How should non-emergency EMS presentations be managed? A thematic analysis of politicians’, policymakers’, clinicians’ and consumers’ viewpoints

Abstract

Objective

In 2023, Australian government emergency medical services (EMS) responded to over 4 million consumers, of which over 56% were not classified as an ‘emergency’, at the cost of AU$5.5 billion. We explored the viewpoints of politicians, policymakers, clinicians and consumers on how these non-emergency requests should be managed.

Design

A realist framework was adopted; a multidisciplinary team (including paramedicine, medicine and nursing) was formed; data were collected via semistructured focus groups or interviews, and thematic analysis was performed.

Setting and participants

56 participants were selected purposefully and via open advertisement: national and state parliamentarians (n=3); government heads of healthcare disciplines (n=3); government policymakers (n=5); industry policymakers in emergency medicine, general practice and paramedicine (n=6); EMS chief executive officers, medical directors and managers (n=7); academics (n=8), frontline clinicians in medicine, nursing and paramedicine (n=8); and consumers (n=16).

Results

Three themes emerged: first, the reality of the EMS workload (theme titled ‘facing reality’); second, perceptions of what direction policy should take to manage this (‘no silver bullet’) and finally, what the future role of EMS in society should be (‘finding the right space’). Participants provided 16 policy suggestions, of which 10 were widely supported: increasing public health literacy, removing the Medical Priority Dispatch System, supporting multidisciplinary teams, increasing 24-hour virtual emergency departments, revising undergraduate paramedic university education to reflect the reality of the contemporary role, increasing use of management plans for frequent consumers, better paramedic integration with the healthcare system, empowering callers by providing estimated wait times, reducing ineffective media campaigns to ‘save EMS for emergencies’ and EMS moving away from hospital referrals and towards community care.

Conclusions

There is a need to establish consensus on the role of EMS within society and, particularly, on whether the scope should continue expanding beyond emergency care. This research reports 16 possible ideas, each of which may warrant consideration, and maps them onto the standard patient journey.

Strengths and limitations of this study.

• This study captures the views of a cross-section of the healthcare system, including consumers, frontline clinicians, executives and politicians.

• This study aims to capture the breadth of viewpoints, rather than any single group in depth.

• Participant statements are taken at face value and not investigated for accuracy.

• Potential improvements in the healthcare system discussed by participants have been captured, categorised and mapped onto the standard patient journey.

Background

Globally, emergency medical services (EMS) report that non-emergency requests now make up the majority of their workload.¹,⁸ If both emergency and non-emergency calls are considered, data suggests that many EMS patients do not require emergency department (ED) transportation at all; a study from Sweden found 16% of all callers did not require ED transport,¹ a number that increased to 35% in the USA² and 41% in the UK.³ A global meta-analysis found that the vast majority (79%) of non-transported EMS patients do not present to the ED and that non-transported EMS patients have a low mortality rate of 1%.⁴ This mortality rate of 1% is comparable with the all-cause 30-day ED postdischarge mortality rate of 1.3%, suggesting no difference in mortality risk from EMS and ED discharges.⁵ In Australia, just 44% of the over 4 million consumers EMS attended in 2023 were classified as emergencies.⁶ Previous research has suggested that this 44% estimate—a determination made at the time of the initial telephone call—may be a significant overestimate: one EMS reported that just 2% of 77 000 patients remained ‘emergency’ after being reviewed by paramedics, while another EMS reported that 23% of ‘emergencies’ were safely left at the scene, and 50% of ‘emergencies’ required no treatment at all.^{7 8}

Having non-emergency EMS requests make up well over half of all requests is problematic, as EMS are not historically structured to meet the needs of what has now become their largest cohort.⁹,¹⁴ EMS was developed to provide rapid triage, response, resuscitation and transport to an ED.¹³ However, all of these may be ineffective and inefficient for non-emergency requests. For example, unnecessary ED transportation exacerbates congestion, increases nosocomial infection and risks iatrogenic harm.¹⁵,¹⁸ Additionally, the emergency response model is resource-intensive and represents a significant healthcare expense with a cost of AU$5.5 billion in Australia alone (the majority of which is government-funded).⁶ The difficulties of EMS managing non-emergency consumers are compounded by the rate of EMS use exceeding population growth; EMS is increasingly being used by society, with the growth primarily in non-emergency cases and the fundamental reasons for this remain unclear.⁹ These issues—increased non-emergency EMS usage and EMS difficulty in appropriately managing these cases—have been recently highlighted by four separate parliamentary inquiries into the delivery of ambulance services in Australia.¹⁹,²²

As early as 25 years ago, the role of paramedic EMS within society was instead envisioned as holistic services operating beyond emergency medicine in primary care fields such as surveillance and injury prevention.²³,²⁶ Despite a growing body of evidence that most EMS callers are not medical emergencies and do not require ED transportation, EMS transportation to an ED remains standard, with 85% of EMS patients transported in Australia last year.⁶ The idea of EMS providing non-emergency care has remained peripheral, with research suggesting EMS retain an ongoing internal organisational culture promoting over-transportation to the ED and that undergraduate paramedic university curricula remain widely focused on resuscitation rather than the urgent and primary care presentations new clinicians face when they graduate and commence practice.^{3 9 10 12}

Appropriate and efficient management of these non-emergency cases has now become a major contemporary challenge facing EMS in Australia.^{9 10 12} Multiple mechanisms to address the disconnect between the non-emergency care consumers are requesting and the emergency care EMS are providing are being investigated, including telehealth,²⁷,³⁰ increased referral pathways away from the ED³¹,³⁶ and introducing specialist community paramedics.³⁷,⁴¹ Individual mechanisms for addressing non-emergency demand are largely being investigated in isolation; however, research into policy changes suggests that broad support among multiple stakeholder groups is necessary to achieve successful implementation.⁴²,⁵⁰

A holistic understanding from across the healthcare system of societal views on how non-emergency cases should be managed is essential to predict which policies are most likely to receive the support necessary for successful implementation and is currently missing. This research seeks to fill this gap by exploring healthcare and societal perspectives, including those of consumers, parliamentarians, healthcare executives and frontline clinical staff, to capture a broad snapshot of how stakeholders believe non-emergency EMS presentations should be managed.

