Ethics part 3: paramedic distribution, or ‘the good, the quick, the cheap’

Does everyone who calls 999 require a paramedic?

This provocative question is likely to divide opinions. Some may consider paramedic practice firmly in the prehospital emergency care domain, where recognition of deterioration and life-saving intervention is the core defining skill of a paramedic. This echoes frustrations that low-acuity and self-limiting illnesses, such as the common cold, fall into the domain of an urgent care practitioner or doctor. Conversely, others may perceive a paramedic as a first-contact clinician—one who can identify a range of conditions, irrespective of acuity, triage and manage appropriately. Additionally, one could argue that non-interventional emergency conditions such as a stroke might not require a paramedic, but rather an ambulance clinician who can recognise the signs and symptoms, and rapidly convey someone to the nearest appropriate facility. Irrespective of viewpoint, perhaps a more important question is: Is it fair for patients to expect a paramedic?

Indeed, paramedic attendance (as opposed to a non-registered ambulance clinician) reduces the likelihood of unnecessary conveyance (O'Cathain et al, 2018), which is partly due to a combination of knowledge and expertise, as well as greater empowerment to facilitate a discharge at the scene (Knowles et al, 2018; Blodgett et al, 2021). Yet, it is known that variation exists among paramedics themselves (O'Cathain et al, 2018). Black (2017) attributed variation as a combination of experience, exposure and education, as well as service demand and non-conveyance performance. In 2018, Lord Carter dissected the costs and efficiencies of ambulance services in England. This was an attempt to reduce variation and maximise productivity in service provision, such as the ‘job cycle’ (from patient contact to response to the outcome), and provide solutions to meet the increasing demand. Within the report, Lord Carter notes that the preferred model is to have a paramedic situated on every vehicle, subsequently acknowledging that with financial and workforce constraints, such a model is unattainable at present.