Changes to the Mental Health Act, Victoria

As all Ambulance Victoria paramedics will be aware, the Mental Health Act governing our actions in relation to the care of patients with mental health issues, changes on the first of July this year.  Changing an Act of parliament, particularly one as far reaching and dealing with such sensitive issues as mental health is a major undertaking.  Fortunately my friend Alan has been involved in this process and is able to give us a good run down on the changes and how they will impact upon us.  Alan also provides some invaluable commentary on specific parts of the act that will be of special interest to paramedics.

For those who do not know Alan, he is perhaps the only person I know who out geeks me in terms of his passion for prehospital care.  Unlike me however, Alan uses his powers for good, not wittering away on the interwebs.  Alan is indefatigable in his pursuit of improving the care of patients and is active in many different areas of professional development of prehospital care providers.

Be warned, this is a very large post, as it must be to cover the pertinent changes to the act.  Nonetheless it is important for paramedics to have a good grasp on what is changing in an area of prehospital care that takes up a very large part of our time and energy, and that many of us find challenging.

(There may be formatting errors in this post from me transcribing it to the web.  These are my fault, not Allan’s)

Mental Health Act 2014 (Victoria)

 

This Act repeals the previous Mental Health Act of 1986 (as amended). It is specific to the State of Victoria within the Commonwealth of Australia, whilst the principles may be similar to other state or territory legislation within Australia I make no comment on these Acts or the impact of the new Mental health Act in Victoria on paramedic practice outside of the State of Victoria.

 

The new mental health Act for Victoria comes into operation on 1 July 2014. It focuses care back to the individual patient and fosters engagement with their families or nominated person.  http://www.health.vic.gov.au/mentalhealth/mhactreform

 

Changing an Act is no small undertaking and the process is slow, complex, and associated with considerable expense. A complete rewrite of an Act is a significant undertaking and the implications are broad, especially when we consider the wide scope of the impact of mental health in our society. The new Act will impact on all parts of the health system, paramedic practice included.

 

The new Act affords paramedics the status of ‘Authorised Persons’ – this provision provides paramedics with certain powers, such as:

  • Ability to enter property and apprehend described persons
  • Authority to search people and belongings, and seize items
  • Administration of sedation independently and also on medical order

It also applies specific requirements to Authorized Persons, these requirements will apply to paramedics, such as:

  • Consideration of a predetermined ‘Advance Statement’
  • Consideration of the advice of a ‘nominated person’
  • Adherence to the (s.11) Mental Health Principles
  • Preservation of dignity

 

The Act creates specific definitions for a range of associated terms. A small number of these are collated at the end of this article for reference. A key aspect of the Act is the statement of mental health principles (s.11), these principles apply to paramedics as they do to all involved in the care of people with mental health issues:

 

The mental health principles

(1) The following are the mental health principles—

(a)  persons receiving mental health services should be provided assessment and treatment in the least restrictive way possible with voluntary assessment and treatment preferred;

(b)  persons receiving mental health services should be provided those services with the aim of bringing about the best possible therapeutic outcomes and promoting recovery and full participation in community life;

(c)  persons receiving mental health services should be involved in all decisions about their assessment, treatment and recovery and be supported to make, or participate in, those decisions, and their views and preferences should be respected;

(d)  persons receiving mental health services should be allowed to make decisions about their assessment, treatment and recovery that involve a degree of risk;

(e)  persons receiving mental health services should have their rights, dignity and autonomy respected and promoted;

(f)  persons receiving mental health services should have their medical and other health needs, including any alcohol and other drug problems, recognised and responded to;

(g)  persons receiving mental health services should have their individual needs (whether as to culture, language, communication, age, disability, religion, gender, sexuality or other matters) recognised and responded to;

(h)  Aboriginal persons receiving mental health services should have their distinct culture and identity recognised and responded to;

(i)  children and young persons receiving mental health services should have their best interests recognised and promoted as a primary consideration, including receiving services separately from adults, whenever this is possible;

(j)  children, young persons and other dependents of persons receiving mental health services should have their needs, wellbeing and safety recognised and protected;

(k)  carers (including children) for persons receiving mental health services should be involved in decisions about assessment, treatment and recovery, whenever this is possible;

(l)  carers (including children) for persons receiving mental health services should have their role recognised, respected and supported.

