In recent years there has been a growing emphasis in developing UK NHS ambulance services’ capabilities in clinical leadership. Several national publications have argued that if the quality of these services are to continuously improve, new leadership frameworks and competencies are required (Department of Health (DH), 2005; NHS Ambulance Chief Executive Group, 2009).
These suggested leadership frameworks encompass a clinically focused career structure for the paramedic profession, enabling the concept of leadership to transcend all levels. The resulting career structure is aligned with the national NHS agenda for change pay awards, where band 5 paramedics can progress through senior clinical roles to the band 8 consultant paramedic (NHS Ambulance Chief Executive Group, 2009).
Yet this concept of a career structure is not new, with an almost identical pathway having been developed within the nursing and allied health professions over the past few decades. Initially, the nurse consultant role was introduced in 2000 as a means of ensuring clinical quality and leadership for front-line clinical teams in healthcare.
Perhaps unsurprisingly, consultant paramedic roles have also begun to emerge as the key clinical leadership posts within the ambulance service. However, unlike the nurse consultant initiative, there are no specific government directives to act as drivers, although the expectations of the consultant paramedic role are included in some frameworks (NHS Ambulance Chief Executive Group, 2009). So far there have been no research evaluations of this role.
This paper presents the findings of the first study of consultant paramedics to evaluate the role using the following research objectives:
Since there are no other studies into this relatively new professional group, it is anticipated that the findings presented will promote an understanding of the NHS consultant paramedic role in the UK, revealing challenges, concerns and variance of practice that may be of use in future workforce planning as other NHS ambulance services seek to develop similar roles.
Policy drivers and literature
The concept of improved clinical leadership through non-medical consultant roles was first introduced in DH guidance Making a Difference (DH, 1999a), and was part of the wider modernisation agenda set out in The NHS Plan (Department of Health, 2000).
The non-medical consultant role was aimed at improving the retention of talented clinicians by removing the ‘glass ceiling’ from their careers that forced many out of the profession and into management or educational pathways (DH, 1999b). Specific DH role requirements were known as the four core functions: expert practice, leadership and consultancy, education and training, service development and research and evaluation, in addition to the requirement for 50% of their time spent in clinical practice (DH, 1999b).
Current nurse and allied health professional consultant studies have suggested that quality and service benefits do result from such posts, although little quantifiable evidence exists to demonstrate cost impact (Coster et al, 2006; Mullen et al, 2011; Kennedy et al, 2012). The main issues of role ambiguity, overlapping skills and responsibilities with specialist nurses, power bases, support and limited evidence of strategic involvement (Shuldham et al, 2004; Woodward et al, 2006; Humphreys et al, 2007; Jarman, 2007; McSherry et al, 2007) were reported, and may be the cause of diminishing numbers in such posts, which Dean (2011) labels as indistinct.
Within the ambulance service context, Taking Healthcare to the Patient (DH, 2005) recognised the need for a significant cultural change within ambulance services, often characterised as working harder rather than smarter. A new vision acknowledged the potential contribution of ambulance clinicians to the urgent care agenda in managing patients away from emergency departments, and led to the development of specialist and advanced paramedic roles and the need for a clinical leadership programme (DH, 2005).
Taking Healthcare to the Patient 2 (Association of Ambulance Chief Executives, 2011) reviewed the progress made since the original report and made further recommendations to strengthen clinical leadership, in what Newton (2012) refers to as the closest document ambulance services have to policy. This document drew attention to the need for a consistently clear clinical career structure with links to a clinical leadership framework.
To many ambulance clinicians, Clinical Leadership in the Ambulance Service (NHS Ambulance Chief Executive Group, 2009) may be viewed as one of the catalysts in the development of clinical career opportunities, which set out a clinical career framework up to consultant paramedic. This framework requires increasing clinical leadership responsibilities and levels of expert practice, making the link between the Skills for Health career framework (2010) and the competence framework set by the College of Paramedics (2008).
Among others, the consultant paramedic role requires a minimum of master's degree leading to PhD, to be an expert resource, have strategic and service improvement responsibilities, review care pathways, and undertake primary research.
Methods
Data collection and ethical considerations
Contact with all 15 NHS ambulance services across the UK was made to identify the numbers of consultant paramedics in employment during early 2013. Each consultant paramedic was given details of the study before gaining consent. Research approval was also gained from each Trust.
Semi-structured face-to-face interviews were conducted covering four themes in addition to some basic demographic data (Table 1). These themes were designed around the objectives of the study. Interviews were recorded and transcriptions sent to participants for respondent validation.
| Theme | Components |
|---|---|
| Consultant paramedic background, experience and qualifications |
|
| Consultant paramedic role in accordance with the four core functions |
|
| Clinical leadership role |
|
| Perceived effectiveness and challenges in their role |
|
Data analysis
Transcripts from the interviews were coded using concept-driven categories from previous non-medical consultant studies as a means to initially develop and label codes. Subsequent repeated analysis used data-driven categorisation to refine the codes using new concepts that emerged which were unique to consultant paramedics. Once the coding categories were identified, themes and concepts were developed as reported in this paper.
Findings
Population characteristics
Seven consultant paramedics were employed at the time of the study. The mean age was 43 years, ranging from 33 to 51 years, with only 1 female consultant paramedic out of the total group.
The first consultant paramedic appointment was in 2005 but the majority were appointed between 2010 and 2011. The mean length of NHS service was 24 years and mean length of ambulance service was 22 years.