Methods

Design

To investigate stakeholder views, this research adopted an interpretivist axiology and a realist framework.⁵¹,⁵⁴ We followed the approach of previous studies, also investigating policy qualitatively⁴⁸⁵⁵,⁶³ and using latent and semantic thematic analysis.⁶⁴,⁶⁷ Methods were designed in advance in a published protocol⁶⁸ using the thematic analysis ‘trustworthiness’ criteria of credibility, transferability, dependability and confirmability.⁶⁹,⁷¹

Acknowledgement and consideration of one’s background and how this may influence data interpretation, known as reflexivity, is a core qualitative mechanism for improving trustworthiness.⁷⁰ The researchers in this team include professors in paramedicine (RB), medicine (GB), nursing (MG), specialists in advanced practice models of care (DC) and in emergency nursing care (CY), and a paramedic doctoral researcher (MW-S). The research team held fortnightly discussions to review methods, data analysis and findings over 6 months. This study will contribute to a larger environmental scan of community paramedicine.⁶⁸

Eligibility and recruitment

This research evaluated the perspectives of participants from a range of stakeholder backgrounds:

1. Consumers.

2. Political stakeholders.

3. Policy stakeholders.

4. Medical stakeholders.

5. Nursing stakeholders.

6. Paramedical stakeholders.

We identified potential interviewees for each relevant group before commencing the study and proactively contacted 179 individuals and 33 organisations; these are provided in the online supplemental materials and published in the protocol.⁶⁸ Interviewees were invited to suggest other potential interviewees (snowballing); responses received stated our list of sources was comprehensive. All interviews were voluntary and not remunerated, except for consumers who were provided with a nominal $15 voucher as an incentive to participate. All participants provided written informed consent, and at the time of enrolment, they were allocated a random participant number between 1 and 100.

Estimated sample size

Saturation was evaluated at fortnightly discussions using the protocol’s criteria of Thorne, applied to our research question.⁷²,⁷⁸ The research team decided that data saturation had been attained after considering factors such as the depth and richness of the data, the consistency and coherence of the emerging themes and the overall scope and boundaries of the research question.⁷²,⁷⁸ Initially, sampling was anticipated to require 30–50 interviews, as specified in the protocol. After 45 interviews, the research team agreed that saturation had been met in all categories except for consumers. There were concerns that the perspectives of healthcare clinicians significantly outnumbered and may ‘drown out’ the voice of consumers. Consequently, ethics approval was granted to increase the consumer cohort and an additional 11 consumers were recruited to ensure that the consumer cohort made up one-third of the final sample. Recruitment ended in August 2023 with 56 interviewees (26% of the 212 invited).

Interview procedures

An interview script was drafted a priori by MW-S that was designed to minimise acquiescence, habituation and wording biases.⁷⁹,⁸² This was also piloted first on MG, RB, DC and CY, then feedback sought via a survey of participants, and then additionally tested during the initial two interviews, with ongoing modification of questions at fortnightly discussions to address areas not yet reaching saturation. To ensure consistency, all interviews were conducted by a single researcher (MW-S), with a second researcher (CY) attending initial interviews to provide feedback on interview techniques. Interviews were conducted online via Zoom (Zoom Video Communications, 2022) and audio recorded.

In the initial stages of our research, we planned to conduct focus group discussions as the primary method of data collection. Focus groups were preferred to individual interviews due to their ability to facilitate dynamic interactions and allow participants to build upon each other’s perspectives, potentially generating richer and more nuanced insights.⁸³ To avoid the impact of group power dynamics on viewpoints, focus groups with consumers were conducted separately from other stakeholder subgroups.^{79 80 84}

However, given the diverse backgrounds and schedules of our participants, it became evident that coordinating focus groups involving all participants would be impractical. To accommodate the varying availabilities and constraints of our participants, we employed a flexible approach that combined both focus groups and individual interviews. While focus groups were conducted whenever feasible with participants who shared similar schedules and could convene at a common time, individual interviews were arranged for those whose availability did not align with the scheduled focus group sessions. It is important to note that while individual interviews may not provide the same level of interactive discourse as focus groups, they still allowed us to capture in-depth perspectives and experiences from each participant. To mitigate the potential loss of interaction and synergy inherent in focus group discussions, we ensured that the individual interviews were conducted using a semistructured guide, which encouraged participants to elaborate on their responses and share detailed accounts of their experiences.

Interviews were conducted from April to August 2023. A total of 16 focus groups were held (11 of healthcare stakeholders and 5 of consumers), covering 41 participants. 15 participants were unavailable during focus group times and participated in individual interviews. Focus groups initially aimed for five participants; however, the initial group of five participants was unexpectedly prolonged as participants spoke at length, and three participants provided feedback that the interview duration should be reduced. Therefore, the focus group size was reduced to a target of 2–3 to reduce their length while still giving each participant sufficient time to express their views. No time limit was provided for interviews, and the median length was 40 min, with a minimum of 27 min and a maximum of 74 min. Intelligent transcription was conducted by a single reviewer (MW-S) in Microsoft Word (Microsoft, 2022) to increase data familiarity.^{85 86}

Data analysis

An inductive analysis was performed on the data collected from both the focus groups and individual interviews, allowing themes and insights to emerge organically from the rich and detailed accounts provided by the participants, regardless of the data collection method.⁶⁴,⁶⁷⁸⁷ Thematic analysis was conducted following the guidance of Braun and Clarke.⁶⁴,⁶⁷⁸⁵ First, data familiarity was achieved via a combination of direct interviewing, constant memoing, direct transcription and continual re-reading and re-coding of the transcripts.⁶⁴,⁶⁷⁸⁵ NVivo (V.1.0 (2020), QSR International, 2022) was used for initial coding, with the first⁶⁴,⁶⁷⁸⁸ two manuscripts being coded and reviewed by the entire research team to ensure consistency; there were no meaningful differences in coding from these audited transcripts. Participants were provided with a list of quotes and the context in which they were intended to be used and asked to comment; this mechanism aimed to improve credibility.^{69 70} From this, some participants removed informal language, and several specific examples of healthcare system failures were removed to ensure confidentiality; none of these changes were considered by the research team to impact findings, and participants were almost entirely supportive of the research team’s interpretation, including of the latent theme. The analysis was reflexive, with the research team meeting fortnightly to discuss the research.^{65 67}

Patient and public involvement

Patients and the public were involved in the selection of research participants via snowballing, and in the piloting of the survey. Beyond this, patients and the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research. Participants were able to elect to receive a copy of any published manuscripts.

