Background – Executive Summary
St John Ambulance Australia (Western Australia) Inc. (SJA) is contracted by WA Health to provide ambulance services throughout the state. SJA is a non-government incorporated association, linked to the international Order of St John. It has a long history in Western Australia (WA) as the primary provider of ambulance services, operating since 1922. In this regard, WA and the Northern Territory are unlike other Australian jurisdictions where ambulance services are provided by government agencies and regulated by legislation.
Last year SJA’s call centre responded to around 163 000 triple zero calls and 112 000 non-urgent ambulance bookings. It dispatched 240 000 ambulances. Demand for ambulances had increased by 24 per cent since 2008-09. Ramping has also put pressure on SJA’s capacity to respond to calls, with ramping at its highest level during July 2012 when ambulances had to wait for over 2 100 hours at hospitals.
Ramping occurs when an Emergency Department (ED) is unable to immediately take over the care of a patient brought in by SJA so that the patient has to stay on the ambulance stretcher and remain in the care of ambulance paramedics. Once the hospital takes over the care of the patient and the patient is removed from the ambulance stretcher the ambulance can return to active service. Only lower acuity patients may be ramped. The number of patients seeking ED services can impact on levels of ramping as it can affect the capacity of the ED to take over care of patients brought in by ambulance. Demand for ED services has increased over recent years.
SJA uses a structured computer based call taking system called ‘ProQA’. Using this system, call centre staff lead callers through a structured set of questions and enter their responses into ProQA which then provides a code assigning a priority for the dispatch of the ambulance. Priorities range from Priority 1 (potentially life threatening emergency) to Priority 4 (non-urgent booked call), and determine how quickly ambulances need to arrive at the scene. Ambulances either retrieve injured or ill people from community settings and take them to hospital (primary transport), or transport patients between hospitals (inter-hospital patient transport or secondary transport).
Response times are the main performance measure for ambulance services throughout Australia and internationally. SJA’s target under its current contract (Contract) with WA Health is to respond to 90 per cent of Priority 1 calls within 15 minutes. SJA’s response time starts from when a call is entered into the dispatch system and ends when the ambulance arrives at the scene. Response times can be affected by a range of factors, most significantly the availability of crews and the location of ambulance centres.
SJA has 30 metropolitan depots and 115 country sub-centres. Metropolitan depots are fully staffed by paid paramedic and transport officer crews. A mix of paramedics and volunteer crews staff 13 larger country sub-centres (career sub-centres). The remaining 102 sub-centres have entirely volunteer ambulance crews (volunteer sub-centres). Last year metropolitan depots undertook three-quarters of SJA’s ambulance activities and country sub-centres one quarter. Just under half of country ambulance activities were undertaken by volunteer sub centres.
Delivering WA’s ambulance services to country areas is a challenge because the population in those areas is widely spread across a very large area. Volunteer services are therefore critical to providing country ambulance coverage. To establish a local volunteer ambulance service, communities have to approach SJA and demonstrate need and commitment. This model has proved resilient in WA, no volunteer sub-centres once established have ceased operation.
The WA Country Health Service (WACHS) operates its own ambulance service from hospitals in Derby, Fitzroy Crossing and Halls Creek as there has never been an approach from these communities to establish a SJA sub-centre. WACHS provides more than 50 per cent of the ambulance activities in the Kimberley. At times, Aboriginal Medical Service nurses, police, emergency volunteers and local community members may also provide assistance.
Most people in WA pay if they use an ambulance, but they do not pay the full cost. In the metropolitan area WA Health, rather than the user, pays for ‘standby capacity’, which is the cost of having enough ambulance crews on standby ready to respond to calls and meet response time targets. This was calculated in 2009 as ambulance crews standing by for 52.5 per cent of the time. In country areas, fees do not recover the labour costs of ambulance crews because they are either SJA paramedics paid for by WA Health or volunteers.
SJA’s ambulance service is the least expensive in Australia by a substantial amount using a cost per person indicator, and managing an efficient and cost effective service is one of SJA’s key objectives. Last year it was $72 per person compared to a national average of $110. There are a number of factors that influence this, including the reliance on volunteers in country areas and relatively low ambulance use in WA, with 36 per cent of ED patients arriving by ambulance compared to 47 per cent nationally.
The 2009 St John Ambulance Inquiry
In 2009 the Government established an inquiry (the Inquiry) into SJA following an ABC ‘Four Corners’ television program. The Inquiry Report said that the program ‘revealed four patients had died after inadequate responses by ambulance services’.
The Inquiry strongly endorsed many aspects of SJA and its arrangements with WA Health but made 13 key recommendations to improve ambulance services. Ten of these were stand alone and the rest contained 19 sub-recommendations (Appendix 1). One-third of all recommendations were directed towards WA Health and the Government.
A key recommendation was that the longstanding Government policy of an external provider of emergency ambulance services should continue. Comparing the cost per person with other states, the Inquiry found SJA was effective overall and cost effective for WA. Other recommendations included investing more in the service and establishing a team to oversee the implementation of all Inquiry recommendations and report within 12 months (by the end of 2010).
Two-thirds of all recommendations were directed towards SJA. These included making changes to SJA’s organisation and operations, increasing staff numbers and agreeing to further monitoring by WA Health. The Inquiry also found that changes in demand and population growth had stretched the largely volunteer model in country areas to its capacity. It recommended further assessment of ambulance needs in country areas.
The Government accepted all the Inquiry recommendations including the need for additional investment in ambulance services. This resulted in funding to SJA increasing from $42 million in 2008-09 to an expected $100 million this year.
Read More – Full Background (including additional information)