(2)  A mental health service provider must have regard to the mental health principles in the provision of mental health services.

(3)  A person must have regard to the mental health principles in performing any duty or function or exercising any power under or in accordance with this Act.

 

Advance Statements under the Act are similar in concept to ‘Advanced Care Directives’ or ‘Statement of choices’ that paramedics should already be familiar with. The document outlines the patients wishes in terms of care when they are unable to express those wishes because they are unwell. Just as with the similar documents they must be clear documents, and witnessed – further, they cannot be amended. To amend an Advance Statement a new Advance Statement needs to be created.

 

Nominated Persons under the Act are similar in concept to ‘Power of Attorney – Medical Treatment’ that paramedics should already be familiar with. The Nominated Person is appointed to advocate on behalf of the patient and to help represent the patients interests and wishes when they are unwell. Just as with the similar documents they must be clear documents, and witnessed. The Nominated Person cannot be a witness on the nomination documents.

 

The language and terminology of the Act has changed considerably. Paramedics may be involved with the transportation of ‘Compulsory Patients’, in this setting there will be either an ‘Assessment Order’ which will have been completed by the authorized Medical practitioner, or the Mental Health Practitioner; or a ‘Temporary Treatment Order’ completed by an authorised Psychiatrist; or ‘Treatment Order’ completed by the Mental Health Tribunal.

 

One new aspect of the Act is the attempt to define capacity and the capacity to give informed consent. The Act also makes it explicit that the overlying presumption of the Act is that all people have the capacity to give informed consent. It is therefore, incumbent on all who seek to provide treatment to patients, to assess capacity and make a determination of the capacity to give informed consent at the time that each treatment episode is to occur.

 

There is delineation in the Act around ‘Medical Treatment’ and ‘Urgent Medical Treatment’. Urgent medical treatment appears to cover paramedic practice, however it is limited to actions that are; life saving, will prevent serious damage to the patients health, or prevent suffering (including pain and distress). Where a Compulsory Patient is unable to give consent, a paramedic in these circumstances may still provide treatment.

 

The deaths of all compulsory patients are reportable deaths under the Act.

 

Bodily restraint and sedation (s.350) is a significant change for paramedic practice. I have copied the full section text for clarity below this paragraph. Paramedics will be able to use bodily restraint and administer sedation under the new Act. The sedation can be independent as a normal part of paramedic clinical care (where such guidelines exist), or on the order of a medical practitioner during shared care models or during transfer activities.

 

Bodily restraint and sedation may be used when taking person

(1) Despite anything to the contrary in Part 6, if a person is required under this Act to be taken to or from a designated mental health service or any other place—

(a)  an authorised person may use bodily restraint on the person if—

.(i)  all reasonable and less restrictive options have been tried or considered and have been found to be unsuitable; and

(ii)  the bodily restraint to be used is necessary to prevent serious and imminent harm to the person or to another person; and

(b)  a registered medical practitioner may administer sedation to the person or direct a registered nurse or ambulance paramedic to administer sedation to the person if—

(i)  all reasonable and less restrictive options have been tried or considered and have been found to be unsuitable; and

(ii)  the sedation to be administered is necessary to prevent serious and imminent harm to the person or to another person.

(2) Subsection (1)(b) does not limit the power of a registered nurse or ambulance paramedic to administer sedation within the ordinary scope of his or her practice.

This change now sees the care provided to Compulsory Patients being the same as that which is provided to all other patients with acute changes in behaviour that are a risk to themselves or others, and those being transferred between facilities.

 

The current ‘Section 10’ whereby Police detain people who are at risk of serious harm to themselves or others is now covered by section 351 of the new Act. Paramedics who have used the Police for access to property previously will find that the new Act allows entry to premises (s.353). Aligned with this, the new status as Authorised Persons provides paramedics with other powers, such as apprehension (s.353), search of a person or of things (s. 354), the seizure and detention of things found during a search (s. 356).

 

All of these powers come with requirements for the Authorised Person to meet in relation to their use. Paramedics will be held to these standards as Authorised Persons, with preservation of dignity specifically outlined in the Act (s.355)

 

351 Power to enter premises, apprehend and take person to a designated mental health service

(1)  This section applies if a provision of this Act provides for a person to be taken to or from a designated mental health service or any other place.

