key health system trends that are influencing the workloads of paid and volunteer ambulance staff. Of particular relevance to this study of volunteer identity work are increasing funding pressures for services, government deinstitutionalisation and community care policies arising from neoliberal style policies, and an increasing chronic disease management workload linked to the ageing population and early discharge pressures from acute care systems.
Ambulance service demand is increasing globally at around 5-7% per year (Joint Standing Committee on Community Development 2003: 54; Lendrum, Wilson, and Cooke 2000: 7). Increasing demand is an important feature of annually increasing health care costs, ambulance being no exception (Australian Institute of Health and Welfare 2005: Table A1-A4 93-96). As well, neo-liberal policies created an environment of limited funding, which pressured services that were dealing with increasing demands and costs. A parliamentary committee report on TAS stated that ‘inadequate funding in the 1990s seriously affected management structures,
communications systems, vehicles and equipment, and volunteer training and support’ (Joint Standing Committee on Community Development 2003: 4). This situation has seen some reversal during the life of this study, as several services have received increased funding from governments as health care becomes increasingly politicised in Australia (Australian Government Productivity Commission 2006: 8A.28). However, the legacy remains where the cost pressures are likely to have been experienced by most services and are likely to have placed volunteers’ interests in conflict with the needs of managers to limit costs. Equally, higher demand is likely to have affected the workloads of volunteers, with resultant consequences evident in volunteer identities.
De-institutionalisation reforms within health care services that devolved more care to the community also created extra demands on ambulance service providers. Both Australia and New Zealand in the 1990s introduced health care policies that devolved responsibility to a more regional level, moving aged care and mental health care away from institutions towards communities (Mulvaney
1998: 262; Swerissen, and Duckett 1997: 24-25). While the theories of normalisation that drove deinstitutionalisation lead many to assume that community based care was preferable, there has been no Australian evaluation of these strategies, but evidence from other countries suggests problems with similar policies in the UK and US (Mulvaney 1998; Rifkin 1986).
It appears likely that deinstitutionalisation policies have failed to account for flow on effects in other necessary services such as ambulance. Siloed funding arrangements for health services prevented planners from factoring in the impacts of
deinstitutionalisation ‘down the line’. Anecdotes suggest these impacts include (amongst many others) more ‘difficult to handle’ mental health care cases for ambulance services, and more elderly clients needing frequent transport to hospital (Joint Standing Committee on Community Development 2003). In rural areas such cases pose particular difficulties when hospital is either a long way off, or there are no specialist services to admit the mentally unwell patient. Recent studies suggest that paramedics are poorly prepared for chronic health conditions, with most training focused on life saving treatments (Lendrum et al. 2000), and it is likely that this situation is the same for volunteers.
The increasing percentage of the aged within our society is affecting ambulance services because there are more individuals with chronic diseases living in the community (Australian Institute Health Welfare (AIHW) 2002a, 2002b). An increase in the numbers of individuals living with chronic disease increases ambulance demand (See for example Newton et al. 2006) and also shifts focus from emergency response work. Chronic disease sufferers are less likely to need acute emergency care and more likely to require transport to hospital, or between hospitals (Department of Health 2001). One service model response has been the development of an expanded scope model for paramedics incorporating a greater primary health care role, with an increase in the level of decision making required at the home to limit the numbers of unnecessary transports (Ball 2005; Department of Health 2005; Mason, Wardrope, and Perrin 2003; Snooks et al. 2004). Another response has been to introduce ‘patient transfer’ services within metropolitan areas that can operate with less skilled staff and lower running costs (Baragwanath 1997a; Joint Standing Committee on Community Development
2003). Lower caseloads have meant that this separation of services is not generally occurring in rural areas.
These trends are international, as are the responses of ambulance service redesign, evidenced by several key reports addressing future directions for ambulance services. The Emergency Medical Services Agenda for the Future report (National Highway Traffic Safety Administrator 1996) painted a picture of a piecemeal US system, and attempted to provide a cohesive vision for the future of US emergency medical services. In the UK, the report Review of Ambulance Performance Standards
(Department of Health 2001) followed the National Health Service Reforming Emergency Care Initiative (Driscoll, Editors, and Wardrope 2003) which aimed to limit inefficiencies in emergency care by treating the system holistically and by placing the needs of the patient at the centre of system design. The ability to review ambulance services in hand with the whole health system is an advantage that the UK have over Australia, New Zealand and the US where federal/state tensions or
private/public competition create discontinuities and inefficiencies.
