In April 2018, the Human Medicine Regulations 2012 were changed to allow paramedics to become independent and supplementary prescribers. As of February 2020, 430 paramedics had gained the independent prescribing qualification, and are registered independent prescribing paramedics by the Health and Care Professions Council (HCPC) (2020a).
Paramedics have previously given medication under emergency exemption legislation or by patient group directives (PGDs). Independent and supplementary prescribing enables a much broader scope of medicines to be prescribed, with the practitioner carrying responsibility for assessment and making the right pharmacological choice (Nuttall and Rutt-Howard, 2016).
Prescribing is complex. It encompasses policy, prescribers’ knowledge and experiences, workplaces, supervision and support, clinical governance, patient safety and patient needs and expectations.
This article presents some of the findings of a survey that explored many of these issues. The aim of this article is to compare and contrast how the implementation of prescribing paramedics within the healthcare system relates to the expectations of stakeholders. First, these expectations and stakeholders are identified; then current literature relating to prescribing paramedics is identified, before methods, survey findings and a discussion are presented.
Background
Expectations were identified in policy papers, published guidance and reports from various organisations with an interest in paramedic prescribing (Department of Health and Social Care (DHSC), 1999; 2005; Association of Ambulance Chief Executives (AACE), 2011; NHS England, 2015; 2016; College of Paramedics, 2018; Health Education England, 2020). This literature was identified following a review of articles that detail the stages involved in the paramedic profession gaining prescribing rights (Cullen, 2016; Peate, 2018; Quaile, 2018; Hilton et al, 2019; Rovardi, 2019; Dixon, 2020). The expectations identified are set out in Table 1.
| Policy intentions | Source |
|---|---|
| Paramedics in advanced roles may be working in areas away from the ambulance service | NHS England (2016); College of Paramedics (2018) |
| Increasing ‘see and treat’ and ‘hear and treat’—creating a mobile healthcare service | Department of Health and Social Care (2005); Association of Ambulance Chief Executives (2011); NHS England (2015) |
| Allow new pathways of care to be established | Department of Health and Social Care (1999); NHS England (2016); College of Paramedics, (2018) |
| Develop the paramedic profession | College of Paramedics (2018) |
| Improve patient access to medications | Department of Health and Social Care (1999); NHS England (2016); College of Paramedics (2018) |
| Only those in advanced roles should be prescribing and should be: |
NHS England (2016); College of Paramedics (2018) |
The definition of advanced clinical practice is important for paramedic prescribing. Guidance suggests that only paramedics in advanced clinical roles should be eligible to gain the independent prescribing qualification (Table 1). Advanced clinical practice has been defined (Box 1) by Health Education England (HEE) (2020) in conjunction with NHS England, and endorsed by the College of Paramedics (2018).
Existing primary research on the topic of paramedic prescribing is limited. Using the CINAHL database and a university search engine, SUMMON, four articles were found (Table 2). The PRISMA guidelines were followed to search the literature (Moher et al, 2009) (Figure 1).
| Author(s) | Title | Study design | Data collection | Participants |
|---|---|---|---|---|
| Duffy and Jones (2017) | Exploratory study into the views of paramedics on paramedic prescribing | Focus group | Six participants from one ambulance service | Mix of paramedics and senior paramedics. Three paramedics were working in a GP out-of-hours service. None held NMP qualification |
| Stenner et al (2019) | Early adopters of paramedic prescribing: a qualitative study; only an abstract from a research conference published so far—slides from the event were reviewed | Mix of telephone and face-to-face interviews | 17 participants from across the UK | Paramedics in specialist or advanced roles in a range of settings. All had NMP qualification. Only six prescribing with the others awaiting annotation |
| Bedson and Latter (2018) | Providing medicines in emergency and urgent care: a survey of specialist paramedics’ experiences of medication supply and views on paramedic independent prescribing | Online questionnaire with both open and closed questions | 78 responses | Specialist paramedics from two separate ambulance services. None had NMP qualification |
| Clarke A (2019) | What are the clinical practice experiences of specialist and advanced paramedics working in emergency department roles? A qualitative study | Semi-structured interviews | One hospital and one university in the West Midlands | Three emergency care practitioners, three student emergency care practitioners and two advanced clinical practitioners. No independent prescribers |
NMP: non-medical prescribing
Only Stenner et al's (2019) work includes the views of paramedics who are actively prescribing. These prescribers are from a variety of settings across primary and secondary care and none are based in the ambulance service. The 103 paramedics questioned in the other studies do not have the prescribing qualification. Ambulance paramedics in Duffy's (2019) and Bedson and Latter's (2018) studies give views on prescribing paramedics working in ambulance services. Conversely, Clarke's (2019) paramedic participants work in secondary care and the study focuses on the advantages prescribing would bring to their current roles. Taken as a whole, the literature provides views of paramedics working in a variety of settings.
