The clinical concept of operation for the UK ambulance service is changing radically and evolving at an increasing pace with greater emphasis upon clinical treatment rather than the historical transport function. This trend, which started accelerating from the 1970s when the first paramedics (then termed ‘extended trained ambulance staff’) were developed, has followed a course of expanding the clinical capability of ambulance professionals.
In essence, this means a fundamental change in priorities with patient assessment, treatment and, where necessary, appropriate referral are becoming more common, with less demand for transport.
The clinical ramifications of these changes are substantial, both operationally and in regard to professional issues for paramedics, upon whom a range of increasing responsibilities fall. This evolution in role has been led by rising patient demand and reconfigurations within the wider NHS, particularly those that have affected general practice, including the amendments in the contractual obligations of GPs.
These changes have taken place against a background of escalating 999 call volumes which have increased from approximately one million in 1966 to nearly eight million today, with a massive increase in the order of 100% occurring between 1996 (3.2 million) and 2006.
The report, Taking Health Care to the Patient (Department of Health (DH), 2005) recommended that the ambulance service take on greater responsibilities as a mobile health care provider, with the broad objective of reducing the number of patient transports to hospital by approximately 25%, or roughly 1 000 000 journeys per annum. It also recognized that improvements in the care of the most seriously ill and injured needed to be made.
Paramedic staff are an important part of delivering these changes that require clinical skills to be developed in line with patient need. The College of Paramedics fully supports this approach and recognizes that it is important that clarity regarding nomenclature, roles and titles are maintained. Paramedics, in common with other allied health professionals (AHPs), are regulated by title, therefore those who develop their career within the NHS AHP career structure or other developmental opportunities should in all cases continue to be identified as paramedics and alternative more confusing titles should be avoided.
History
A number of developments have occurred to address the professional needs of paramedics to have a scope of practice that matches the changing demand from both patients and the NHS requirements.
Practitioners in emergency care (PEC)
In 2000, the Joint Royal Colleges Ambulance Liaison Committee (JRCALC), in partnership with the Ambulance Service Association (ASA), proposed the development of practitioners in emergency care (PEC) to broaden the skills and knowledge of paramedics in order that they could meet the diverse requirements of patients, particularly those with undifferentiated but not life-threatening health care requirements.
The role of the PEC was designed to ‘up-skill’ the workforce and support modernization efforts. Many ambulance professionals were keen to expand their roles and such advancement had wide support from the trade unions.
Quality Assurance Agency (QAA) Benchmark Statement
The Benchmark Statement produced by the QAA at the request of the DH and with the involvement of the Health Professions Council (HPC), clearly identified that paramedics should have the competency set to meet patient demand, and specifically enhanced patient assessment and clinical decision–making. The document also embraced the EU system directives relevant to paramedics (QAA, 2004).
The British Paramedic Association (BPA) Curriculum Guidance
The BPA produced the first Curriculum Guidance for the profession in February 2006 (BPA, 2006). This document included a career framework for paramedics with the level of ‘paramedic practitioner’ reflecting an increased primary care role for paramedics, embracing the concept laid down in the QAA statement.
Allied health professions with a special interest
The DH acknowledged the value of paramedics with an extended scope of practice in the form of community paramedics in the document, Implementing a scheme for allied health professionals with special interests (DH, 2007).
Ten Key Roles for Allied Health Professionals (DH)
In August 2003, the DH published the ten key roles of AHPs to clarify the role and what they should aim towards. It indicated that all AHPs (including paramedics) should be able to act as the first point of contact for patient care having the skills of diagnosis, ordering diagnostic tests, prescribing, discharge, referral, teaching and health promotion. (DH, 2003).
Standards of Proficiency (HPC)
The current Standards of Proficiency (HPC, 2007) for paramedics reflect that all paramedics should be able to undertake full patient assessment, have clinical reasoning skills and refer patients appropriately.
Taking Health Care to the Patient
The DH report, Taking Healthcare to the Patient (2005), outlined the need to develop a paramedic career framework in line with the changing workload demand.
The Allied Health Professional Career Framework
There are 15 groups of allied health professionals, with paramedics joining the ranks of AHPs in November 2000 as the twelfth professional group to be admitted to the register. The NHS AHP Career Framework applies to all AHPs and provides an opportunity to build a clinical career path within each professional group.
Emergency care practitioner (ECP) development
Alongside paramedics developing within the higher education setting as first contact practitioners (following QAA, HPC and BPA standards), the NHS Modernisation Agency adopted the PEC concept and called this an ‘emergency care practitioner’ (ECP).
