Exploratory study into the views of paramedics on paramedic prescribing.

Background and literature review

In 1999, a Department of Health medicines review chaired by Dr June Crown identified that there was overwhelming support for the extension of prescribing rights for a range of health professionals, including specialist nurses, dieticians, podiatrists, physiotherapists and paramedics (Crown, 1999). The 2005 Department of Health paper, ‘Taking healthcare to the patient – transforming NHS ambulance services’ recognised the need for appropriately trained paramedics to be independent prescribers. As this would enable them to meet quality requirements for urgent care by assessing, treating and discharging a greater number of patients (DOH, 2005). Historically, paramedics would arrive at a patient, administer basic first aid and transport them to hospital. Gradually, over the years they would provide more and more interventions to their patient's. Over the last 20 years, since the profession formed links with Higher Education Institutes (HEI's), this has changed dramatically. The development of paramedic degree schemes was introduced, and in 2000, paramedics were to become the 12th Allied Health Professional to register with the Health and Care Professions Council (HCPC) (Caroline, 2007). Further developments were made; as the British paramedic Association, now known as the College of paramedics (CoP), was formed in 2001 (College of paramedics, 2017). Paramedics now had a body that could represent them and develop their role even further. The CoP collaborate with bodies such as the Joint Royal Colleges Ambulance Liaison Committee (JRCALC), the aforementioned HCPC, and the Department of Health to move the role forward and shape the future of pre-hospital care (Blaber, 2012).

The paramedics' skill set has to be wide and varied to encompass all they encounter, it includes advanced airway management, intravenous drug administration, and an in-depth clinical assessment of the patient. Additionally, in recent years, the paramedics' responsibility has increased further as their specialist patient pathways indicate them to bypass local accident and emergency departments, to transport patients direct to stroke specialist hospitals, cardiac centres and major trauma centres, to improve patient outcome from life-threatening conditions. ‘Pre-hospital treatment, that paramedics offer, gives the patient the best chance of survival’ (NWAS, 2017). Lethbridge and Pilbery (2015) inform us that paramedics are proficient in the examination and management of emergency conditions, have a wide range of clinical skills and options to treat the patient, and are experts in emergency care. Although training of paramedics and ambulance dispatch targets are geared more towards seriously ill or injured patients, only around 10% of 999 calls involve a life-threatening emergency (DOH, 2011). Paramedic's knowledge and experience of chronic long-term illnesses has changed over the years as they deal more and more with non-life-threatening or urgent care patients.

Nowadays, paramedics are not just employed by ambulance trusts; for the last few years, paramedics can be seen in walk in centres, GP surgeries and hospitals. They are sometimes known as Emergency Care Practitioners (ECP's), paramedic practitioner or Advanced paramedics (Blaber, 2012). Woollard (2006) informs us that, ‘paramedic practitioners can reduce the number of patients inappropriately transported to hospital by approximately half, thus meeting an NHS aim of ‘treating the right patients in the right place at the right time’. A number of ambulance services have taken this phrase in their forward planning and corporate statement, as it encompasses what their goal should be as a modern ambulance service. The role of the paramedic has moved on from being a simple transport service to giving a more holistic professional approach to the health and welfare of the community. Paramedics are now trained to a higher level to assess a patient's needs, treat them accordingly and if appropriate refer them elsewhere, or discharge them at scene. This has become necessary as admissions to the accident and emergency departments of hospitals has been on the rise year on year, on occasions becoming unmanageable (Table 1.1).

