Apprenticeships have a long and interesting history in the UK but this history goes beyond the remit of this editorial. Following a long period of decline in funding and apprentice numbers from the 1970s, the apprenticeship programme was re-launched in England in 1994 to try to meet the changing economic situation.
Apprentice numbers increased steadily to reach 200 000 by the year 2000 and to just under 300 000 by 2009 (Steedman, 2010). There are in excess of 190 apprentice occupations in England and unsurprisingly, Health and Social Care is in the top ten of the sectors chosen by apprentices.
Amongst the health and social care apprenticeships available are occupations such as children’s care, learning and development; dental nursing; pharmacy technicians and assistants; housing and youth work (National Apprenticeship Service, 2010). In April 2009, a new organization, the National Apprenticeship Service (NAS), was officially launched with the task of bringing about a significant growth in the number of employers offering apprenticeships (National Apprenticeship Service, 2011).
Apprenticeships are of value in that they help to develop skills and employment for people who are not in education, employment or training; they provide job-specific skills and allow trainees to earn a wage while working alongside experienced staff,
but are apprenticeships the right pathway to lead to registration as a health care professional? Modern apprenticeships are not just for the 16–18 year old pursuing a so-called ‘oily rag’ profession (Learning and Skills Council, 2008), but I am not certain that this is the route that paramedics should be pursuing and I believe that we should instead be embracing the opportunities afforded by higher education.
Of course I would say that given that in my current role I am the Course
‘There is no logical argument for paramedics to be at a lower academic level than other health professionals’
Director for the Foundation Degree in Paramedic Science at Coventry University, but what ultimately matters is what is best for the profession and best for the patient.
The position we are in at the moment is that ALL of the health professions currently registered by the Health Professions Council (HPC) undertake their pre-registration education and training in a higher education establishment with the exception of paramedics. Not only
that but paramedics have the lowest academic threshold level for entry to the HPC register of any of the allied health professionals (HPC, 2009) and yet we work largely unsupervized in potentially life-threatening situations, delivering skills and care that demand high levels of knowledge and understanding.
Academic level of paramedics
There is no logical argument for paramedics to be at a lower academic level than other health professionals, especially when we analyze the Standards of Proficiency set out by the HPC. The Standards of Proficiency for paramedics extend to four pages, more than those for operating department practitioners (ODP) whose academic entry threshold is a level higher than ours. It is reasonable to argue that the length of a SOP publication cannot be used to correlate directly with academic level but, when you read through the two sets of SOPs it is very difficult to sustain an argument that paramedics should sit at ‘equivalent to certificate’ level while ODPs are working at diploma level. I am not suggesting that ODPs should be brought down to our level, quite the contrary; I am arguing that we should be looking to uplift the threshold for entry to our register and I am not sure that seeking alternative pathways to paramedic registration through apprenticeship schemes is the direction we should be taking.
Skill level of paramedics
In his article, Mr Howson states that the skill level of paramedics has remained the same, if not reduced and he goes on to state that it is hard not to make reference to intubation, which was not included in the outset of some paramedic foundation degrees (Howson, 2011).
It is not clear over what period of time Mr Howson believes that the skill level of paramedics has reduced nor is it clear which universities were not including tracheal intubation within their foundation degrees, but both points require some expansion if we are to accept their voracity.
To suggest that the skill level of paramedics has stayed constant or even reduced is not true irrespective of the interpretation of the term ‘skill level’. As an example, I qualified as a paramedic in 1992 where the IHCD programme of study provided me with the additional skills of tracheal intubation, intravenous cannulation, drug administration (atropine, lignocaine and adrenaline), fluid administration (colloids and crystalloids), manual defibrillation instead of automated external defibrillation, and additional ECG rhythm recognition.
I also left with more knowledge but not necessarily with a greater understanding or an enhanced ability to apply my knowledge into practice. The array of drugs and clinical skills now available to paramedics has increased significantly since that time and the skill-set has continued to develop even from the time of our first forays into higher education.