Many of the participants in previous studies hold the view that the policy expectations of prescribing listed in Table 1 will be met. Duffy and Jones (2017) and Bedson and Latter (2018) show that: paramedics believe independent prescribing will improve access to medication; paramedics agree hospital admissions could be reduced by allowing paramedics to prescribe in response to a 999 call; and there appears to be a consensus that paramedics need to be working in some form of specialist role with a higher level of education in order to prescribe independently.
Methodology and methods
A survey was used to collect both quantitative and qualitative data. A survey allows numerous questions to be asked of participants, and gathering narrative and numerical data gives both depth and breadth to the study (Fineout-Overholt and Johnston, 2005; Ritchie et al, 2013). Using quantitative and qualitative data is also a logical step forward from the pre-existing literature.
Quantitative work enables themes identified in the literature to be tested with a more deductive approach (Parahoo, 2014), while qualitative analysis would contribute to identification of further themes and attempt to establish if a point of data saturation is reached (Ritchie et al, 2013).
The method employed was a web-based questionnaire. Ethical approval for this study was gained from a university research and ethics committee. There were no monetary or similar incentives for participants to complete the survey.
Participant recruitment
Convenience sampling was used. Recruitment of participants was done in two ways. Firstly, the link to the questionnaire was posted on the ‘paramedic prescribing UK’ Facebook group. At the time the survey was being advertised on the site, the group had 371 members.
The survey was open to anyone who clicked on the link. However, only these who were actively prescribing were invited to take part.
Along with the link to the survey, a Facebook post was created explaining more about the study to allow informed consent. Secondly, the link to the survey also featured in the College of Paramedics’ monthly newsletter, which is emailed to their 14 000+ membership, and was posted on their website.
Data collection
The questionnaire used open and closed questions. Some questions were adapted from a previous questionnaire formulated for prescribing nurses (Latter et al, 2011). The questionnaire was created and administered using the SurveyMonkey platform. The link was posted, and the survey opened on 23 January 2020 and closed on the 23 February 2020. No repeat IP addresses were found.
Data analysis
Data were downloaded from SurveyMonkey as individual responses into a Numbers spreadsheet. Descriptive statistics were used to simplify the data and present it in a manageable way.
For the answers to the open-ended questions, an inductive, exploratory approach was taken to thematic analysis of the answers (Ritchie et al, 2013). Codes were established after comments made by participants were read and re-read. The codes were then applied to the data.
The survey had 63 responses. The total number of prescribing paramedics, and therefore that eligible to take part in the survey was 430. This sample therefore represents 14.65% of prescribing paramedic population. Three questionnaires were less than 50% completed and were rejected. Fifty-four (86%) respondents answered the open-ended questions.
Findings
Prescribing paramedics are working in a variety of settings in the health sector (Figure 2). The hospital specialty paramedics worked in areas including acute medicine, intensive/critical care units and paediatric intensive care units (ICUs). General practice was the most common setting for paramedic prescribers, with 38 respondents working in this area.
Nearly half (47%; n=28/60) of respondents worked in more than one setting. There were more than 20 combinations of settings in which paramedics work. Eleven of 60 respondents (17%) were still working in an ambulance role, as well as in other settings. Only two respondents were using their prescribing qualification in ambulance roles; both were working full time for the service.
Figure 3 shows that two respondents have been qualified as a paramedic for less than 3 years. Only 12% (n=7/60) of respondents have held the prescribing qualification for more than 1 year, and 27% (n=16/60) of respondents have had the prescribing qualification for only 0–3 months.
