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Road Ambulance Service Cuts Highlight Vulnerability Of Ownership Model

The vulnerability of Aotearoa New Zealand’s road ambulance service was highlighted by the announcement last month than the largest ambulance (Hato Hone St John) was looking to pull ambulances off the road because of rising fiscal deficits.

It raised the question of whether the government ambulance service should also be government run. Presently it is provided by two charities. These recognised charitable organisations but is the model fit for purpose?

New Zealand’s health system already has a specific crisis in those public hospital laboratories that were privatised under both Labour and National led governments (to the shame of both).

These laboratories are integral to the functioning of around 70% of clinical decision-making in  their hospitals, including surgery.

The result has been disastrous including disintegration, equipment rundown, poor planning, and the devaluing and demoralisation of a highly skilled and committed laboratory workforce.

Privatisation has led to profit-maximisation asserting primacy over quality, service provision, and workforce health and wellbeing. Privatised laboratories is not fit for purpose for the functioning of public hospitals.

The ambulance service is different from the privatised laboratories in that they are not driven by profit maximisation.

However, the St John’s situation raises the question of whether charities are best suited to provide this service. It is just as integral to public hospitals as laboratories; just in a different way.  

The announcement

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St John’s announcement was reported by Stuff journalist Mariné Lourens in The Post on 17 February: Should ambulance service be government run?  

It was also covered by Ruth Hill on Radio New Zealand (19 February): Ambulances pulled of road due to deficit.  

The following day, as a  health commentator, I was interviewed by Mike Hosking on Newstalk ZB: Underfunding and need for ambulance service to be integrated more with hospitals.     

How the ambulance service works

So how does New Zealand’s ambulance service (called a ‘team’ by Health New Zealand – Te Whatu Ora) work. The system is described in reasonable plain language on Te Whatu Ora’s website: how the ambulance service works.

The service provides emergency services on behalf of Health New Zealand (medical) and the Accident Compensation Commission (injuries).  They are the prime funders. Donations and fundraising also provide revenue.

There are two ambulance providers – Hato Hone St John and the Wellington Free Ambulance.

The latter does not charge fees. Its additional funding comes from donations but is confined to the greater Wellington region. St John covers the rest of Aotearoa. It does charge fees for medical patients.

The highest priority of both charities is urgent or life-threatening situations such as cardiac arrest and serious injuries.

The ambulances are staffed by employees who are much more than drivers. They are paramedics; that is, they are registered health professionals with degrees in health science.

They possess the knowledge, skills and experience to assess and treat a wide range of clinical conditions, from relatively minor concerns to life-threatening illness.

When called to locations paramedics first assess whether they can either treat the patients themselves or take them directly to an emergency department (perhaps with some temporary holding treatment).

In some situations, where practical, paramedics can also assess whether it might be more clinically appropriate to divert patients to a local general practice.

Wellington Free Ambulance presently provides this diversion to general practices scheme on the Kāpiti Coast although it has been overwhelmed by rapidly increased 111 calls.

It is a good innovative initiative despite being caught in the tightening vice of staff shortages and increasing patient demand.

The funding deficit threat

Radio New Zealand’s Ruth Hill reported that the actions planned by St John involves ‘actively managing recalls’ of back-up staff, reducing so-called “non-essential travel”, and delaying some plans for medium to long-term improvements.

The ambulance service is already under significant pressure. For example,  ambulances sometimes forced to be parked up outside emergency departments because the latter are already overcrowded.

This is called ‘ambulance ramping’. On 25 October 2023 Newshub reported a serious case of this increasing phenomenon at Waikato Hospital: Ambulance ramping at Waikato Hospital.   

Further, reportedly some patients are already having to wait for five or six hours for an ambulance to arrive at their location because of understaffing.

Reducing resources and services only worsens the situation for both patients in need and overworked paramedics.

Integration and public ownership

In her account of this issue Mariné Lourens in The Post makes an additional highly pertinent observation.

She reports Faye McCann, national ambulance coordinator at First Union which represents paramedics, calling for the ambulance service to be publicly owned. Further:

New Zealanders need an ambulance service they can rely on, not a service that relies on donations. There shouldn’t be pressure for people to donate to ensure the ambulance service can be there for them when they need it.

… a government-run service… would allow healthcare services to be more streamlined and for pressures to be addressed in a way that ensures the brunt doesn’t always fall on ambulance workers.

The ambulance service is the one service that people fall back on when other health systems have failed them. It is often talked about the ambulance being at the bottom of the cliff. It simply doesn’t make sense to have them running as a charity.

This is a compelling argument which I agree with. The ambulance service is integral to the functioning of emergency departments. Along with the rest of the public hospitals within which they are located, emergency department doctors and nurses depend on this service.

It would make more practical and operational sense for the ambulance service to be structurally integrated with public hospitals rather than through charities, as well meaning and committed as they are.

Our ambulance service being government owned would not be internationally unique. This is the case, for example, in the United Kingdom and much of Australia.

The final word – for now!

A national ambulance dependent on charities is not fit-for-purpose in a modern health system.

The final word I will leave to Dr Frances Matthews, a general practitioner and medico-legal adviser.  

In response to my Mike Hosking Newstalk ZB which I subsequently posted on LinkedIn, she observed that the ambulance service with particular reference to rural areas:

…is an emergency service, yet it is run by a charity. Time to fully fund it and not have an emergency service that has to fund-raise for itself. Services are poor in rural areas and heavily dependent on volunteers who often feel exploited and undervalued by St John’s.

Yes it is part of the under resourcing of healthcare, but in rural areas it has been under resourced for decades.

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