In the UK, the Department of Health and the government have recognised that changes are needed to reduce pressures on accident and emergency (AandE) departments. Paramedics are the first point of contact for many patients and consequently can influence patients' care pathways (Birch, et al, 2012). The importance of finding alternatives to hospital admittances has never been more prevalent, paramedics now have the skills to make a full clinical assessment of the patient, immediately treating any life-threatening condition. When the patient is not in a life-threatening condition, alternatives to hospital admittance must be explored. Blodgett, et al (2017) informs us that improved training and education have given paramedics added scope to evaluate and determine if the patient needs A and E attendance. In some areas, paramedics can refer a patient to an out of hours General Practitioner (GP) service; this may well be followed up by a telephone consultation or visit. This referral system is not as reliable as it sounds, GP's can be difficult to speak to, they may not be able to visit for a number of hours, or even the next day, and meanwhile the patient could have a further relapse. If there were an independent paramedic prescriber at scene, it would alleviate the problem. Many examples of how a paramedic prescriber would benefit patients in their own home were given in the proposal to the CHM; such as, an asthma or chronic obstructive pulmonary disease(COPD) patient in exacerbation, as they had lost their inhaler (Nixon, 2013). Or, that many falls in the elderly can be sourced to an underlying infection, such as a urinary tract infection (UTI), a prescribing paramedic on scene could prescribe antibiotics, which would alleviate a hospital admittance and possible prolonged stay (NHS England, 2015). Nixon continues, ‘paramedic prescribing would sit very comfortably within the ethos of a patient-centred health service, supporting the accessibility of medicines to the public’ (Nixon, 2013).

paramedics at present have access to administer a certain range of medicines, under a statutory exemption, the Prescription Only Medicines (Human Use) Order 1997 (Bradley and Nolan, 2008). This includes controlled drugs such as diazepam and morphine sulphate, the range of drugs and administration routes are closely monitored. In addition to this paramedics working in other areas, such as GP surgeries and walk in centres will work under a Patient Group Direction (PGD) or Patient Specific Directions (PSD). Patient group directions permit healthcare professionals to supply and administer specified medicines to a pre-defined group of patients, without need for a prescription (NICE, 2017). A large number of patients benefit from the administration of drugs from paramedics working under these mechanisms (Sharman, 2015). But they do have their limitations, Collen (2016), informs us that, ‘The usefulness of PGDs decreases as the patient becomes older and more co-morbid, and the basis for independent prescribing addresses these issues through proposing improved decision making and care planning options available to prescribers'. In the public consultation, which NHS England administrated, there were 5 options of independent prescribing which were discussed, which are detailed on table 1.2. During the consultation, 536 responses were received, from organisations and individuals. From this, 90.7% supported alterations to current legislation to allow paramedics to become independent prescribers, with option 2 as the favoured option (NHS England, 2016).

Methods

The research question is to explore the views of a group of paramedics on paramedic prescribing. Due to the nature of the research question, it was decided to employ a qualitative study design. With time constraints and lack of funding, a focus group of a small group of paramedics was established as the appropriate method. Boswell and Cannon (2017) describe focus groups as ‘an increasingly popular way of eliciting the attitudes and opinions of populations regarding sensitive, under-investigated topics’. As recognised in the literature review, there was very limited data specific to the subject matter, and the views of paramedics into this possible major development to their role have yet to be investigated. The researcher sent invites to thirty HCPC registered paramedics who were employed in the locality of the venue were the focus group was to take place. The researcher chose the 30 at random from a list of 60 or so local paramedics, the number of 30 was selected as a sufficient number to elicit the participation of at least six paramedics. Prior to this, ethical approval was sought and obtained. Interested parties were asked to respond if they wished to participate, six paramedics responded and attended the focus group. The group consisted of four paramedics and two Senior paramedics, ages ranged from 38 to 54, with a mean of 44, and experience ranging from 4 to 28 years, with a mean of 14. Although all six are employed by a local ambulance service, three of the group has at some point been employed by local GP out of hour's services, and two of those currently work under PGD's for these services as community intravenous clinicians, also giving telephone triage to patients. Two of the six are educated to Degree level, three to Diploma level and one is an in-house trained paramedic. These three levels of educational status in the ambulance service would cover in excess of 90% of paramedics: therefore this group is a good representation of paramedic's in today's ambulance service. The data collection method was to audio record the focus group. Confidentiality was established and assured throughout the study. Consent forms were not required as the participants had implied consent to the recording by way of their attendance to the focus group. Green and Thorogood (2014) describe the number required for a focus group to be 6–12 participants, as this minimum was reached the researcher recognised there was not a need for further data collection. The first stage of data analysis was intelligent verbatim during the transcribing process. The data was then themed and coded to produce the results.

Results

There were five key themes which emerged from the data.

