The College of Paramedics continues to campaign for a formal position where an undergraduate degree is the prerequisite for entry. This position is based on the strategic direction necessary to enable ambulance services to respond to the changing demand confronting them. In the first part of this article, Andy Newton traces the history and development of the ambulance service and paramedic profession to date, and proposes a ‘shift to the left’ in ambulance service operations. In the second part of the article, to be published in June, the actions needed to achieve this shift will be described.
Learning from the past, living in the present, but looking to the future
The past is indeed another country; they do things differently there. In comparatively recent mid-20th century history ambulance services operated to a simple formula, conceived and designed function essentially as transport providers as even in the earlier days transport was the main, but not sole purpose, with little capability to influence patient outcome. But times have moved on with technological advances, heightened community expectations and changes to the professional, cultural, and economic backdrop.
This article argues for an urgent shift in ambulance operations, from predominantly care and transport focused approach, to a more explicitly targeted service delivery model emphasising clinical decision-making and facilitated by an investment in paramedic education and the development of specialised practice at the post-registration level.
A brief history of the ambulance service
A few decades ago, ambulance personnel were regarded as essentially manual labourers, employed primarily as ‘drivers’, with first aid training courses provided by the voluntary aid societies, principally the St John Ambulance Brigade. The task assigned to ambulance crews was a relatively simple one, the service itself was generally regarded as something of a ‘Cinderella service’ in comparison to the other emergency services.
Vehicles and equipment were rudimentary, and while science had developed modern resuscitation techniques (Safer and Elam, 1958; Kuwenhoven at al, 1960), these had yet to be widely adopted. The technologies taken for granted today (defibrillators, 12-lead ECG machines etc.) were the weight of a small family car often requiring mains power to operate. Only in the late 1960s, with the publication of a major national report (Ministry of Health, Scottish Home and Health Department, 1966; 1967), the Ministry of Health, which itself followed an earlier BBC Panorama broadcast in 1963 (BBC Panorama, 1963) identifying major weakness in the ambulance service, did the situation begin to change.
The dominant philosophy in the 1960s, still echoed in the media today, is that the ambulance service exists to serve the needs of the seriously ill and injured and to transport patients to local hospitals, a concept that can be traced to a much earlier period of pre-hospital care. Dominique Jean Larrey, a French surgeon of the Napoleonic period, is often credited as the originator of the ‘modern’ ambulance and the developer of triage. In many ways he is the father of ambulance services (Richardson, 1974).
His rigorous focus in developing the live-saving potential of early pre-hospital treatments has become a guiding principle and has shaped the concept of the operation of ambulance services since. Indeed, the services' reputation accelerated dramatically in the 1970s and 1980s, precisely because it became far more capable at saving lives (and managing serious cardiac illness in particular), due largely to the work of pioneers such as Douglas Chamberlain and Peter Baskett, who developed paramedic [led] advanced resuscitation, with particular focus on cardiac care in the UK (Baskett et al, 1967; Chamberlain et al, 1976).
Today's world is a radically different place and the pattern of epidemiological demand has changed significantly. Yet, Larrey's inspiring and beguiling principles continue to exercise a strong influence over the culture, ethos and role of paramedics and doctors, who shape the ambulance service and influence other developments such as the new sub-speciality of pre-hospital emergency medicine.
This is probably the wrong paradigm for ambulance services in the modern world and may be leading ambulance services in the wrong direction or at least distorting public and professional perceptions, thereby limiting the speed at which the service and paramedic practice adapts to the needs of most patients today.
Larrey's work helped inform the subsequent development of the Union Army's medical services during the American Civil War with his ideas being translated into the civilian setting in a number of American cities after the war (Post and Treber, 2002).
A visiting Liverpool surgeon, Reginald Harrison, was so impressed by what he saw of the ambulance services in America in 1881, that he introduced a similar service in England on his return (Burr, 1969) setting the pattern in the UK and elsewhere.