Education levels are shown in Figure 4. Of those with a degree or postgraduate certificate, the prescribing course was offered by their employer in four out of five cases. Respondents were asked to select which best describes their role (Figure 5). Three of those who were specialist paramedic were working towards or had obtained an MSc.
Paramedics were asked which setting they were working in before and after achieving the prescribing qualification to establish whether those gaining the prescribing qualification changed where they worked as a result (Figure 6). Just over three-quarters (78%; n=47/60) of respondents were already working in advanced primary or secondary care roles before gaining the prescribing qualification and 51% (n=31/60) worked for the ambulance service (including full-time, part-time and bank staff). After gaining the prescribing qualification, only 18% (n=11/60) continued to work for the ambulance service. Achieving the prescribing qualification resulted in some respondents moving from secondary to primary care; moving from accident and emergency to general practice was the most popular change.
Paramedics were asked what classes of drugs they were issuing before and after qualification (Figure 7). The majority (15) of drug classes were given more following qualification (e.g. antibiotics). Ten drug classes, such as anti-arrhythmics, were given less commonly following qualification. Overall, gaining a prescribing qualification does not appear to lead to a substantial increase the range of drug classes being issued.
Figure 8 shows how those in roles requiring prescriptions to be written for patients obtained them before gaining the prescribing qualification. Often, practitioners used a combination of these methods.
Figure 9 shows how prescribing paramedics feel their prescribing qualification has changed their practice.
Qualitative data
Respondents were with asked if they saw a role for prescribing paramedics within an ambulance service. Following thematic analysis, views fell into three categories.
First, some were keenly in favour of prescribing on ambulances. For one, it ‘was the next logical evolutionary step’ and another said it would ‘keep more out of hospital’. These views were in a minority. Second, there were those who thought this was possible with conditions. These conditions included prescribing only by those in advanced/specialist roles. ‘Maybe for ambulance paramedics to refer to specialist paramedics within certain parameters,’ was one suggestion. Finally, there were those against, which formed the majority of the comments. Reasons given included: an inability to access patient records; PGDs and emergency exemptions being sufficient in frontline paramedic work; encouraging demand in an overstretched 999 system; and clinical governance not being in place in ambulance services.
Some respondents appeared to make distinctions between advanced paramedic practice and advanced practice. One who worked in primary care wrote: ‘My scope of practice has moved away from emergency care and I have become somewhat deskilled as I don't do it regularly.’ Another wrote: ‘I see a role for prescribing in advanced practice roles (this does not include in-house advanced paramedic roles).’ This respondent split advanced paramedic roles in the ambulance service from advanced practice roles outside the service.
Discussion
Each expectation of paramedic prescribers highlighted in Table 1 can now be considered in relation to the findings of this survey and the wider literature.
Paramedics in advanced roles may be working in areas away from the ambulance service
Paramedics are working in many areas of healthcare, often away from the ambulance service. This was expected and has been demonstrated in other paramedic prescribing literature (Clarke, 2019; Stenner et al, 2019). However, research by Duffy (2019) and Bedson and Latter (2019) assumed that paramedics would be prescribing within ambulance services. This study shows this is largely not the case.
It is of concern that many paramedics are working in multiple settings. It may be assumed it is difficult to have a good working knowledge of the different medicines that would be prescribed across multiple healthcare settings. While some combinations of workplace settings probably do require a complementary knowledge base (for example, work in a GP clinic and a walk-in-centre both require knowledge of primary care), others do not. It is difficult to see how ‘accident and emergency, ICU, GP out-of-hours and primary care’, as one respondent identified, would be complementary. In an era of increasingly specialised medicine, this way of working is difficult to understand.
Further research is required to investigate prescribing paramedics in multiple settings. It needs to be established how safe it is to prescribe with such a broad knowledge base.
Increasing ‘see and treat’ and ‘hear and treat: a mobile healthcare service
Claims have been made in paramedic prescribing literature (DHSC, 2005; Duffy and Jones, 2017; Bedson and Latter, 2018; Peate, 2018; Quaile, 2018; Dixon, 2020) that paramedic prescribing would enhance the ability of the ambulance service to ‘see and treat’. However, these are purely opinions of paramedics, policymakers and the College of Paramedics. No empirical evidence has yet demonstrated this.