Discussion

The research question was to establish the views of paramedics on paramedic prescribing. Based on the views from six volunteers who participated in the study, five points were established for discussion. Firstly, the role of the paramedic, this included the education and training required to be a competent independent prescriber. The education would have to be very specialised and held in a higher education institution, it would involve enrolment on a non-medical prescribing course; with evidence of the ability to work at Degree level as an entry requirement. Applicants would also have completed at least 3 years post registration experience and have the support of their employer. The course will usually last 6 months and will include practical supervised prescribing hours with a designated medical prescriber. With the aforementioned stipulations the paramedic prescriber would inevitably be a specialist role, with limited numbers of paramedics being eligible to apply. Each ambulance trust would have to view how this role would fit into their organisation and their patient's demographics and health needs. The literature has shown how the role of the paramedic has evolved over the years into a competent healthcare professional, who has a high level of knowledge and is an expert in their field, who already has an enormous amount of responsibility. The second point raised was that of patient safety. Every one of the participants had concerns around this issue, if they were to prescribe medications to patients in their own home, they would want to have access to the patient's healthcare records, as other prescribers do. The reasons for this was to establish any previous pharmacological interactions, also, concerns are high in healthcare at the moment surrounding antimicrobial resistance, or the overuse of antibiotics. Some ambulance services are continuing work towards the use of electronic patient report forms, the use of such technology could incorporate access to patient's records, and alleviate this concern. Opinion was that access should be restricted to authorised personnel only, to establish patient confidentiality. As shown, a number of paramedics are currently employed by GP's and health centres, as they already have access to patients records this step would be a simple one. The next point which rose from the data was the effect on patient care. It was established early on in the data collection process that patient care would be improved. A larger number of patients could be cared for in their own home, without the need for a hospital admittance, this would enhance the patient experience. There has been an emphasis in recent years of reducing hospital admissions, as hospitals, at times are struggling to cope, which in turn can have an effect on care. If prescribing paramedics can reduce the number of admissions by even a small amount, this could have a positive influence on patient care and the patient journey as a whole. Although literature was limited in this study, it was recognised that paramedic prescribing would have a positive financial impact on the whole NHS. Concerning patient types encountered and the options of prescribing; the patient groups who would benefit from paramedic prescribing could be many. The main groups were discussed, such as chronic respiratory problems, patients who have muscular pain or minor injuries. Furthermore, the importance of rapid treatment of simple infections cannot be understated, the chance of progression to severe infection and sepsis is greatly reduced the sooner patients commence with antibiotic treatment. It was established many patients would benefit from paramedics being given prescribing rights. The options of the different levels of prescribing were given a mixed response from the focus group, which was not the case in the literature findings. Prior to the focus group, the knowledge of the group into the various prescribing levels was very limited, which could have influenced the data. The final point of discussion is the effect on the wider NHS; the group would want the support of the local GP services and hospitals, as both would benefit from the implementation of paramedic prescribing. Their input would be crucial to the success of any rollout of paramedic prescribing; initially supporting the training of the paramedics by way of supervised prescribing in the GP surgery or hospital placements. When qualified the paramedic prescriber would be actively reducing calls to the GP service and admissions to hospital, although still requiring the support of these services. As discussed in the literature paramedics have a large part to play in a patient-centred healthcare system, and prescribing rights could only improve on this. The future could also see an increase in the number of paramedics working in primary care settings.

Limitations

The limitations to the study are that the data collection process was taken from only a small group of paramedics, from a particular geographical area. Due to the subject matter, there was a limited amount of literature available to the researcher.

Conclusion

The study has shown that the group are in favour of paramedics being given prescribing rights, which is supported by the literature. The group had mixed feelings on the level of prescribing given, some of these feelings could be a fear of the unknown and a lack of knowledge of prescribing procedures. It was established from the study that paramedics being given prescribing rights would be positive for the patient, their carers and the NHS as a whole. Both the focus group and the literature did not show any great concerns around the implementation of paramedic prescribing. If the correct personnel are chosen and the education and training is of a high level, the researcher cannot see any reason why paramedics as a profession cannot be given prescribing rights. The benefits are multi focal; firstly, the profession would be given more credibility, patients would be able to be cared for in their own homes, without the need for sometimes-lengthy hospital visits, this would bring obvious cost advantages to the National Health Service.

Key Points