The British Paramedic Association (BPA) Curriculum Guidance (Second Edition)
The College of Paramedics; (BPA) issued the second edition of the Curriculum Guidance in January 2008. This document, which was revised following wide stakeholder input, clearly identifies the role of the paramedic and associated competency set. It also outlines a scope of practice and a career framework for specialist, advanced and consultant paramedics.
Critical care paramedics
Many of the approximately 750 paramedics who have undergone clinical development in the specialist paramedic role undertake responsibilities in the area of managing patients with undifferentiated primary health care needs.
More recently, roles to support improvements to services for patients with serious injury and illness have been developed. The NHS has funded a curriculum for this role and two universities offer programmes designed to produce critical care paramedics.
These staff are trained to plan a role in the delivery of trauma and resuscitation care and have a developing scope of practice geared to these needs, potentially fulfilling elements with ‘enhanced care team,’ or similar initiatives.
Developing specialist paramedic clinical practice
The change in ambulance workload has led to a number of developments across the country to ensure that patient need is met. Fundamentally, these developments have taken a paramedic and with extended education have developed a practitioner who has an extended scope of practice, beyond the minimum standards of proficiency for registration.
Generally these developments have been in primary care, aimed at increasing the paramedic’s ability to deal effectively with patients in the community to reduce the number of inappropriate hospital admissions. However, developments have also occurred in neonatal and critical care.
As a profession develops, it is natural for specialist areas to emerge and for individuals to become expert in areas of professional knowledge in response to the demands and requirements of healthcare provision.
The Allied Health Professions (paramedic track) Career Framework
As the role of the paramedic increases with a variety of specialist areas, it is vital that the profession itself overseas the developments. This is achieved through the work of the professional body.
The College of Paramedics believes that embracing a career ladder model best facilitates the development of paramedics to meet the needs of patients. This concept is outlined in the curriculum guidance in the form of a career framework for the paramedic based on the national NHS career framework. This clearly shows that paramedics should be supported to develop into specialist practice to meet patient need, with an associated qualifications framework.
Specific job titles, with the exception of consultant AHP, are the prerogative of the employer, but employers should be cognisant of both the regulatory dimension, discussed later and aware of the Allied Health Professions Career Framework (AHPCF).
The structure of AHPCF outlines a career progression and utilizes ‘senior/ specialist’, ‘advanced’ and ‘consultant’ designations at career framework levels, 6, 7, and 8 respectively. The College of Paramedics recognizes the value in having similar role titles across the country for all grades to facilitate collaboration, patient awareness, and inter-professional liaison.
The regulatory dimension
In the UK, the HPC regulates all paramedics. As with other AHPs, the title ‘paramedic’ is protected in law. For paramedics operating beyond first level registration, for example in extended roles such as specialist paramedics it is important that the protected title ‘paramedic’ continues to be used. This approach is also recommended by the HPC, which prefers to see those with an extended scope of practice continue to use a designation which contains the professional title that is protected by law.
Future developments
Paramedic practice is developing rapidly and while only two clinical career specializations are relatively widely available in primary and critical care, other initiatives are anticipated and some new disciplines, such as neonatal paramedic practitioners, have been developed recently—other areas are likely to follow. This approach follows the pattern set by medicine, nursing and the other allied health professions.
In the area of primary care, a new potential nationally available examination will be offered from summer 2011 and it is anticipated that this may well be jointly endorsed by both the Royal College of General Practitioners and the College of Paramedics. If approved, this development will enable all paramedics working in this area to demonstrate a similar level of proficiency and competence and will therefore contribute to patient safety and clinical governance.
The issue of paramedic prescribing is being considered and may become a reality in the next few years. The availability of a national examination of the type described above may act as a ‘gateway’ to such responsibilities.
Consideration is being given to annotations to the statutory register by the HPC, and could potentially provide the framework for protecting enhanced paramedic roles.
Statement
In conclusion, the College of Paramedics welcomes initiatives that enhance the scope of paramedic practice to meet changing patient need, leading to improved outcomes. The following points underpin the management, development and implementation of a career framework and regulation for the paramedic profession:
Conclusion
The term ‘specialist paramedic’ as supported by the College of Paramedics is a useful reference point to aid standardization, as having similar role titles across the country enhances collaboration, patient awareness, and inter-professional liaison. The standard term, ‘specialist paramedic’ should therefore be accompanied by identification of specific specialist areas as they are developed. E.g. specialist paramedic (primary care), specialist paramedic (critical care), with other titles superceded. For paramedics working at higher levels of the career framework, ‘advanced paramedic’ and ‘consultant paramedic’ are relevant titles. This approach is therefore recommended as being most appropriate.