Results

There were 56 participants, with an approximately equal third split between paramedicine, consumers and other healthcare stakeholder perspectives as per the protocol.⁶⁸ The backgrounds of the participants are shown in figure 1. To illustrate themes using the participant’s own words, a small selection of quotations is presented. These are chosen for their clarity and conciseness rather than breadth of representation, and significantly expanded lists of quotes totalling 16 000 words, organised by theme and subtheme, are available in the online supplemental materials.

Figure 1. Participants broken down by background: as per the protocol, an approximately equal split between paramedics, consumers and all other backgrounds was sought.

During thematic analysis, three themes and six subthemes were identified. Theme names were taken directly from participants’ own words where a suitable quote existed. Where no suitable quote could be found, a plain-language description was used. The first theme, ‘facing reality’, captured candid reflections on the current EMS and emergency healthcare experience, and the theme name was taken from a participant’s quote that all stakeholders ‘need to start facing reality’ in acknowledging the severe impact of non-emergency EMS requests. The second theme, ‘no silver bullet’, acknowledged the complexity of the healthcare system and that multiple solutions are necessary, and the theme additionally gathered and organised suggestions to address non-emergency EMS use raised by participants. This theme name was taken from a participant’s quote that managing non-emergency EMS requests has ‘no one silver bullet’ and instead requires multiple approaches. The final theme, ‘finding the right space’, covered the fierce debate as to what the role of EMS in society should be in the future, with the theme title reworded from a participant quote that paramedicine is yet to ‘find the right space for itself’ in the broader healthcare system.

Facing reality

The first theme was recognising the reality of EMS, emergency, urgent and primary care workloads. Three subthemes were captured, shown in table 1. ‘Picking up the pieces’ reported views—largely from within EMS—about how EMS is currently being used in practice to ‘clean up’ unmet demand in the primary-urgent-emergency sectors. ‘The perspective throughout healthcare’ reports the views of those in the primary-urgent-emergency care junction on their experiences outside of EMS. ‘Exploring contemporary EMS usage’ draws mainly from consumer perspectives to identify possible reasons why non-emergency requests now dominate EMS demand.

Table 1. ‘Facing reality’ subthemes.

Subtheme		Example quotes
Picking up the pieces: urgent-primary overload in EMS		‘The ambulance service is on fire. Just to put it into words.’ #67, Paramedicine, Manager‘The system, just by my observation, is broken.’ #20, Paramedicine, Academic‘We’ll never catch up.’ #62, Parliamentarian‘We see huge numbers of people who don't need an emergency department…But they also need something pretty much now.’ #65, Paramedicine, Manager‘We are currently sending people by taxi.’ #1, Paramedicine, Manager‘It just is clogging up the healthcare system… (we need to) help paramedics with actually responding to the high acuity stuff.’ #74, Consumer‘We can’t begrudge the situation. I mean, I feel that really deeply. Quite a lot of my team—they’re bloody good people—they say, “This is bullshit, we’re always the ones who have to pick up the pieces at the end.” My response to that is, “Yeah, damn straight we do.”’ #26, Paramedicine, Executive‘Clearly, there’s a cohort of patients that could access the ambulance service but don’t necessarily need to access emergency services and could be treated at home.’ #62, Parliamentarian‘This person needs to go somewhere. Now, either that’s available in the community, or (paramedics are) going to provide it.’ #5, Chief Officer (State)‘Whose job is that to do it? I don’t know. It’s just a gap in the system, and at the end of the day, if we don’t close the gap, it defaults to us.’ #81, Paramedicine, Manager
The perspective throughout healthcare		‘They come and sit in my ED. And then they stay there all night, and then I just send them home, anyway.’ #25, Medicine (ED), Clinician‘There’s trouble with access to GPs. So I know for me, I've got patients booking out two-and-a-half months in advance to see me.’ #99, Medicine (GP), Clinician‘We've been warning that we don't have enough GPs for between 15 and 20 years, and we've also watched all of these kind of solutions come and go for 15 or 20 years, and the numbers of GPs have just steadily gone down.’ #41, Medicine (GP), Policy (State)
Exploring contemporary EMS usage	Culture	‘Until every single person in Australia is medically trained, we’ll continue to call ‘000’ for everything. We don’t know what is serious, or what to do. That’s for you to tell us.’ #16, Consumer‘Our rulebook says to call ‘000’ anytime there is anything medical. It’s because of our duty of care. It doesn’t say to consider a GP, or transporting ourselves…We will continue to do that.’ #16, Carer‘There is a lot of misinformation in the media…that if you don’t get to the hospital as soon as possible you’re going to die.’ #70, Consumer‘I’ve seen someone waiting 6 hours on a building site because they had a cut finger. Because somebody there said they have to have an ambulance. That medicolegal risk aspect, how do we manage that?’ #51, Paramedicine, Clinician-Researcher
	Convenience	‘The ambulance service that we have today is a victim of its own success. We’re really, really good at our job, and we’re really nice people, and people like us. The public like us, and they know that all they need to do is pick up the phone and dial ‘000’, and they’re going to get really nice people turn up who are going to look after them. And that’s what people want.’ #9, Paramedicine, Clinician(Referring to the previous quote) ‘Yeah. I agree with that. Pretty wholeheartedly to be honest…People expect a certain level of care, and they expect it now, and they expect it for free.’ #25, Medicine (ED), Clinician‘I’ve also had my GP take the view of, ”Let’s get it out of my practice, it’s Friday afternoon, I want to go home, phone an ambulance and that way I can sign off.” I’ve had that happen.’ #54, Consumer
	Cost	‘It’s free, and it’s easy to access… (My general practitioner) still cost me $180 sometimes, and it’s just insane. I didn't choose to be sick.’ #74, Consumer
	Lack of alternatives	‘We have nobody in our life. Paramedics are the window to the world. We are reliant on you. You are our substitute family in that exact moment.’ #70, Consumer‘There are no doctors outside of hours and it takes 3 weeks to get a doctor’s appointment…you would call ‘000’ because there’s no bloody options.’ #12, Consumer‘The unfortunate situation with ambulance now is it’s seen to be the one stop shop that everyone funnels their troubles into, because the phone’s picked up and they get some sort of response.’ #62, Parliamentarian‘I’m calling ‘000’ because I have no idea who else to call. They always sort it out.’ #10, Consumer

EMSemergency medical services

There was a universal acknowledgement of a shift towards urgent-primary workload in EMS. Those within EMS viewed EMS as being unable to appropriately cope with this non-emergency demand due to being historically structured for emergency response. They also recognised their role as a ‘service of last resort’, and that they could not turn consumers away. The perspective from the wider medical community, including EDs, general practitioners (GPs) and Urgent Care Centres, mirrored the sentiment of increasing primary and urgent demand, which is being referred to EDs due to a lack of other options. Participants speculated on causes for this and raised four main reasons for the shift in presentations, including the convenience of receiving care quickly and at home, cultural changes (including lower healthcare self-efficacy and increased expectation for fast and easy services), cost avoidance (EMS in Australia are largely free, while GP appointments routinely incur an out-of-pocket ‘gap fee’ for patients, which may incentivise consumers to seek emergency assistance for non-emergency conditions) and lack of alternative services (including shortage of GPs).