In contrast to the literature, the idea of the paramedic prescriber role in the ambulance services split the opinion of paramedic prescribers in this survey. It would be helpful to establish if paramedic prescribing would improve ‘see and treat’ with empirical evidence and thereby allow ambulance services to make evidenced policy decisions. This article has added more opinion but been unable to provide evidence.
This study has also shown that paramedics are leaving the service after gaining the prescribing qualification. The policy of ‘see and treat’ relies on suitably trained and experienced paramedics making decisions about healthcare needs in the patient's home. This is less likely to be achieved if experienced and prescribing paramedics are leaving the ambulance service for advanced roles elsewhere. Conversely, the policy of ‘hear and treat’ is being made more successful by prescribing paramedics as more respondents were working in call centres for NHS 111 or the ambulance service since qualification.
Prescribing paramedics are working in alternate areas of healthcare to the ambulance service and therefore could be contributing to a ‘brain drain’ from the ambulance service. However, some prescribers still work part time for the service (although largely not prescribing there) and may be bringing knowledge back to the ambulance service from their other roles and their prescribing qualification. The impacts of paramedics gaining the prescribing qualification on the ambulance service requires further study.
Allow new provisions of care to be established
Prescribing paramedics do not appear to be establishing widespread new pathways to care as the vast majority of paramedics in this study are working in healthcare settings that are already established and in roles that have previously been filled by advanced nurse practitioners.
It may be argued that placing paramedics in these advanced roles is, in itself, a new pathway to care. However, from a patient perspective, I believe they simply see a clinician in a role they are familiar with. It may well be the case that, given the very recent addition of prescribing paramedics to the healthcare system, there has been too little time to develop new provisions of care and this may change in the future.
A new provision of care would certainly occur if paramedics could prescribe following a call to the ambulance service. This has happened in some areas of the country (Murphy, 2019; Patel, 2019). Advanced paramedics are rotated through GP settings, emergency departments and the ambulance service to gain necessary prescribing experience. This is complicated to set up and some would argue unsustainable because of budget constraints, rotas and funding (Patel, 2019).
In this study, only two paramedics were prescribing in ambulance services. Others who wished to prescribe in the ambulance service reported that prescribing mechanisms, governance and access to patient information were not in place. This problem was anticipated in the previous literature (NHS England, 2016; Duffy and Jones, 2017; Bedson and Latter, 2018) before the legislative change and appears to be true in practice.
Develop the paramedic profession
When considering this expectation, there is a risk of confusing the independent prescribing qualification with advanced practice. However independent prescribing and advanced practice are synonymous. By definition, paramedics have to be working in an advanced role to become independent prescribers and an independent prescribing qualification allows paramedics to practise at an advanced level by giving full autonomy in decision-making.
A respondent to this survey suggested that an advanced paramedic and an advanced practitioner are different roles. In the lead author's previous role as a paramedic working for an ambulance service, advanced paramedics in his trust had better clinical knowledge than regular paramedics and took a clinical leadership role, but their scope of practice was significantly different from that of an advanced practitioner working in primary or secondary care. Advanced practitioners commonly manage a full episode of care and independently diagnose a wide range of pathologies.
There is no single organisation that regulates advanced practice in the UK. At present, all paramedic advanced practitioners (and advanced paramedics) are regulated by the HCPC under the title ‘paramedic’, whereas nurses who practise at an advanced level are regulated by the Nursing and Midwifery Council. In the lead author's own practice as an advanced clinical practitioner, he now has more in common with advanced practice nursing colleagues than paramedic colleagues. If advanced clinical practice were to become regulated as a separate profession, as it is in other countries (Knowles, 2018), it would arguably become a profession in its own right.
During the summer of 2020, the HCPC undertook a ‘policy project’ around advanced practice (HCPC, 2020b). This involved speaking to registrants and other stakeholders to make informed decisions to ensure the public is protected and on how best to support registrants practising at an advanced level.