(2)  For the purposes of this section, an authorised person may—

(a)  enter any premises at which the authorised person has reasonable grounds for being satisfied that the person may be found; and

(b)  apprehend the person for the purpose of the person being taken to a designated mental health service.

(3)  Before an authorised person enters any premises under this section, the authorised person must—

(a)  announce to any person at or in the premises that the authorised person is authorised to enter the premises; and

(b)  state the basis of the authority to enter; and

(c)  give any person at or in the premises an opportunity to permit the authorised person to enter the premises.

(4)  An authorised person may use reasonable force to gain entry to the premises if the authorised person is not permitted entry under subsection (3)(c).

(5) On gaining entry into the premises, an authorised person must, to the extent that it is reasonable in the circumstances—

(a)  identify himself or herself to the person who is to be apprehended; and

(b)  explain to the person why he or she is to be apprehended; and

(c)  give the person the details of the place to which he or she will be taken.

354 Search powers

(1)  This section applies to a person who is required under this Act to be taken to or from a designated health service or any other place.

(2)  An authorised person may search a person to whom this section applies before the person is taken to or from a designated mental health service or any other place if the authorised person reasonably suspects that the person is carrying any thing that—

(a)  presents a danger to the health and safety of the person or another person; or

(b)  could be used to assist the person to escape.

(3)  Before searching a person under subsection (2), the authorised person must, to the extent reasonable in the circumstances, explain to the person the purpose of the search.

(4)  In this section—search means a search of a person or of things in the possession or under the control of a person that may include— (a) quickly running the hands over the person’s outer clothing or passing an electronic metal detection device over or in close proximity to the person’s outer clothing; and

(b)  requiring the person to remove only his or her overcoat, coat or jacket or similar article of clothing and any gloves, shoes and hat; and

(c)  an examination of those items of clothing; and

(d)  requiring the person to empty his or her pockets or allowing his or her pockets to be searched.

355 Preservation of privacy and dignity during search

(1)  An authorised person who searches a person under section 354 must, as far as is reasonably practicable in the circumstances, comply with this section.

(2)  The authorised person must inform the person to be searched of the following matters—

(a)  whether the person will be required to remove clothing during the search;

(b)  why it is necessary to remove the person’s clothing.

(3)  The authorised person must ask for the person’s cooperation.

(4)  The authorised person must conduct the search—

(a)  in a way that provides reasonable privacy for the person searched; and

(b)  as quickly as is reasonably practicable; and

(c)  if the person being searched is of or under the age of 16 years, in the presence of a parent of the person or, if it is not reasonably practicable for a parent to be present, another adult.

(5)  The authorised person must conduct the least invasive kind of search practicable in the circumstances.

(6)  A search that involves running the hands over the person’s outer clothing must be conducted by—

(a)  an authorised person of the same sex as the person searched; or

(b)  a person of the same sex as the person searched under the direction of the authorised person.

356 Power to seize and detain things

(1)  An authorised person may seize and detain a thing found as a result of a search conducted under section 354 if the authorised person is reasonably satisfied that the thing—

(a)  presents a danger to the health and safety of the person or another person; or

(b)  could be used to assist the person to escape.

(2)  If a thing is seized and detained under subsection (1), the authorised person must make a written record that—

(a)  specifies the thing seized and detained; and

(b)  specifies the name of the person from whom the thing was seized and detained; and

(c)  specifies the date on which the thing was seized and detained; and

(d)  includes any other prescribed details.

(3)  The authorised person must securely store any thing seized under subsection (1) unless the thing is described in subsection (4). 

(4)  The authorised person must give a thing seized under subsection (1) to a police officer as soon as practicable after the thing is seized if—

(a)  the thing is a prohibited weapon, a controlled weapon or a dangerous article within the meaning of the Control of Weapons Act 1990; or

(b)  the thing is a drug of dependence or a substance, material, document or equipment used for the purpose of trafficking in a drug of dependence within meaning of the Drugs, Poisons and Controlled Substances Act 1981; or

(c)  the thing is a firearm within the meaning of the Firearms Act 1996; or

(d)  the authorised person has reason to believe the thing would present a danger to the health and safety of the person or another person if the thing were returned to the person.