No silver bullet

The second theme addresses participants’ discussion of perceived solutions and what direction they believed policy should go. Three subthemes were captured, illustrated in table 2. ‘The complexity of models’ captures the unanimous opinion that no single solution to managing shifting presentations exists and that multiple avenues will need to be pursued. ‘To each their own’ is a latent subtheme identifying the focus of each healthcare participant on their own profession. ‘Down to brass tacks’ lists the 16 suggestions raised by participants (tables36).

Table 2. ‘No silver bullet’ subthemes.

Subtheme	Example quotes*
The complexity of models	‘There is no one silver bullet.’ #51, Paramedicine, Clinician-Researcher‘This is absolutely a complicated space, and every thought or every concept has multiple tentacles that come out from it. And then they start to overlap over time.’ #5, Chief Officer (State)
To each their own	‘This research is a good opportunity to send back that what we actually need are more GPs.’ General practice policymaker‘I think there’s a lot of magical thinking around what we can do in the community… I think EDs will stay big.’ Emergency department policymaker‘Paramedicine is so well positioned for this.’ Paramedic policymaker‘There’s clearly a broader role for nursing in primary healthcare, making sure that nurses, and midwives to some extent, but in this context mostly I would think nurses, to be able to work to their full scope of practice.’ Nurse policymaker
Down to brass tacks	Quotations organised into 16 concepts, provided intables36below

^*As several participants hold unique roles, from which they can easily be identified, a different quote attribution layout is used in ‘To each their own’ to identify the background of the participant without undermining confidentiality.

EDemergency departmentGPgeneral practitioner

Table 3. Participant suggestions for managing non-urgent EMS demand: broad ideas.

Increased EMS acceptance of risk	‘(EMS) are worried about getting in the newspapers… There are some who are breaking themselves to try and have very low tolerance of risk. And they’re breaking their people, and it’s just it’s going to end very poorly in a number of jurisdictions very soon. The wheels are already falling off.’ #5, Chief Officer (State)‘We’re very, very litigation avoidant.’ #67, Paramedicine, Manager‘Be willing to do the bad news stories. Where we get it wrong, understanding that on top of that it’s a whole bunch of good news stories where somebody didn't have to wait in emergency. Or we didn't have a situation where we had no cars on the road for those people who did have a stroke, or did have a heart attack.’ #3, Chief Officer (State)‘Ambulance services, their culture traditionally is, there is almost this sort of paramilitary, paternalistic, and it’s holding paramedics back.’ #51, Paramedicine, Clinician-Researcher
Increased use of management plans for frequent consumers	‘You’ve got the same old people calling the same old number, for the same old thing. And it’s amazing what you can achieve if you’ve got a clinical management plan. You have a discussion between the ED and the ambulance services, work on a management plan for that patient, and what the red flags would be to necessitate a transfer, and which is a kind that you can manage at home.’ #75, Medicine (ED), Policy (State)‘More than three visits to the local ED within three months, or something like that, you got flagged for a review by this programme and that was good.’ #64, Medicine (ED), Policy (National)
Better paramedic integration with the healthcare system	‘We'll start to see Chief Paramedic Officers across all the jurisdictions…similar to your Chief Medical Officers and your Chief Nursing Officers, and they will be kind of acting as the custodians of the profession, and then we hopefully… one day, we'll see a Federal Chief Paramedic Officer as well. So I think right now really it’s just Victoria that’s got it and I think the structure where it sits outside of jurisdictional system is perfect.’ #80, Paramedicine, Manager‘Paramedicine has historically been excluded from a lot of conversations around this. I just can’t get my head around it. Like a hospital going, ‘we’re busy because ambulances are bringing in people, but don’t integrate, don’t work with us.’’ #51, Paramedicine, Clinician-Researcher

EMSemergency medical services

Table 6. Participant suggestions for managing non-urgent EMS demand: ideas affecting on-scene paramedics.