Previous literature has always assumed that prescribing will develop the profession (Cullen, 2016; Duffy and Jones, 2017; Bedson and Latter, 2018; Peate, 2018; Quaile, 2018; Rovardi, 2019; Dixon, 2020). However, if advanced practitioners become viewed as a separate profession, with a working environment away from the ambulance service, it could be argued that allowing paramedics to independently prescribe may develop individuals, enabling them to enter a new profession, to the detriment of the paramedic profession. This needs further study. A similar debate is ongoing in nursing (Nadaf, 2018) as nurses also transition to advanced practice roles.
Improve patient access to medications
This study was unable to determine whether paramedics, after gaining the prescribing qualification, improve patients’ access to medications.
There are ways around not having the prescribing qualification. Before the prescribing qualification was introduced, paramedics in advanced roles would ask other health professionals to prescribe. However, this study shows that, before gaining their qualification, more than 25 respondents who were already in advanced roles were requesting new or repeat prescriptions without a discussion or a review with a prescriber. This breaks General Medical Council (2013) and Royal Pharmaceutical Society (2016) prescribing guidance and could, ultimately, have led to loss of registration to professional bodies for those involved in this practice. So, while not necessarily improving access for patients, prescribing for paramedics improves accountability and ensures practitioners are acting within the law.
There was no large increase in the classes of drug being prescribed after a prescribing qualification had been achieved. Indeed, the majority of paramedics believe they cannot meet all patients’ prescribing needs. This is contrary to previous literature that suggested having the prescribing qualification would increase the range of drugs that could be provided to patients as prescribing paramedics no longer have to use PGDs and ask others to prescribe (DHSC, 1999; NHS England, 2016; College of Paramedics, 2018).
Conversely, it could be argued that prescribing paramedics improve patient access to medicines. Paramedics believe that both their capacity to see more patients and the quality of care increase after gaining the prescribing qualification. Also, with increasing numbers of paramedics in areas of healthcare that require medication to be issued—GP services and hospitals as opposed to responding to 999 calls—it follows that patients should have greater access to a prescriber. For example, when a paramedic joins a GP practice, this makes more appointment slots available and more patients can be seen.
Prescribing in advanced roles
It was expected by organisations instrumental in ensuring paramedics gained prescribing rights that only those working at an advanced level should be able to prescribe. As shown in Box 1, those working at an advanced level should have obtained or be working towards an MSc in their chosen area of practice and have 3 years’ post-registration experience in the clinical area in which they are working.
This study has shown that this is not always the case in practice. In some cases, employers are paying for those without master's qualifications to complete the prescribing qualification. Advanced practice is a role in which higher clinical reasoning is needed. Without an MSc and experience, the quality of higher clinical reasoning could be called into question. This would include the quality of prescribing decisions.
Strengths and limitations
This study used convenience sampling which, as Parahoo (2014) explains, has poor validity. Often motivated, interested conformists will volunteer and bias the sample. The authors would suggest that only motivated, interested people are likely to take up paramedic prescribing at this early stage, so this may be less of an issue in this study.
Web-based surveys are often criticised as being unrepresentative (Eysenbach, 2012). However, in time-constrained studies when little is known, they can be used to generate hypotheses that can be tested in a more controlled environment and, when collecting data from a wide geographical area, they can be very useful (Ritchie et al, 2013). The circumstances of this study lent themselves to web-based surveys as little is known about paramedic prescribing and this study involved paramedics right across the UK.
Conclusion
Paramedics are implementing their prescribing qualification in many different areas of healthcare as expected. GP services, emergency departments and walk-in-centres are the most commonly found locations for paramedic prescribers. Ambulance services have generally not made widespread use of prescribing paramedics, despite ambitions to ‘see and treat’ patients. It is yet to be shown with empirical evidence that prescribing paramedics will improve ‘see and treat’.
To truly generate new provisions of care, prescribing paramedics should be routinely placed in the 999/NHS 111 system. If this was determined worthwhile, it would involve changes to ambulance services to embrace autonomous practice and to develop facilities for prescribing paramedics, including technology to access patient medical records and frameworks for the development and governance of prescribing paramedics.
This study raises concerns that paramedics are prescribing without an MSc (or working towards an MSc) or experience in a prescribing role. Some prescribing paramedics have their courses paid for by an employer, have been issued a certificate from a university course and have been annotated by the HCPC, yet do not have the qualification and experience that organisations such as the College of Paramedics and NHS England expect.