(5)  The authorised person must take reasonable steps to return any thing stored under subsection (3) to the person from whom it was seized when the reason for the seizure of the thing no longer applies.

 

The new Act recognizes that the previous Act limited paramedic practice and restricted access to clinical care that was available to all other persons not recommended by the Act. The new Act allows for fair and equitable care to all persons. This comes with responsibilities for paramedics as Authorised Persons, but these responsibilities are already part of contemporary paramedic practice.

 

Paramedics are recognized within the Act as being professional providers of care and integral to the holistic care that mental health patients deserve. They have been entrusted with great responsibility despite the current absence of paramedic registration, a reflection of the quality of care and professionalism that they demonstrate each and every day.

 

 

If you would like to download a complete copy of the Act it can be found in PDF here: http://www.legislation.vic.gov.au/Domino/Web_Notes/LDMS/PubStatbook.nsf/f932b66241ecf1b7ca256e92000e23be/0001F48EE2422A10CA257CB4001D32FB/$FILE/14-026aa%20authorised.pdf

 

 

 

Definitions (sumarised)

 

advance statement – An advance statement is a document that sets out a person’s preferences in relation to treatment in the event that the person becomes a patient.

Assessment Order

(1)  An Assessment Order is an Order made by a registered medical practitioner or mental health practitioner that enables a person who is subject to the Assessment Order to be compulsorily—

(a)  examined by an authorised psychiatrist to determine whether the treatment criteria apply to the person; or

(b)  taken to, and detained in, a designated mental health service and examined there by an authorised psychiatrist to determine whether the treatment criteria apply to the person.

(2)  An Assessment Order referred to in subsection (1)(a) is a Community Assessment Order. (3)  An Assessment Order referred to in subsection (1)(b) is an Inpatient Assessment Order.

bodily restraint means a form of physical or mechanical restraint that prevents a person having free movement of his or her limbs, but does not include the use of furniture (including beds with cot sides and chairs with tables fitted on their arms) that restricts the person’s ability to get off the furniture;

capacity to give informed consent

(1) A person has the capacity to give informed consent under this Act if the person—

(a)  understands the information he or she is given that is relevant to the decision; and

(b)  is able to remember the information that is relevant to the decision; and

(c)  is able to use or weigh information that is relevant to the decision; and

(d)  is able to communicate the decision he or she makes by speech, gestures or any other means.

(2) The following principles are intended to provide guidance to any person who is required to determine whether or not a person has the capacity to give informed consent under this Act—

(a)  a person’s capacity to give informed consent is specific to the decision that the person is to make;

(b)  a person’s capacity to give informed consent may change over time;

(c)  it should not be assumed that a person does not have the capacity to give informed consent based only on his or her age, appearance, condition or an aspect of his or her behaviour;

(d)  a determination that a person does not have capacity to give informed consent should not be made only because the person makes a decision that could be considered to be unwise;

(e) when assessing a person’s capacity to give informed consent, reasonable steps should be taken to conduct the assessment at a time at, and in an environment in, which the person’s capacity to give informed consent can be assessed most accurately.

compulsory patient means a person who is subject to—

(a) an Assessment Order; or

(b) a Court Assessment Order; or

(c) a Temporary Treatment Order; or

(d) a Treatment Order;

consumer means a person who—

(a)  has received mental health services from a mental health service provider; or

(b)  is receiving mental health services from a mental health service provider; or

(c)  was assessed by an authorised psychiatrist and was not provided with treatment; or

(d)  sought or is seeking mental health services from a mental health service provider and was or is not provided with mental health services;

forensic patient

(1) In this Part—forensic patient means—

(a)  a person remanded in custody in a designated mental health service under the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997; or

(b)  a person committed to custody in a designated mental health service by a supervision order under the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997; or

(c)  a person detained in a designated mental health service under section 30(2) or 30A(3) of the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997; or

(d)  a person deemed to be a forensic patient by section 73E(4) or 73K(8) of the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997; or

(e)  a person detained in a designated mental health service under section 20BJ(1) or 20BM of the Crimes Act 1914 of the Commonwealth; or

(f)  a person who is an international forensic patient within the meaning of section 73O of the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997; or

(g) a person taken from a prison to a designated mental health service in accordance with a direction made by the Secretary to the Department of Justice under section 306.