Addressing overtransportation to EDs by paramedics	‘I want to see people who have like an actual acute problem that can’t wait until tomorrow, because that’s what I’m good at fixing. People presenting with like vague abdominal complaints, who’ve got normal obs, and they’re 22 years old, or they’ve come in with COVID, and their sats are normal, like, I just *grimaces* you know, it just doesn’t… it’s a… it’s a real drain.’ #25, Medicine (ED), Clinician‘We should have a look at that case…as opposed to having a blanket rule going, “From now on every back pain must be transported.”’ #2, Paramedicine (Intensive Care), Clinician‘The philosophy of ambulance is often a bit about a one night stand, right? Come in, wham bam thank you ma’am. Drop her at the hospital, you know, nice seeing you, never see you again.’ #66, Consumer Representative(Referring to paramedics leaving people at home) ‘That makes me less afraid than having all these people in my waiting room…The ED is a time sink where badness happens.’ #25, Medicine (ED), Clinician‘Don’t bring everybody to us.’ #75, Medicine (ED), Policy (State)‘These complex tier patients need a different sort of process of how we approach them. Walking in, throwing a blood pressure on, taking their temperature, firing 50 questions at them, and then ten seconds later, “Oh well. Get in the ambulance then.” That’s not an approach.’ #51, Paramedicine, Clinician-Researcher
Paramedic services recognising the move away from hospitals and towards primary care	‘People will still fall through the cracks if they don't have a GP at the centre of their care.’ #21, Paramedicine, Academic‘The future is not hospitals. You know, the future is primary care.’ #85, Paramedicine, Policymaker (National)
Viewpoints on hiring more paramedics	‘I would say, number one, hire more paramedics.’ #57, Consumer‘The solution’s not to put more emergency paramedics on. You’re just shoving more into a system that’s already full.’ #14, Paramedicine, Academic‘You can put more paramedics on in every State. Is it going to fix the problem? No, it’s not. It just means more paramedics will be lined up at the front door of the hospital.’ #62, Parliamentarian
Viewpoints on Urgent Care Centres	‘The commonwealth Urgent Care Centres have been tried previously. They’ve all universally failed every other time. I can’t imagine that this investment is going to last beyond the decade. And so we’re going to have to work out a solution that doesn’t necessarily depend on those.’ #5, Chief Officer (State)‘Urgent care is problematic in Australia, which is not set up for it. It’s falling over in New Zealand.’ #64, Medicine (ED), Policy (National)‘My personal experience has been all of (my patients) have ended up having to go to hospital anyway.’ #99, Medicine (GP), Clinician
Multidisciplinary teams working to full scope, including pharmacists, nurse practitioners, and allied health	‘The primary healthcare system is very medical-centric. The models that we currently deliver, our fee for service model, it focuses around an individual practitioner. It doesn’t facilitate multidisciplinary teams. And yet all of the science tells us that, particularly with an ageing population, management of chronic disease, it is the multidisciplinary team methodology that will deliver the best outcomes for patients and the best system response.’ #30, Chief Officer (National)‘Too often it is medicine and nursing. You know, pharmacy, physio, everyone outside of medicine and nursing needs to be included.’ #48, Paramedicine, Clinician-Academic‘We’re still so MBS obsessed.’ #41, Medicine (GP), Policy (State)
Increasing all-hours virtual EDs	‘I would love to see a 24 hour virtual care clinic…a lot of this stuff happens after hours.’ #7, Paramedicine, Clinician‘A big part of (success) is decision support through the virtual ED and expanding the availability of medications and referral pathways that paramedics have available to them.’ #65, Paramedicine, Manager
Revising undergraduate paramedic education to reflect the reality of the role	‘We’re not training them for the job that they do…they’re not trained to deal with probably 50% of what they’re exposed to, and they turn around and just go, “Oh, they’re complex.” Well, yeah. That’s the reality.’ #51, Paramedicine, Clinician-Researcher‘Having a, I don’t know, a subject on “When can I be super confident that the GP can see this in 3 days’ time”, would be really helpful.’ #99, Medicine (GP), Clinician‘One of my jobs as a team leader is going speak to the interns about everything primary healthcare, and there’s just big blank faces.’ #1, Paramedicine, Manager‘Early in the degree, early, early, early.’ #20, Paramedicine, Academic‘At an undergraduate level…we set people up for disillusionment and failure.’ #5, Chief Officer (State)‘I don’t know what the hell we’re supposed to be teaching them? I’m just not too sure what paramedics do.’ #6, Paramedicine, Academic

EDemergency departmentsEMSemergency medical servicesGPgeneral practitioner

Urgent and primary care service models were universally recognised as highly complex, and all stakeholders agreed that multiple potential changes would need to be pursued. The latent theme ‘To each their own’ captured that very few interviewees advocated for other professions than their own as being better suited to meeting consumer needs, and no stakeholder group appeared to have a holistic view of the consumer perspective. For example, several emergency doctors recommended more ED funding, GPs more primary care funding, nurses more nursing scope, and paramedics increasing paramedic roles.

Finally, ‘down to brass tacks’ captures stakeholder comments on how they believed non-emergency EMS demand should be managed. The data provided were collated into 16 concepts, organised into four categories. The first category, presented in table 3, captured broad ideas that may impact multiple points in the patient journey and includes changing the EMS risk profile, using patient management plans (documents developed by a multidisciplinary team to guide the treatment of a single patient, particularly for frequent users) and integrating paramedicine with the wider healthcare system.

The second set of suggestions, outlined in table 4, are those mainly aimed at reducing EMS requests before they occur; this includes avoiding media campaigns to ‘save EMS for emergencies’, increasing general public health literacy at the school level and a debate around disincentivising callers to call EMS.

Table 4. Participant suggestions for managing non-urgent EMS demand: reducing requests.

Reducing ineffective media campaigns to ‘save EMS for emergencies’	‘We still – including myself – stood in front of TV cameras in our uniforms saying, “Please, save ‘000’ for emergencies.” No one listened. Like, seriously, no one listened.’ #13, Government, Policymaker (State)‘All these ghastly “Don’t call ‘000’” campaigns, which I loathe. They’re a waste of everyone’s time and money… it’s dumb to now sit here and go, “Stop! Stop! Stop using this service!”’ #9, Paramedicine, Clinician‘For too long the focus has been on saying, “Don’t call, unless it’s an emergency.” The reality is a more helpful position to take is “Call us irrespective of the circumstances, and we will augment our services around your healthcare need.”’ #26, Paramedicine, Executive
Increasing general public health literacy, particularly at the school level	‘You got a lot of education in school that if you ever need help, you know, just call ‘000’.’ #74, Consumer‘There’s that lack of medical knowledge of like, Oh, should we? Should we not?’ #57, Consumer‘We get a lot of abuse, verbal, physical in the service, because we just don’t just take to hospital. And it takes a lot of education.’ #67, Paramedicine, Manager‘As a teacher I would say we need to start from kindergarten. Let’s make sure this is part of a compulsory curriculum in health community education that we have people from ambulance go out to primary schools, kindergartens and high schools and give that community-based education to students.’ #70, Consumer
Discouraging callers from using EMS, including via increasing cost	‘There’s got to be some levers, there’s carrots and sticks which often are cost or time, which make it easier for people to go to their GP and harder for people to get transported to hospital. “Oh it costs me money to get into my GP.” And go, “Well. Okay. Well it costs you 60 bucks to get into your GP. We’re now going to charge you 60 bucks (for an ambulance).”’ #3, Chief Officer (State)(Responding to the above quote) ‘So I completely disagree with it. I think it’s increasing the gap between rich and poor access to healthcare. It’s a model that works in the top half of your socioeconomic band. Market forces work if you’ve got money to spare. Completely disagree with that.’ #99, Medicine (GP), Clinician‘It makes access to care difficult for the most marginalised cohort in our society and that I can’t get my head behind.’ #5, Chief Officer (State)‘I think that disincentivisation would need to be thought through very carefully.’ #63, Government, Policymaker (State)‘Paramedics are such a safe haven for people to go to.’ #57, Consumer

EMSemergency medical services

Third, there were suggestions that aimed to provide alternatives to dispatching paramedics once a call had been received. These are outlined in table 5 and include modifying or replacing the Medical Priority Dispatch System (MPDS, the telephone triage system used by most paramedic services throughout the world), increasing telehealth and empowering consumers to seek alternate care by providing estimated wait times.

Table 5. Participant suggestions for managing non-urgent EMS demand: reducing paramedic attendance.