In Australia, ambulance services are beginning to address service design issues more collaboratively through the Council of Ambulance Services Inc, which has funded studies looking at volunteers (Fahey, and Walker 2002), and rural service models (O'Meara et al. 2006). These studies centre around workforce issues largely because ‘workforce’ shortages are beginning to affect all health care areas, particularly rural, and because ideas of an expanded scope paramedic role are seen as a solution to workforce problems (Ball 2005; O'Meara et al. 2006).
Workforce shifts –from ambulance technician to paramedic
The movement of ambulance workers from a technical to professional base is another important trend of relevance to the study. Ambulance services as we now understand them, only really began in the 1960s with the development of effective cardiac resuscitation techniques (National Highway Traffic Safety Administrator 1996: 48). Prior to this, ambulance services were largely about rapid transport to hospitals with basic first aiders trained to levels such as the St John First Aid certificate or Bronze Medallion (Willis, and McCarthy 1986: 58). This meant that
at least in the first half of the 1900s ‘ambulance drivers’ were low status, working class health workers, with workers largely drawn from other driving jobs (Willis, and McCarthy 1986: 61). At this time it was unlikely to be difficult to train volunteers to the same standards as paid workers as training requirements were low.
With increased use of technology and the commencement of more intensive life- saving treatments in the prehospital environment, ambulance drivers became ‘ambulance officers’, through the introduction of a new training course in the 1960s that better reflected a paramedical health occupation status (Willis, and McCarthy 1986: 61). Potential industrial problems caused when ‘older, less formally trained officers were suspicious of the new graduates’ (Willis, and McCarthy 1986: 61) were overcome by granting equal recognition to ‘drivers’ of five year standing. After this shift, many services appear to have attempted to bring volunteers either to the same training level or close to the level of the ambulance officer, which is where we find them at the beginning of the 21st Century.
By the mid 1980s intensive life-saving developments had advanced so much that in the Australian state of Victoria approximately ten percent of ambulance officers had higher training in areas such as coronary and intensive care, leading to the new category of paramedics (Willis, and McCarthy 1986: 58). The development of the paramedic profession has left ambulance services with two main classifications for ambulance field staff, the ambulance officer and the higher trained paramedics. Volunteers operate at around the level of ambulance officers, of which there are many standards.
While there is little literature or standardisation of these roles, one study found the perceptions of desirable ambulance officer attributes were based on commonsense, manual handling and driving (Kilner 2004: 377). These attributes are likely to reflect the traditional ‘ambulance driver’ role. While there is room for both classifications, in a sense the trend is for a move from the ambulance officer, first clearly identified in the 1960s, to the paramedic professional, a more recent classification.
The differences however, between paramedics and ambulance officers appear to rely largely on differences in technical skills. This is because until recently most
paramedic training has been delivered in-house by ambulance services. Only with increasing use of university based curriculum are paramedics expected to gain the independent, reflective and research skills that are the hallmark of professionals (Cooper 2005; Kilner 2004; Lendrum et al. 2000). The professionalisation of the paramedic workforce has meant that higher levels of care can be delivered where paramedics operate, but there has been little consideration about what this means for volunteer serviced populations as the gap in qualifications between paramedics and volunteers widens.
The professionalisation of ambulance paramedics has gathered speed over the life of this study. In 2003 the UK introduced statutory registration for paramedics and an increased focus on the development of primary practitioner type roles (Ball 2005: 896-898). As Ball notes (2005: 898) the evidence base around the piloting of
paramedic practitioners is still developing and therefore hard to assess, but it suggests that such a role will work to decrease emergency department admissions and response times. Ambulance services are trialling new work roles and practices in England (Snooks et al. 2005) and Australia (O'Meara et al. 2006).
There are increasing moves to tertiary based training in Australia, away from ‘in- house’ training with the development of a national university based curriculum for Australia recently approved by the Council of Ambulance Authorities (Australian College of Ambulance Professionals 2005). The professional body, the Australian College of Ambulance Professionals, have shifted focus too, they have developed standards of self-regulation and control and increasingly represents the professional, not industrial, interests of paramedics (Australian College of Ambulance Professionals 2005; Marr 2003: 1; O'Meara 2002: 201).
These are important developments, but so recent that they are not strongly felt, in the field, and are therefore less likely to impact on volunteer services. The situation where paramedics have been trained in-house more accurately reflects the education level of Australian and New Zealand paramedic staff at the time of this study.
The increasing use of technology in medical and transport interventions is also implicated in the rising status of paramedics. Methods such as helicopter transport, drug administration and on-site intubation, has seen the role of ambulance personnel increase in medical complexity and responsibility concurrently with increasingly sophisticated equipment and procedures (Fahey, and Walker 2002). Some of this technology, such as automatic defibrillators and intubation have been introduced into some volunteer delivered services, adding further to the training and accountability requirements for volunteers, but where it is not introduced it increases the divide between paramedic provided services and volunteer provided services.