(2) A person does not cease to be a forensic patient under subsection (1) if he or she—

(a)  is on leave of absence from a designated mental health service; or

(b)  is absent from a designated mental health service without leave.

 nominated person The role of a nominated person in relation to a patient is—

(a)  to provide the patient with support and to help represent the interests of the patient; and

(b)  to receive information about the patient in accordance with this Act; and

(c)  to be one of the persons who must be consulted in accordance with this Act about the patient’s treatment; and

(d)  to assist the patient to exercise any right that the patient has under this Act.

patient means—

(a) a compulsory patient; or

(b) a security patient; or

(c) a forensic patient;

restrictive intervention means seclusion or bodily restraint;

Secure Treatment Order means an Order within the meaning of section 275;

security patient means a person who is not subject to an Order made under Part 4, but is detained in a designated mental health service and is subject to (irrespective ofwhether the person is absent with or without leave from the designated mental health service)—

(a) a Court Secure Treatment Order; or

(b) a Secure Treatment Order;

Temporary Treatment Order

(1)  A Temporary Treatment Order is an Order made by an authorised psychiatrist after assessing a person (in accordance with an Assessment Order or a Court Assessment Order) that enables the person who is subject to the Temporary Treatment Order to be compulsorily—

(a)  treated in the community; or

(b)  taken to, and detained and treated in, a designated mental health service.

(2)  An Order referred to in subsection (1)(a) is a Community Temporary Treatment Order.

(3)  An Order referred to in subsection (1)(b) is an Inpatient Temporary Treatment Order.

treatment criteria – The treatment criteria for a person to be made subject to a Temporary Treatment Order or Treatment Order are—

(a)  the person has mental illness; and

(b)  because the person has mental illness, the person needs immediate treatment to prevent— (i) serious deterioration in the person’s mental or physical health; or (ii) serious harm to the person or to another person; and

(c)  the immediate treatment will be provided to the person if the person is subject to a Temporary Treatment Order or Treatment Order; and

(d)  there is no less restrictive means reasonably available to enable the person to receive the immediate treatment.

Treatment Order

(1)  A Treatment Order is an Order made by the Tribunal that enables a person who is subject to a Treatment Order to be compulsorily— (a) treated in the community; or (b) taken to, and detained and treated in, a designated mental health service.

(2)  An Order referred to in subsection (1)(a) is a Community Treatment Order.

(3)  An Order referred to in subsection (1)(b) is an Inpatient Treatment Order.

Urgent medical treatment (s.77)

(1)  A health practitioner may perform medical treatment on a patient without obtaining the informed consent of the patient or a person specified in section 75 if the health practitioner is satisfied on reasonable grounds that the medical treatment is necessary, as a matter of urgency—

(a)  to save the patient’s life; or

(b)  to prevent serious damage to the patient’s health; or

(c)  to prevent the patient from suffering or continuing to suffer significant pain or distress.

(2)  A health practitioner who, in good faith, carries out, or supervises the carrying out, of medical treatment in the belief on reasonable grounds that the requirements of this section have been complied with is not—

(a)  guilty of assault or battery; or

(b)  guilty of professional misconduct or unprofessional conduct; or

(c)  liable in any civil proceedings for assault or battery.

(3)  Nothing in this section affects any duty of care owed by a health practitioner to a patient.

 

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9 Responses to Changes to the Mental Health Act, Victoria

  1. rfdsdoc says:

    thats a detailed update and review of it, thanks! As far as I can tell this will now mean Victorian paramedics will have more legal powers in care of the acute mental health patient than other paramedics in Australia or NZ. Am I correct in this interpretation?

    No other ambulance service in Australasia has entry and search powers for mental health clients..these have only ever been powers of police.

    I wonder if this was a deliberate move by Victorian police to divest themselves of this duty?

    As for bodily restraint, once again this is usually province of police so will Victorian paramedics be getting accredited restraint training?

    • Alan Eade says:

      Thanks Minh … sorry about the length, it was tough to summarise so much material.