Revising or removing the MPDS	‘The phone people aren’t very helpful. Everything gets treated as if you’re about to die. Even if I say to them, “This isn’t an emergency, I just need guidance”, they still ask me questions as if I’m about to die, like “Are you able to breathe?”, and then they ask me nothing about why I actually rang.’ #10, Consumer‘We should be looking at the MPDS, the ProQA. The algorithm involved that, as soon as you mentioned breathing difficulties, bang, you get a Code 1. We all use it. It’s been around for years. That’s one part of the system puzzle.’ #68, Paramedicine, Academic‘Grow backbone in the phone system.’ #67, Paramedicine, Manager‘I’m not sure that there’s an opportunity to necessarily make MPDS fit for purpose.’ #5, Chief Officer (State)‘(MPDS) specificity is poor, any paramedical student that’s done more than five days on road knows that… it’s very risk averse, we see too many cases that are code ones.’ #2, Paramedicine (Intensive Care), Clinician‘Things that can be changed? The MPDS system. MPDS is appallingly bad. And what inevitably happens is that there is a one-off bad outcome from under coding, so the service changes that entire category to be a Code 1 from fear and risk aversion and to look like they are responding appropriately, and it’s totally inappropriate. The services seem inclined to make everything a Code 1, whereas the reality is that it’s almost nothing. Whole ambulance services are built on that. Like, how…?’ #51, Paramedicine, Clinician-Researcher
Increasing the use of telehealth	‘Do a FaceTime consult. You can actually get a lot of patient information from telehealth. I think it’s really good.’ #25, Medicine (ED), Clinician‘We end up getting a lot of calls from 13Health. Once as a clinician you arrive and you go, well, it seems like odd advice. They’re pretty conservative, you know.’ #52, Paramedicine, Policy (National)‘I think raising greater awareness of the other help lines, nurse-on-call and other after hours services. I don’t know how that’s going to work, but probably raising that awareness is one way to ensure that people don’t use ‘000’ as their main number.’ #94, Consumer
Empowering callers by providing them with estimated wait times	‘If you try to ask how far away it is, you always get a bureaucratic non-answer like “It has been arranged.” Keeping secrets from us isn’t helping anyone. It’s like being gaslit by the government.’ #43, Consumer‘We should empower people to make good decisions, and they can’t do that if they’re expecting the ambulance, if they ring and you go, “No worries. See you soon.” When they ring back they get told ”The ambulance has been arranged”, which to most people sounds like it’s coming even though it’s not.’ #5, Chief Officer (State)‘I had an issue where my mother fell and I couldn‘t get her up off the ground myself. In the end it took an ambulance about 7 hours to get here to help get her up. Now if we had of known that it was going to be a very long wait… I probably would have tried to find somebody else who could help lift her.’ #12, Consumer

EMSemergency medical servicesMPDSMedical Priority Dispatch System

Fourth, table 6 outlines suggestions that impact on-scene care. This includes reducing EMS transportation rates, paramedic services building pathways to refer to alternate care rather than transporting to the ED, avoiding reliance on hiring more paramedics, avoiding reliance on Urgent Care Centres, forming multidisciplinary teams that work to full scope, increasing all-hours virtual EDs and revising undergraduate paramedic education to reflect the reality of the contemporary role.

Ideas were not universally suggested or supported by all stakeholders, and to capture this, which stakeholder groups overall supported or opposed different suggestions is provided in table 7. Later focus groups additionally had the opportunity to comment on ideas raised by earlier focus groups.

Table 7. Participant suggestions for managing non-emergency EMS requests for service.

The suggestion	Where it would affect the patient journey	Stakeholder groups*
		Supportive	Oppositional
Increased EMS acceptance of risk	Broad ideas that apply to multiple stages in the consumer journey	Emergency physicians (clinical)Government policymakersParamedics (clinical)	Government policymakers Emergency physicians (policy)
Increased use of management plans for frequent consumers		Emergency physicians (policy)General physicians (policy)
Better paramedic integration with the healthcare system		Paramedics (academic)Paramedics (managerial)
Reducing ineffective media campaigns to ‘save EMS for emergencies’	Reducing non-emergency EMS calls	ConsumersEmergency physicians (policy)General physicians (policy)Government policymakersParamedics (academic)Paramedics (managerial)Parliamentarians
Increasing general public health literacy, particularly at the school level		Government policymakersParamedics (managerial)Paramedics (academic)Paramedics (clinical)
Discouraging callers from using EMS, including via increasing cost		Government policymakers	Government policymakersEmergency physicians (policy)General physicians (policy)Paramedics (academic)Paramedics (clinical)Paramedics (managerial)Consumers
Revising or removing the Medical Priority Dispatch System	Alternatives to dispatching emergency paramedics after an urgent-primary call was received	Government policymakersConsumersParamedics (academic)Paramedics (clinical)Paramedics (managerial)
Increasing the use of telehealth		ConsumersGovernment policymakersParamedics (academic)Emergency physicians (policy)General physicians (clinical)Parliamentarians	Government policymakersParamedics (academic)Paramedics (policy)General physicians (policy)
Empowering callers by providing them with estimated wait times		Government policymakersConsumers
Addressing over-transportation to the ED by paramedics	Ideas affecting on-scene paramedics	Government policymakersParliamentariansParamedics (clinical)Paramedics (academic)Emergency physicians (policy)Emergency physicians (clinical)Consumers	Paramedics (managerial)Emergency physicians (policy)
Paramedic services recognising the move away from hospitals and towards primary care		Paramedics (academic)Paramedics (policy)Emergency physicians (policy)
Viewpoints on hiring more paramedics		Consumers	Paramedics (academic)Parliamentarians
Viewpoints on Urgent Care Centres		Government policymakersConsumers	Government policymakersEmergency physicians (policy)Emergency physicians (clinical)General physicians (clinical)
Multidisciplinary teams working to full scope, including pharmacists, nurse practitioners, and allied health		Government policymakersParliamentariansParamedics (policy)Paramedics (academic)Emergency physicians (clinical)General physicians (clinical)
Increasing all-hours Virtual EDs		Paramedics (clinical)Paramedics (managerial)
Revising undergraduate paramedic education to reflect the reality of the role		Government policymakersParamedics (clinical)Paramedics (managerial)Paramedics (policy)Paramedics (academic)General physicians (clinical)

^*Categorisation represents the majority or strongest view within a stakeholder group following analysis, not any individual participants’ views.