Increasing complexity of emergency health care and professionalisation of
paramedics have placed pressures on volunteers to increase skill standards, and on managers to ensure volunteer standards are adequate (Arbon 1997). These pressures are reflected in the increasing training requirements evident within most ambulance services, which in turn is believed to exclude many potential volunteers (Fahey, and Walker 2002: 8-14). One response has been revival of First Responder (first-aid) services for areas with low demand or where services are struggling to retain adequate numbers of volunteers (Guppy, and Woollard 2000). For, example, there are some innovative First Responder programs being introduced for remote aboriginal
communities in parts of Australia. The First Responder is based on basic first-aid with cardio-pulmonary resuscitation skills and automatic defibrillation, and in a sense is a reversion to the original level of volunteer ambulance services. First responders though are not the same as the ambulance volunteers of interest to this study, who are closer to, or equivalent to, ambulance officers. While First Responders are not the subject of this thesis they represent an increase in the variety of emergency responses available to populations, with some areas receiving a lower level of emergency response.
The professionalisation of paramedics is an important context of this study. Professionalisation increases the divide in standards of training and the division of labour between ambulance volunteers and paramedics, and also increases the pressure to increase volunteer standards. However, it is not clear how this is affecting
managerial matters has been highlighted as impacting on volunteer identity in the previous chapter, the increase in the standards between paramedics and ambulance volunteers raises issues around the divisions of labour. Volunteer identity work will provide some insights into how changing standards are affecting volunteers and services, for example, are relations between the two ‘workforce’ groups changing? Is there likely to be more or less conflict with paid staff? More generally, the way that services are including volunteers into the adaptive mechanisms they employ can be understood in part through examination of volunteer identity work, as managers and volunteers work to adapt the discourses about volunteer roles into a coherent
volunteer identity.
Ambulance services in the context of rural health
Rurality is important to this study as the 7000 Australian and New Zealand ambulance volunteers are largely a rural workforce (See Table 2 for breakdown of numbers per jurisdiction). In the US, ambulance volunteers (called EMTs) service more than 25% of the population (National Highway Traffic Safety Administrator 1996: 20),
comparative figures are not available for Australia and New Zealand. It is the role of ambulance services to bring a sick individual together with a health care intervention whilst overcoming the barriers of ‘time and distance from care’ (O'Meara 2002: 47). Rural Australian ambulance services in particular have problems of distance and sparse populations that are experienced by few other countries, while New Zealand has mountainous terrain that can significantly increase time to care.
Table 2: Numbers of ambulance volunteers per jurisdiction6
6
Numbers taken from Australian Government Productivity Commission (2006).
7
VIC = abbreviation of Victoria, an Australian state 8 TAS = abbreviation of Tasmania, an Australian state
The level of volunteer involvement in ambulance services is generally directly related to the degree of rurality. Though there are still some volunteer units that service the perimeters of cities, volunteer ambulance officers operate largely in non-metropolitan areas, which can be considered as those areas with populations of less than 100,000 (Hugo 2002: 13). The majority of Australian ambulance volunteers come from towns with less than 5,000 people, though only 47% of New Zealand’s ambulance volunteers come from these smaller towns. Overall less than 10% of Australian and New Zealand ambulance volunteers operate in towns with more than 100,000 people (Fahey, and Walker 2002: 24). The rurality of the volunteer workforce is likely to create administrative difficulties for services that are urban centric and is likely to influence volunteer identity.
Measures of rurality
When discussing rurality it is important to define what one means, particularly as there is considerable debate around definitions or rural, regional and remote. It is particularly important to consider urban/rural variables and accessibility/remoteness variables when discussing non-metropolitan populations (Hugo 2002: 13).While two major classifications systems are used in Australia to define rurality: the
Accessibility/Remoteness Index of Australia (GISCA 2000); and the Rural, Remote and Metropolitan Areas classification (Australian
9
QLD = abbreviation of Queensland, an Australian state 10 NT = abbreviation of Northern Territory, an Australian territory 11 WA = abbreviation of Western Australia, an Australian state 12 SA = abbreviation of South Australia, an Australian state 13 NSW = abbreviation of New South Wales, an Australian state 14 NZ = abbreviation of the country of New Zealand
15
Based on the Stand Up and Be Counted information (Fahey and Walker 20002) as year books do not specify ambulance volunteer numbers)
Volunteer
Government Department of Health and Ageing 2005) these classifications are not relevant to this study. Rurality and accessibility are important contexts for this study, but as anonymity is also important, populations will not be closely defined. The term regional will be used to talk about larger rural towns with populations between 1,000