However, I think we need to define ‘skill’ more broadly than just those activities encompassed within the psychomotor domain and expand it to include cognitive skills; the skills of clinical decision making, the skills of critical thinking, the skills of interpreting clinical observations, the skills of analysing literature, and many more higher level skills.
From my perspective, the clinical skills are the easier part of the job. The tasks performed by a paramedic require a certain amount of learning and practice but in reality most skills can be taught to most people who have reasonable psychomotor skills.
It is less straightforward to teach and to apply the decision–making processes undertaken by the paramedic when deciding when, and when not to apply a particular clinical skill. This can be illustrated if we think about performing patient assessment.
It is not difficult to teach a person how to take a pulse or blood pressure and to give them a list of questions they should ask to a patient presenting with abdominal pain.
‘The decisions that have to be made on a daily basis require significant intellectual skills if they are to be made safely’
What is difficult is interpreting the results of the observations and understanding the answers to the questions in the context of the presenting patient. Patient assessment is not undertaken just to document findings so that they can be interpreted by a more qualified health care professional at hospital, it is undertaken to enable the paramedic to make a safe and justifiable decision about patient care.
In order to do this, the paramedic has to have sound understanding of normal anatomy and physiology,
pathophysiology, pharmacology, ethics, and current research. Gone are the days of the protocol books that told us when to implement our newly learned paramedic skills, replaced by guidelines (and not just JRCALC guidelines) that the paramedic can work within. The decisions that have to be made on a daily basis require significant intellectual skills if they are to be made safely and I would argue that the way to develop those high level cognitive skills is through higher education.
On-the-job training
On-the job training is extremely difficult in prehospital care due to the necessity for the most qualified member of staff to travel in the back of an ambulance in order to treat the patient, although I accept that assessment and care does take place before the patient is transported and also that not all patients will be transported.
Those of us who progressed to paramedic qualification through the ‘on-the-job’ learning route may remember having to drive when we had sick patients on board because the qualified member of staff had to be in the back of the vehicle with the patient (and rightly so). Those who are fortunate enough to follow the university route usually have access to supernumerary status which means that they can look after patients under supervision all of the time.
If a person is being employed by an ambulance trust, even on apprentice wages, it is unlikely that the supernumerary option will be open to them and they will be left to drive the vehicle whilst learning about patient care through their rear-view mirror.
Public perception and professional standing
There are a couple of other factors that we need to consider when looking at our education and training: public perception and professional standing. The perception of the public was exposed on Monday 17 January 2000 in a BBC Panorama programme (Panorama, 2000); the transcript of which is still available and a link is offered at the end of this editorial.
While there was outcry from the profession at the time and accusations of unfair broadcasting, the programme did open up to scrutiny some of the inadequacies of paramedic training at the turn of the century yet it seems that over a decade later we are being asked to contemplate a move back to the ‘on-the-job’ apprenticeship approach that we had 20 years ago.
I wonder whether a move towards apprenticeships will enhance our reputation among the public or perhaps be seen as a retrograde step that sees us shunning higher education for ‘on-the-job’ training.
Professional standing is about being able to have professional dialogue and respect for and from other health care professionals and it is something we have struggled with for many years. This is not about status through rank it is about status through professionalism.
We need to be at a the point where we talk the same language as the consultant, make clinically sound assessments, diagnoses and judgements, and have the credibility and respect to be taken seriously by other professionals. Like it or not, we are judged by other health care professionals against our relative academic standards and the route to attaining professional standing has to be through higher education.
Conclusion
My personal belief is that higher education should be the route to registration as a paramedic but that does not mean that there is no place for apprenticeships in the ambulance service. Advanced apprenticeships exist for other health professions, such as physiotherapy assistants, dietetic assistants and radiotherapy assistants but the key word in all of those roles is ‘assistants’.
Perhaps it is not inconceivable for ambulance services to embrace apprentices on a ‘grow-your-own’ philosophy with the ethos that these individuals may then want to progress up the professional/clinical career ladder should they wish to at a later date (Sibson, 2011). However, registration as a paramedic should be through the higher education route in order to provide the critical thinking required to perform safely in the complex care world that is our domain in the 21st Century.