EDemergency departmentEMSemergency medical service

Finally, the research team mapped how the 16 suggestions provided are theorised to affect the patient pathway. This is illustrated below in figure 2.

Figure 2. How participant suggestions may influence the consumer pathway.

Finding the right space

The third theme captured a large topic raised both semantically and latently throughout nearly all interviews: what the role of EMS should be. Two subthemes were identified, presented in table 8. ‘Focus on resuscitation’ captured the view that EMS exists to provide life-threatening care and that other presentations, such as non-emergency cases, are fundamentally not the responsibility of EMS, regardless of making up the majority of caseload. ‘Adaptation to what the community wants’ instead held that EMS has a responsibility to meet community needs and that these needs are increasingly non-emergency.

Table 8. Finding the right space subthemes.

Subtheme	Example quotes
Focus on resuscitation	‘The ambulance service should be focused towards that emergency response, as it has always had being its role.’ #85, Paramedicine, Policymaker (National)‘The paramedics’ role is immediate care and assistance.’ #64, Medicine (ED), Policy (National)‘I’ve always regarded ‘000’ as an emergency-only system and that if in fact it is something that you can deal with by some alternative method, then you shouldn’t be using ‘000’.’ #18, Consumer‘We don’t want more people calling ‘000’ because our service is too good.’ #19, Medicine (ED), Policymaker (State)
Adaptation to what the community wants	‘We need to do a better job of recognising that we’re not an emergency service anymore.’ #9, Paramedicine, Clinician‘Calling ‘000’ is the safest option that relegates the decision making to the emergency services.’ #53, Consumer‘I also live on my own. I don’t have any friends, I don’t have any family, and that’s okay, but it puts my reliance just on me. I have to do what’s right for me.’ #70, Consumer‘(The general public is) paying for all this. The question is, do they get any say in how it’s deployed? The answer is probably not really.’ #66, Consumer Representative‘Is it our job? Is it a paramedic’s job to be in the primary healthcare area? I’m going to say, well, if we're not there, whose job is it to pick up the pieces? And people go, “Well, it’ll default to ambulance.” If it’s going to come to us, we might as well be proactive.’ #81, Paramedicine, Manager‘It’s a great opportunity to accept that that’s how people want to access unplanned healthcare. Embrace it, build a system around it, and the system copes better, and the patients are happier and do better. I would really like us to see it as an opportunity.’ #65, Paramedicine, Manager

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The views in ‘focus on resuscitation’ suggested that primary-urgent care should be dealt with by EMS through diversion and referral. ‘Adaptation to what the community wants’ instead advocated for EMS as directly providing urgent and primary care, including proactive instead of reactive patient monitoring (with health education and injury prevention), increased paramedic abilities and specialist community paramedics. These two subthemes were not mutually exclusive, and many participants supported both.

Discussion

This research is the first to broadly cross-section societal perspectives on how EMS should manage non-emergency presentations, and in doing so, it adds to the existing literature in four main ways. First, the participant statements candidly outlined several major reported drivers of EMS use for non-emergencies, which could provide guidance on identifying alternative care pathways and educational initiatives to direct these patients to more appropriate and cost-effective care settings. Reasons consumers call EMS for urgent and primary care problems have been previously explored, and our findings are largely consistent with past findings. Booker et al analysed 50 patients who called EMS for ‘primary care problems’ in depth and also found a lack of alternative options was a driver of calls. In that study, they reported patients being motivated to call EMS by roadblocks to alternative care and feelings of isolation.¹¹ While Booker et al did not use the code ‘culture’, many of their other participant quotations fall into how we used that category, particularly patients feeling overwhelmed or unsure what symptoms constitute an emergency (eg, any rash potentially being meningococcal meningitis).¹¹ However, our other findings of convenience and cost—both primarily reported by consumers themselves, the same population as in Booker’s study—were not reported by Booker et al.¹¹ This may be partially due to differences in either country’s sample (their study’s sample was drawn from the UK, while ours is Australian) or time period (their study was conducted pre-COVID, while ours is post-COVID), both of which may reasonably be expected to influence EMS usage.

Dejean et al interviewed 19 paramedics in Canada, who reported that they suspected drivers for patient non-emergency calls included difficulty accessing the healthcare system, culture changes (including subjective consumer definitions of what is an emergency and a lack of consumer healthcare self-efficacy) and system failures leading to a lack of alternative options.⁸⁹ All of these are consistent with our research, with the exception of cost, which was raised by our consumers and the majority of our policymakers but not by Dejean’s paramedics; this may be because our research sampled a broader population beyond paramedics only and cost was instead raised by consumers, academics and policymakers.⁸⁹ Mills et al surveyed 564 participants (148 with a healthcare background) about healthcare literacy, experimentally showing that over 40% of participants inaccurately stated that a non-emergency required EMS and that nearly 100% inaccurately stated that an emergency did not require EMS and that youth correlates with lower accuracy in identifying the requirement of EMS.⁹⁰ This correlates with our finding that low health literacy may be driving non-emergency EMS calls.

Similarly, our research adds to previous research on drivers of non-emergency EMS demand by surveying a broad cross-section of the healthcare system, rather than only patients or paramedics, and is the first to interview policymakers, politicians, and clinicians beyond paramedicine (including emergency medicine, general practice, nursing, allied health, and others). Drivers of demand identified in our research that we have not seen reported elsewhere include relatively low costs. This may be more relevant in Australia than in other countries, as EMS in Australia is largely free, while GP appointments routinely incur an out-of-pocket ‘gap fee’ for patients. That may incentivise consumers to seek emergency assistance for non-emergency conditions, particularly with increasing GP gap fees.^{91 92} A second novel driver of demand we identified is medicolegal or organisational policy requirements from residential aged care facilities, disability carers and workplace health and safety representatives to automatically request EMS for assessment of any potential injury, regardless of how minor.

Second, while previous literature has long discussed EMS moving into proactive and preventative healthcare,^{23 24} we are not aware of any existing literature that contrasts the views of a large cross-section of the healthcare system on this. The most significant finding in this research was the disagreement on the role of EMS within healthcare. Some healthcare participants stated EMS should be limited to their traditional mandate of emergency care and resuscitation. These participants viewed alternatives, such as community paramedics and secondary triage, as not the responsibility of EMS. They considered that increased non-emergency calls should be dealt with via telephone referral elsewhere and stated that urgent-primary presentations reflect a failure in primary healthcare that, despite having flow-on effects for EMS, does not require addressing by EMS. Conversely, other healthcare participants viewed the role of EMS as meeting societal needs and that EMS should proactively adapt to answer emerging healthcare gaps. This research does not identify either of these approaches as being right or wrong, but consistent with research on policy implementation, it is reasonable to suggest that the unresolved differences of opinion are likely to inhibit fully effective pursuit of one direction or the other and exacerbate mixed messaging; a national-level policy direction is likely necessary to resolve conflict and ensure effective service delivery.

