Content warning: This article makes references to suicidal ideation and chronic mental health conditions.

When Ally McWilliams opened her eyes, she noticed three things. The unfamiliar face of a nurse asking her to smile. The pile of dense, wet vomit sitting in her hands. And the unmistakable feeling that she could not talk or move her body.

As McWilliams looked around at the frightened faces in the café around her, she says she felt confused and very embarrassed.

Of course, she had no recollection of the life-threatening seizure she had just experienced.

“All of a sudden I had a seizure”

It was a usual Saturday morning for the McWilliams family as they ventured to a local café to enjoy a shared breakfast. McWilliams’ sister was visiting from Broome and the family was looking forward to spending some quality time together after months apart.

Food was ordered, eaten, and enjoyed as stories were shared around the table.

As the plates were collected and the family prepared to leave the café, a strange feeling washed over McWilliams. She says she turned to face her sister and told her she suddenly felt quite unwell.

“My sister thought I was joking because I didn’t want to go with them afterwards to the shops,” she says.

“Then all of a sudden I had a seizure.”

In the middle of the café, the 24-year-old human resources officer began to shake uncontrollably, losing control of her movement and eventually blacking out. Her frightened sisters and parents attempted to help her, while her brother-in-law dialled triple zero and asked for an emergency ambulance.

A nurse seated at a nearby table came over to help, and when McWilliams awoke, she prompted her to smile and move her face. She could do neither of those things.

She doesn’t remember the seizure but can recall the moment she woke up.

“I couldn’t understand why everyone was looking at me and why everyone was around me,” she says.

“I couldn’t comprehend at all what was happening.”

Ally McWilliams

The ambulance arrived within 10 minutes. By that stage, McWilliams felt fine but says her eyes were still jolting around the place and showing signs that she’d had a seizure. The paramedics recommended that she go with them to the hospital so she could be treated more quickly by medical staff. McWilliams waited in emergency for five hours.

After running numerous tests, doctors concluded she had experienced a seizure as a result of a COVID-19 infection. She had no idea she was positive for the virus and had tested negative on a RAT test the day before.

Several weeks later, an envelope arrived in McWilliams’ post box. She opened it and found a bill from St John Ambulance Western Australia for $1072.

“It was all my savings”

The bakery was about to close when Mel Grike felt a numbness travelling down her face and into her arm.

The 24-year-old was sitting and enjoying a coffee at the end of her shift when the unsettling symptoms began, throwing her into a state of panic. Sitting at the back of her workplace, she began to google her symptoms and quickly realised she could be having a stroke.

Grike says she sobbed uncontrollably as she told the other staff member on shift that something was wrong, and she needed urgent medical treatment. Her co-worker dialled triple zero and requested an ambulance, handing the phone to her so that she could describe her symptoms.

“I was crying, and I said, ‘I can’t go home right now’,” she says.

“I was struggling to talk.”

The ambulance arrived shortly after, with the operator staying on the phone to Grike throughout the whole process. Paramedics performed a variety of tests, checking her blood pressure, heartrate, and blood sugar levels. They also tested her coordination and balance.

None of Grike’s levels looked unusual, so it was considered unlikely she was having a stroke. Nonetheless, the paramedic team recommended that she go with them to hospital to receive a full diagnosis from the doctors in the emergency department. Grike felt that she had no choice as she did not drive and therefore could not transport herself to hospital.

After a series of tests and consults with her GP, Grike now believes her symptoms were the result of a severe migraine.

“I do get migraines a lot,” she says.

“I just had never felt that sensation before.”

Three weeks after the incident, Grike received a bill from St John WA. She owed them $1072. She began to panic at the thought of paying the fee, knowing she didn’t have much cash to spare. 

“It was all of my savings,” she says.

“It was all of my money.”

Mel Grike

A co-worker offered to pay some of the fee which Grike tells me she’s extremely grateful for. The extra money allowed her to pay the invoice in one instalment, preventing the ongoing stress of having to deduct income each month to pay the fee. Without the support, Grike worries her stress and panic may have continued long after her medical incident.

The state of pay

These stories are not anomalies. In the 2021-22 financial year, more than 350,000 patients needed ambulance services in Western Australia with 124,457 of those people requiring support for emergency incidents. In that same year, St John WA received $149.4 million in transport fees.

In Australia, each state has a different approach to ambulance costs. In Queensland and Tasmania, ambulance services are covered by the state government which means residents don’t pay any out-of-pocket expenses. In other states, ambulance fees can be thousands of dollars.

St John WA is the sole provider of ambulance services in Western Australia. Its fees are categorised based on the level of priority a call out requires. Life threatening and urgent calls will set you back $1072 whilst non-urgent and patient transfer services cost $576.

