Set up to assist in managing emergencies in rural locations, PRIME has recently seen some welcome changes to the remuneration models for on-call responders. However, campaigners say a full review of PRIME and after hours is required to best support the health needs of rural New Zealanders.
Funded by the Ministry of Health and ACC and administered by St John, PRIME was initially set up to coordinate emergency responses and leverage the skills of specially trained rural GPs and nurses to support the ambulance service. In some cases, the PRIME responder may be called where response times for an ambulance may impact patient wellbeing or where additional medical skills are required.
“PRIME was absolutely set up with good intent, however, we can see that since its inception, the current model is no longer fit for purpose and requires a full review,” says Mark Eager, CEO of Mobile Health and PRIME Chair.
Recent changes to PRIME have included changes to how PRIME’s on-call responders are paid to create a more equitable system. Rural Health Centres are now paid for each PRIME medical emergency they attend in person or clinically triage on the phone with the patient at the scene. This is in addition to the banded fund they already receive.
“The new payments help things but don’t solve the overwhelming issue of being under-resourced,” says Mr. Eager. “Money doesn’t make you less tired at the end of 64 hours on-call over a weekend, but at least it is recognition for the effort you put in.”
For Paul Walmsley, Practice Manager at Hanmer Springs Health Centre, the recent funding changes have been welcome as the centre runs at a loss in order to ensure on-call support is there for their rural community when required. “For the patients we serve, the Emergency Department is 135kms away,” says Mr. Walmsley. “We have a small but dedicated team at the health centre who take turns to be on-call after working a full day. I need to balance their safety and wellbeing against our overall aim to prevent or delay our local patients having to go to the ED in Christchurch.”
The challenge faced by the team at the Hanmer Springs Health Centre (and likely other similar rural health centres) is the low number of staff available to work as part of a team to cover 24 hours a day, 7 days a week. Mr. Walmsley decided to invest in recruiting a Paramedic practitioner to work directly for the health centre, not St John. This person has an intensive care paramedic skillset and the Hanmer Springs Health Centre paid for him to go on the 5-day PRIME training course. “Unfortunately, due to legislation, while he is more than adequately qualified to respond to emergencies, he is not allowed to respond to accidents and the health centre receive the – associated ACC payments.” For this reason, Mr. Walmsley is calling for urgent changes to legislation and contracts issued by the National Ambulance Sector Office to allow paramedics to work in primary care and be able to respond to both accident and medical emergencies respectively.
Mr. Walmsley gives an example of a situation where the Paramedic Practitioner was working after hours, dealing with urgent calls, when a life-threatening incident job came through from the 111-dispatch team. “Due to this legislation, he was not allowed to respond to that call, yet the nearest ambulance was over an hour away,” says Mr. Walmsley. “At some point, there will be a serious outcome for a patient as a result of the combination of being under-resourced and having out of date legislation.”
Acknowledging that the system is better than it used to be due to the recent changes made, Mr. Eager and the PRIME Board can see there are still significant gaps around country. “I believe we will only get it right if we do top-to-toe review. We need to look at after-hours care in its entirety, consider what would be the best response for emergencies and also how to best utilize the skilled practitioners we have in rural,” says Mr. Eager. “The PRIME Board is pleased to note we have now had a commitment from Te Whatu Ora to start that process with a newly announced team to lead it.”
For Mr. Walmsley, his vision for how PRIME could work in the future is focused on a new approach of setting up centralised facilities in key rural areas with all emergency services (including PRIME) on site. “With our local St John paramedic in Culverden stating that a call-out that ends in a trip to the Christchurch Emergency Department (ED) involves a round trip of 4-hours, it is easy to see how keeping patients local will allow more timely responses to patients in need of urgent or emergency care,” says Mr Walmsley. “I’d love to see rural out-of hours urgent and emergency health hubs with observation beds on site too so patients could be monitored and stabilized without needing to make the trip to hospital. This would reduce the load on ED and potentially save costs by keeping people out of the ED taking up beds and resources. It would also provide a better experience, closer to home, for the patient.”