The model worked well during the industrial age and adapted to the modern plagues of the 20th century with what the European Resuscitation Council called the ‘frst hour’ quintet of cardiac arrest, chest pain, stroke, acute breathlessness and major trauma.'. But these, and other life-threatening conditions no longer represent the core demand for most ambulance services.
This is gradually being recognised in the UK (Swinburn and Martin, 2012) and abroad, the acuity of patients does appear to be changing as a recent study from Munjal et al (2011) shows. Nevertheless, emergency ambulance providers have been slow to react and appear to struggle with defining what ‘appropriate’ emergency ambulance care actually is (Judge, 2004).
In the 21st century, life-saving remains a key objective and a key competency for paramedics and ambulance services delivering ever more effective services for patients with life-threatening conditions, recently acknowledged in a position statement from the National EMS (Emergency Medical Service) Advisory Council (EMS, 2009). However, it can no longer be regarded as other than one priority among many responsibilities as recently acknowledged by Jerry Overton, a leading EMS commentator, who lamented the slow response of American services to recognise a need for change (Heightman and McCallion,2011). What is required today is a new guiding principle coupled with a new concept of operation taking into account demographic change, a professionalised paramedic workforce and harsh realities of the current economic climate.
Though the modern ambulance service has demonstrated greatly enhanced clinical capabilities in a short period, transport continues to be the dominant theme, and new concepts of operation, based on a more clinical, decision focused approach have not yet become fully embedded, resulting in a delay of progress.
Changing business, before the money runs out and ‘shifting left’
The challenges of the economic climate will continue for some time, therefore ambulance services need absorb increased activity (much of it comprising what in earlier years would have been dealt with by primary care) and assimilate this into a lower unit cost, all against a backdrop of falling funding. Indeed, 999 call volumes have increased from approximately 1 million in 1966 to over 8 million today, with a massive increase in the order of 100 % occurring between 1996 (3.2 million) and 2006 with a continuing upward trend today, albeit with a reduced growth.
As far back as 1999, informed commentators were describing this trend as ‘astonishing’ (Carney, 1999) while others opined about the legitimacy of demand and ‘inappropriate’ use (Palazzo et al, 1998). Such concerns are not new, in 1903, Hadfield (Hadfield, 1903) observing the Liverpool horse-drawn ambulance service stated that,
‘there can be little doubt in the mind of an independent observer that a considerable proportion of those carried in ambulances get there, either directly of indirectly through the abuse of drink. Either their own bad habits have been the cause of injury, or they have been the victims of the drunken violence of others.’
He also noted the small number of ‘chronic malingerers’ encountered. Papers regarding ‘inappropriate’ use seem less common today, perhaps due to the introduction of triage systems from 1996 (Department of Health, 1996), but more likely due to studies showing that many of these cases are generated by genuine concerns over the severity of systems (Sanders, 2001) due to patients finding that accessing care, particularly out of hours, ‘confusing’ (Lakhani et al, 2007) or because the actions of bystanders, whose public spiritedness it would be churlish to deride (Volans, 1998). It could also be partly as a result of the failure of media campaigns to mitigate the issue and perhaps also because the advent of tariff creates an incentive to deal with demand that presents itself. After a review of the literature, Snooks et al (1998), suggested that ambulance services should worry less about ‘appropriateness’ and devote more effort to providing appropriate care.
Raised productivity and ensuring that high standards of clinical service are essential therefore, but no longer a sufficiently expansive objective for paramedics or the ambulance service. Further urgent reforms in operation and the introduction of modern managerial methods are now essential. The current model as it stands will continue to unnecessarily transport many patients to hospitals, which is unsatisfactory and unsustainable when other options are available.
There are several keys to accelerating and completing the changes that are urgently needed. The first is to recognise that a major shift in health care is taking place within the developed world, but it is less explicit than might be expected and not yet entrenched in policy. This change is mostly financially driven, but clinical benefits also exist, if executed effectively. This shift will be discussed more fully in the second part of this article due to appear in the June issue of JPP.