“There really isn’t anything you can do afterwards”

Sal Cleveray has lost count of how many ambulances they have had to call. As a youth worker for the past 12 years, they have worked with a variety of young people, many of whom have faced complex mental health challenges and significant disadvantage.

In Cleveray’s work, calling an ambulance is a regular occurrence. Clients often present with symptoms that suggest a risk to themselves or others and youth workers need to make an assessment about whether they need emergency medical treatment. In some circumstances, this has to occur without their consent.

Cleveray tells me the most difficult moments of their career have been deciding whether or not to call ambulances for clients experiencing ongoing and persistent suicidal ideation. For people in this category, mental health treatment is constant and hospital visits are frequent, so a high threshold is required for ambulance transport.

“These people are chronically at risk all the time, so this is a weird grey space,” they say.

“There are significant enough changes that I’m concerned for them, but they’re not in an immediate position to justify calling an ambulance because the ambulance will come, and they won’t take them anyway.”

“[Sometimes] I’ve been genuinely not sure they’re going to make it through the night…but there wasn’t anything to be done.”

Sal Cleveray

Cleveray says these difficult decisions are confounded by the extortionate cost of ambulance services. Many of their clients are already significantly disadvantaged so the added cost of an ambulance fee, or multiple, adds a heavy burden – both financially and psychologically.

“If you have debt collectors chasing you, they start chasing you in other ways,” they say.

“You can’t access the things that allow you to get employment and care for people who you care for, and generally be a part of society.”

Cleveray says they have seen organisations trying to combat this issue in the past by providing financial support to clients.

“Lots of programs I’ve worked for have fronted the cost [of private ambulance cover for clients] knowing that it’s worth every cent,” they say.

“It’s always been about getting on the front foot so you don’t have to worry because there really isn’t anything you can do afterwards.

“There’s no waiver arguing hardship and there’s no one reducing the cost.”

A longstanding issue

Discussion around the cost of ambulance services is not new.

In March 2020, then-Greens MLC Alison Xamon delivered a speech in parliament after she “had been contacted by a constituent with disability who was being chased by debt collectors for failing to pay ambulance charges that he had incurred because he was unable to pay them.

“People should feel that they can call an ambulance in an emergency and should not be concerned about the cost when looking at potentially lifesaving intervention,” she said.

“There is the potential for people to die if they feel they cannot call an ambulance, or they will not call an ambulance because they are concerned about fees.”

Her speech was delivered a few months prior to service agreement negotiations between the state government St John Ambulance. It did nothing to change ambulance fees.

Since then, the COVID-19 pandemic and subsequent cost-of-living crisis has only exacerbated the situation. Economic pressures are forefront of everyone’s mind and the unexpected need for an ambulance presents an unanticipated challenge. In the three-year period since Xamon’s speech, the price of doing business has increased for St John WA. So too has its revenue.

“It becomes a punitive system”

St John WA was contacted for a statement but declined to comment. Its website says “to meet the high standards the community requires, we invest in trained paramedics and communication officers, fully equipped Ambulance vehicles, and enough depots to ensure we can respond to calls within expected response targets. Whilst we understand the cost of using an Ambulance can be a problem for some, Ambulance transport invoices need to be paid in order for us to continue to provide this essential service to the West Australian community”.

Ally McWilliams can’t speak highly enough of the service she received from paramedics and says they provided great care throughout the experience. She worries, however, that some people will never get the opportunity to receive the same quality of healthcare due to a fear of the cost.

“What would you do if you actually couldn’t afford it?” she says.

“Imagine if someone elderly [didn’t order an ambulance] and then heaven forbid something actually happens to them and they pass away.”

Mel Grike says paying the fee was difficult to manage but she would call an ambulance again in the same circumstances.

“In that moment, you have no choice,” she says.

“You just have to call and then pay it off.”

Both say they have subsequently considered getting ambulance cover. If they do, they will join the estimated 55.1% of Australians paying for private health insurance. According to iSelect’s comparison tool, cheapest health insurance for a single female costs $69.52 per month.

Sal Cleveray believes these types of initiatives mask the problem by hiding the inequality that sits behind ambulance costs.

“The people calling the most ambulances are often the most disadvantaged,” they say.

“You start with them help seeking in some shape or form by calling an ambulance and then on a number of levels after that, it becomes a punitive system.”

“[Calling an ambulance] saves lives, but people question whether to use that service based on money, which loses lives.”

In a year where cost-of-living has become a commonplace term, perhaps the issue with ambulance fees is about more than just money. It’s about caring for the most vulnerable Australians and providing an accessible service to the community. The real cost of failing to do so? An expense that is worth more than $1072.