Third, while there is a vast body of literature exploring different individual suggestions for how EMS should manage non-emergency presentations, we are not aware of any research collating these suggestions and mapping stakeholder perspectives. As policy requires broad support across stakeholder groups to be successfully implemented,⁴²,⁵⁰ understanding which proposals have broad support and which have narrow support or conflicting opinions is critical to effective policy development. However, while the breadth of views is the main strength of this study, it is important to note that the size of each individual stakeholder group is limited. Broad support was found for increasing general public health literacy (particularly via education at the primary and high school level), modification or removal of MPDS, increased use of multidisciplinary teams, increased use of 24-hour virtual EDs and redesigning undergraduate paramedic education to capture the contemporary reality of the role. Narrow support was found for increasing the use of management plans (supported by ED and GP physicians), better paramedic integration with the healthcare system (supported by academic and managerial paramedics), empowering callers to make informed decisions or seek alternate care by giving anticipated wait times over the phone (supported by consumers and policymakers) and EMS moving away from hospital transport and towards providing urgent and primary care (supported by clinicians and policymakers in paramedicine and emergency medicine).

There were conflicting opinions on introducing barriers to limit calls to EMS (supported by a small number of policymakers, but opposed by almost all other participants), increased EMS acceptance of risk (supported by emergency medicine and paramedic clinicians, with policymakers opposing), increasing telehealth use by EMS (primarily supported by medical clinicians and opposed by policymakers), addressing a culture of over-transportation to the ED (supported by all participants with the exception of some ED policymakers and several ambulance managers), hiring more paramedics (supported by consumers, and opposed by almost all other stakeholders) and increasing the availability of Urgent Care Centres (supported by some government policymakers and consumers, with most other stakeholders opposing). Importantly, media campaigns to ‘save EMS for emergencies’ were almost universally opposed, with policymakers stating the evidence showed no impact. The potential for many of the suggestions provided by participants is exemplified in this single consumer quote, reproduced in full here due to its significance:

I feel off. Nothing serious, but not normal. I don’t know what to do, I don’t know if it’s an emergency. I call ‘000’. The telephone folks ask five questions then hangs up. I wait for 3 hours. The paramedics turn up. They ask a few questions then tell me to go in the car. They drive me to hospital. I wait for 3 hours. A doctor talks to me for fifteen minutes, tells me it’s nothing, tells me to go home. I can’t get home. They order me a taxi. I wait for 2 hours. The taxi takes me home. I’ve just wasted everyone’s day, including my own. Three days later it happens again. #16, Consumer

Fourth, while research on policy has long identified that a convergence of stakeholder interests is necessary to achieve implementation,⁴²,⁵⁰ this research is the first we are aware of to have policymakers explicitly confirm this in the field of paramedicine. Policymakers in this research discussed both the political cycle and broad stakeholder support as being important to deciding what position to take on EMS managing non-emergency workload. This is consistent with previous research in other contexts that have identified influences on policymakers, including political partisanship, voter views, stakeholder lobbying and media coverage and tone.⁴²,⁵⁰⁹³ Past research has also speculated that stakeholders may seek to use research to support a pre-existing position,⁴⁷ and this research supports that proposition: stakeholders from all healthcare backgrounds were noted to advocate for greater use of their own professions (a GP policymaker stated more GPs are needed; an ED policymaker stated more ED funding is needed; a nursing policymaker stated nursing roles should be expanded, and paramedics stated paramedic roles should be expanded). This suggests that there remains an ongoing disconnect between consumers, different providers and policymakers, each of which approaches healthcare with a unique perspective that is often inconsistent with each other. Informed healthcare policy therefore may benefit from development methods such as focus groups, where differing perspectives are able to be shared and consensus sought.

Translation of research into practice

This research provides several opportunities for translation into practice.

1. Among the healthcare professions, there is a need to establish consensus on the role of EMS, particularly on whether EMS should move beyond emergency care.

2. Consumers currently have an unmet expectation that EMS can be used as a general health service; this should be addressed by either providing those services or by challenging the expectation.

3. Each healthcare discipline was noted to be focused on its own contributions to consumers rather than commencing from a consumer perspective and identifying how all professions could work collaboratively to meet needs. This may be alleviated by greater involvement of the consumer perspective in policy discussions and multidisciplinary policy that seeks to move beyond a strict medical model to holistically meet consumer needs.

4. This research reports 16 possible ideas to manage urgent and primary care workloads within EMS. The validity and impact of each of these is not investigated here; each of these ideas could be individually considered and evaluated by EMS.

Limitations

There are four key limitations to this research. First, this research does not identify or evaluate the evidence on any potential improvements to the healthcare system; it simply reports stakeholder perspectives. The accuracy of these statements has not been investigated.

Second, as statements are taken at face value, no attempts were made to identify any incongruity between statements and actual beliefs (ie, it is assumed that participants genuinely believe what they have said). However, attempts were made to identify latent themes.

Third, the stakeholder group, while large for qualitative research at 56 participants, is small in each individual stakeholder group (eg, one representative from allied health). This study was designed to capture broad views of a cross-section of the healthcare system, rather than the views of any single group in depth.

Finally, all investigators are from within the healthcare system. While a multidisciplinary team from multiple backgrounds, including those with no prior knowledge of paramedicine, was included, no consumers were on the research team. Particularly given that a disconnect between clinicians and consumers was identified within this research, this is a weakness of this research, and future researchers may wish to include consumers within their team.

Conclusion

There was strong consensus that consumer presentations have shifted to primarily non-emergency requests and that EMS face an emerging role as the standard point of entry to the healthcare system, regardless of presentation severity. Consumers reported calling EMS routinely due to convenience, culture, cost and accessibility, and participants believed that EMS was not managing this appropriately. Sixteen potential solutions were discussed by participants. A latent theme was that stakeholders are focused on their own field, with no overall ownership to drive collaborative solutions to meet consumer presentations. Finally, there was a deep divide in how participants viewed the purpose of EMS: one group felt treatment should be limited to resuscitation, while another group felt EMS should move into meeting community presentations.

Data availability statement

Data are available upon reasonable request.