In the College of Paramedics’ article in the March issue of the Journal of Paramedic Practice, John Martin introduced a piece by Andy Swinburn highlighting the increase in calls experienced by ambulance services and noting that the number of genuine life-threatening emergencies had not increased in kind (Martin and Swinburn, 2012). Their experience is typical and refects the ever-increasing emphasis on nonurgent patient workload in ambulance services across the country. Now, most 999 patients are not critically ill or injured, and usually suffer a wide range of less critical medical problems. While paramedics will continue to be expected to manage all critical patients effectively, they are now also expected to treat and refer a vast range of conditions with the added pressures of achieving hospital avoidance and maintaining patient safety.
With the concerted drive for the use of alternative treatment pathways, as opposed to the long-established mantra of conveyance to accident and emergency (A&E) departments, the way in which paramedic students are educated to deliver such a versatile care is paramount to their future within a developing profession and therefore raising the academic level of entry to the profession has become a key issue in the development journey.
Making the case for raising the educational qualification for entry to the paramedic profession
The traditional entry route
The first concerted attempt at regulation of ambulance service training was prompted by the Millar Report of 1966/67 (Ministry of Health, 1996) but it was not until the middle of the 1980s that the Department of Health (DH) requested that the then NHS training directorate develop a training package for the introduction of paramedics into the ambulance service (Kilner, 2004). In 1996 a company by the name of Edexcel was formed and in 1998 it acquired the Institute of Health Care and Development (IHCD). For the best part of a decade, the IHCD was the primary provider for paramedic training in the UK (Edexcel, 2010). Now operating as Pearson Work Based Learning, the paramedic curriculum offered by the IHCD continues to focus on a task-orientated skills approach.
Vocational Limitations
As a high percentage of the UK’s current paramedics have qualified through a vocational route, it is easy to adopt a nostalgic view of this approach to training. Many paramedics will have refected, with varying degrees of affection, on their own experiences in gaining entry onto the Health Professions Council (HPC) register, via this route. However, as reported by Morrow et al, 2011), the inadequacies of this vocational approach to paramedic training were highlighted by the HPC validation of IHCD courses and by recent research on professionalisation (Morrow et al, 2011). As the paramedics, and the ambulance services in particular, continue to evolve from the traditional model of a transport organisation to the concept of a mobile healthcare provider, paramedics are now required to develop a skill and mind set supporting a different method of work.
This was initially identified by the Director of UK ambulance services, Peter Bradley, in his now landmark strategic review of the ambulance service in England in 2004, which formed the basis of the DH report Taking Healthcare to the Patient: Transforming NHS Ambulance Services (DH, 2005). No longer was paramedic training to be the sole domain of the ambulance service (under the verification of the IHCD), and the DH also recommended that: ‘Ambulance clinicians should be equipped with a greater range of competencies that enable them to assess, treat, refer, or discharge an increasing number of patients and meet quality requirements for urgent care’ (DH, 2005).
Why raise the standard of entry?
There has been a fundamental shift in the paramedic skill set now required by changing service demands, increased expectations from the general public and the needs of the health economy in general. It is therefore difficult to see how the vocational approach to paramedic training, which does not emphasise the underlying cognitive elements of practice, nor the attitudes and values to support the new care paradigm, can continue to be ft for purpose.
Despite the need for paramedics to become more critically enquiring and acquire a greater spectrum of skills, HPC Standards of Education and Training still regards paramedics as the only allied health profession requiring a registration threshold entry at ‘equivalent to a certificate of higher education’ (HPC, 2009), equating to a level 4 academic award. The College understands that the HPC places more emphasis on the criteria set out in its Standards of Education and Training (HPC, 2009) and Standards of Proficiency (HPC, 2007) than academic levels, but this has resulted in a perverse incentive for some training providers to design and offer courses at a minimal standard, almost mirroring the previous vocational pathway and providing a perpetual alternative entry route into the paramedic profession, effectively creating a ‘two-tier’ competence system.
The case for hgher education
The promotion of public sector higher education (HE) is not new, as the Dearing Report of 1997 advocated active partnerships between HE and industry, commerce and public service (HMSO, 1997). Both the DH and the College of Paramedics have acknowledged the need for HE as a way of to underpinning safe practice (DH, 2005). The concept of paramedics having a broader range of clinical skills was also reinforced by the DH in 2008 where the High Quality Care For All report submitted by Lord Darzi called for a change in focus in the NHS from building capacity to an emphasis on quality of care (DH, 2008). The current government recently proposed new criteria for assessing the quality and performance of ambulance trusts and introduced, for the first time, indicators to look at the actual clinical care given to patients, not simply operational response times (DH, 2010a).
A paramedic’s clinical knowledge needs to be more detailed than ever before and with this, enhanced clinical reasoning skills can develop. More informed decision-making abilities allow for appropriate identification of alternative care pathways, affording patients more effective treatment. A wider use of autonomous pharmacological interventions can be supported and though independent prescribing remains a more distant development, it should be recognized that such developments rely on clinicians able to function as autonomous evidence-based practitioners at degree or postgraduate level (Donaghy, 2008). In addition, HE educated paramedics are in a far stronger position to contribute to more generic ideals of health promotion, and, on an individual level, have a greater array of development opportunities available post registration.
The College of paramedics influence on professional standards
Earlier this year, the College of Paramedics launched its new HE approvals process (which I am privileged to have been asked to lead). Any HE institution wishing to have its paramedic science course approved will need to satisfy robust criteria for quality. Central to this is the core principle that any course which is designed at a lower academic level than HE Diploma (level 5) will not be approved, as recommended by the College’s Curriculum Guidance and Competency Framework (2008).
The reality is that despite the few education providers at level 4, the majority of UK paramedics now graduate from HE programmes at levels 5 or 6 (diploma or degree) despite the minimum standard (level 4) accepted by the HPC, a trend for some years, and confirmed by the recent College of Paramedics and Centre for Workforce Intelligence (CfWI) findings. There are currently 25 universities in the UK offering 46 paramedic science programmes at level 5 , and nine offering programmes at level 6. There are eight training providers producing registrants at the HPC minimum, though these are reducing in favour of the HE route, and almost all these providers are ambulance trusts developing existing technicians staff, an important point, as there should be a pathway for current ambulance technicians to a paramedic level, but it must be through a conversion pathway to a HE qualification.
Conclusions
A move away from the traditional vocational approach to paramedic training currently offered by the IHCD is both logical and necessary, but it must be accompanied by a more holistic development of a student paramedic’s clinical knowledge and skills. It must also be done with the benefit of learning from the nursing profession’s experience, where a similar move away from a skills-based approach attracted some criticism (Grundy, 2001). That cautionary note accepted, with greater involvement of HEs prompting change in focus from ‘training’ to ‘educating’ paramedic students, raising the entry threshold into the profession to diploma level is the natural progression in the development of a comparatively young profession.
It is incumbent on the College of Paramedics to exert a professional influence on the quality of this process. While the College recognizes that such influence can generate anxiety amongst some of those affected by raising the minimum standard, we are passionate about driving forward the standards that will underpin the move to diploma level entry into the profession as a positive step to underpin further academic progression in the future.