      I haven’t mapped the new Act in Victoria with the other jurisdictions but the scope of the Act is significant. Some paramedics have entry powers afforded to them under associated Acts in other jurisdictions (e.g.: Ambulance Service Act), Michael EBURN has posted about this aspect, as well as restraint practices by paramedics previously http://emergencylaw.wordpress.com

      Bodily restraint has been a part of paramedic practice in Victoria for many years. From rudimentary beginnings this has evolved to include specifically designed ‘soft’ restraints for ambulance the stretcher as well as education around manual handling and aggression or assault. Regardless, there is a close relationship between paramedics and police in responding to patients that require restraint, to ensure a safe outcome for all.

      What service providers may be considering for future education needs, time will tell.

      Take care

      Alan EADE

  2. Boof says:

    Thanks for the update Al, much more informative than anything I have seen to date.
    Are you aware of any arrangements being made within AV to back crews up for search?
    It would appear that I will be prevented from searching a patient of the opposite sex, in some circumstances I may be reluctant to transport without this, particularly with the increasing incidence of ice and the like.

  3. Alan Eade says:

    The actions that employers of paramedics may take in relation to the changes to the Act will be established by each of the employers based on their risk and exposure. What each organisation is doing in response to the new Act will no doubt be communicated internally to their staff over time.

    In regards to search – the S.11 provisions highlight the objective and best practice in terms of care. It may not always be possible to meet the test (s.355) of same gender (patients and person/s conducting the search). As far as practicable the test of same gender should be facilitated, where this cannot be achieved, and it would be unsafe for the patient and/or those who will be around the patient during the transfer process for the search not to occur, then search may still be undertaken but the principles of both S11 and s.355 need to be best adhered too.

    At all times, do all that is practicable to maintain the dignity of the individual. This may involve other paramedic resources, the Police, use of a private / semi-private space for the search, etc. Each situation and each patient contact will be different with variable risks and options.

  4. Hi Alan, I note the section on ‘Urgent medical treatment’. I think it is important to remember that the common law doctrine of necessity does not allow for the justification of the treatment of a person who is mentally ill who retains decision-making capacity. Even in an emergency a person with capacity has the right to determine what treatment they will, or will not accept. Any diminishment of this would be to deny an individual’s human right to self determination and conflict with a paramedic’s duty to uphold the rights of their patients.

    • Alan Eade says:

      Ruth, as always, makes a salient point that deserves to be emphasised. In addition to the provision of the Mental Health principles in S.11, a key point within the new Act is the definition / description of capacity, and of capacity to give informed consent.

      From the initial post:
      “The Act also makes it explicit that the overlying presumption of the Act is that all people have the capacity to give informed consent. It is therefore, incumbent on all who seek to provide treatment to patients, to assess capacity and make a determination of the capacity to give informed consent at the time that each treatment episode is to occur.”

      “Urgent medical treatment appears to cover paramedic practice, however it is limited to actions that are; life saving, will prevent serious damage to the patients health, or prevent suffering (including pain and distress). Where a Compulsory Patient is unable to give consent, a paramedic in these circumstances may still provide treatment.”

      Being unable to provide connect due to an absence of capacity (e.g.: unconscious, or no capacity due to severity of current illness) is different to refusing to consent when capacity exists to make such a decision. Where a person retains capacity for consent (including refusal to consent) then this is to be respected.

      Alan EADE

  5. Good work Al. I knew it was you as soon as I saw the words – even more geek.
    Seriously though these powers bring with them huge responsibilities. I would hope there will be a significant education program from the employers.
    On that note of employers (being plural), does this allow for NEPT to transport these patients. In that I mean the patients who previously were described as involuntary.

    • Alan Eade says:

      Any practitioner who has a role in supporting people with mental health related concerns in Victoria will need to be aware and conversant with the new Act. The significant changes to the Act as they relate to paramedics will need to be fully explored by all paramedics who practice in Victoria.

      Employers or organisations who provide paramedic services would certainly have a clear interest in ensuring that the paramedics that they retain were aware of the changes in the Act and that they were providing paramedic services in a manner that is consistent with the Act and the principles that it highlights (S.11)

      As for expanding the appropriate transportation options for patients with mental health concerns, the Act does not create any impediment to this occurring. The existing regulation of the Non-Emergency Patient Transport (NEPT) space in Victoria would need to be amended to take advantage of the opportunities within the new Act. Given the likely advantages this would create within the emergency health, mental health, and emergency ambulance components of the health system it is reasonable to conclude that this will be explored over time.

      Alan EADE

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