Salary packages for non-medical consultants are expected to be in the NHS Agenda for Change band 8 corresponding with the Skills for Health and College of Paramedics competence and career frameworks (Department of Health, 1999b; College of Paramedics, 2008; Skills for Health, 2010). Table 2 shows the pay band frequencies for the population group, with the highest two bands reflecting dual roles such as Assistant Clinical Director and Director level appointments.
| Pay band | Frequency |
|---|---|
| 8a | 1 |
| 8b | 1 |
| 8c | 1 |
| 8d | 3 |
| VSM (very senior manager | 1 |
With the formal educational expectation of the non-medical consultant being up to or beyond master's degree level (Department of Health, 1999b; NHS Ambulance Chief Executive Group, 2009b; Skills for Health, 2010), Table 3 shows each consultant paramedic's educational attainment.
| Participant | Level of educational attainment |
|---|---|
| P1 | Degree |
| P2 | Degree, master's degree, currently undertaking doctorate studies |
| P3 | Master's degree |
| P4 | Master's degree, currently undertaking doctorate studies |
| P5 | Degree, two master's degrees |
| P6 | Degree, currently undertaking doctorate studies |
| P7 | Master's degree |
Consultant paramedic role activity
Expert practice
All seven consultant paramedics considered themselves to be experts in their professional field, their expertise ranged from patient safety fellowships, cardiology, resuscitation and triage systems, to urgent care and critical care. The requirement to work clinically for at least 50% of their working time varied considerably, as shown in Table 4.
| Participant number | Amount of clinical practice |
|---|---|
| P1 | 1 day per month |
| P2 | 1 day per month |
| P3 | 2–3 days per week |
| P4 | 13 hours per week |
| P5 | 1 day per month |
| P6 | 1 day per month |
| P7 | 2 days per week |
Professional leadership and consultancy
All participants reported this function to be the most significant part of their role and was associated with a strategic focus on professional and service development. Some referred to their roles as the head of profession in their organisation, making it clear that no significant decision should be made without their awareness of it.
Leadership activities included patient safety walk-rounds, providing clinician support at coroners’ court or incident debriefs, and at strategic level involving national collaboration to influence the profession's development.
Education, training and development
All consultant paramedics had developed links with universities holding positions such as associate lecturer, senior clinical fellow, to visiting professor. The majority were also the lead link with higher education institutes in developing and influencing the local education agenda for their profession.
Practice and service development, research and evaluation
All consultant paramedics took the lead on service and pathway development. Given that most ambulance services are large organisations often covering several counties, these activities frequently amounted to large scale change initiatives.
Examples included the redesign of cardiac care pathways requiring considerable collaboration with stakeholders in their local health economy, and the introduction of new clinical triage systems in the emergency control rooms and clinical assessment tools for clinicians to contribute to the reduction of unnecessary hospital attendances.
Undertaking primary research was the most challenging function for most participants citing work and time pressures as the most frequent problem, with Table 5 showing levels of research activity.
| Description of research activities | Frequency |
|---|---|
| No primary research undertaken | 1 |
| Primary research conducted as part of master's degree | 2 |
| Primary research conducted as part of doctorate level studies | 3 |
| Primary research currently conducted as part of consultant paramedic role | 1 |
Thematic analysis
Credible clinical leadership
Visibility was a principle frequently discussed among the cohort as an important element of clinical leadership that served to demonstrate to paramedics that they had a clinical leader in their profession, and that they were in touch with the issues on the ground.
Some consultant paramedics expressed a sense of responsibility in leading by practicing clinically in the field and not just from the office. This led to the conclusion that clinical credibility was essential in clinically leading their profession.
‘Being able to regularly get out there and practice is important, if you're called the head of profession and you can't get out there and practice then people will say that you don't know what you're talking about.’
For some, clinical practice was linked to credibility by providing legitimacy as head of profession, noting that other managers who were once paramedics and did not retain their clinical competence demonstrated the distinction between management and clinical leadership.
‘We need more consultant paramedics like [name] and less like [name], this is not personal, but we need more consultant paramedics who are out there, they've got the troops with them and they're going forward.’
A particular challenge noted by the group was the geographical size of their organisations, and the difficulty in being visible to all clinicians across all sites.
‘For me the biggest issue is the wider influence in such an organisation which covers X.X thousand square miles. Despite the fact that we send out lots of communications, you still walk into ambulance stations who don't know there's a consultant paramedic.’
An emerging empowered profession.
A key concept discovered through the research related to the level of empowerment of the paramedic profession in its ability to influence its own development. The term ‘clinicalising the structure’ brought focus to the purpose of clinical leadership through consultant paramedics.
Some consultant paramedics referred to clinicalising the structure as a slow emerging process enabling the profession to take ownership over decisions made within their organisations since most decisions impacted on clinical care.
‘I think that the challenge is, we've got to help our non-clinical managers understand the consequences of the decisions they're making where they can't see the link between patient safety and clinical care.’
Clinicalising the structure was seen as a gradual transition away from traditional operational management structures with a historical focus on operational performance. This traditional model was considered inadequate in delivering clinical outcomes, and allowing clinicians to flourish in excellence of clinical practice.
Linked to this was the issue of improving the career framework for paramedics by utilising the advanced paramedic roles as part of a career ladder in line with national guidance.
‘We need to turn ourselves around and be a clinically focused organisation and to do that the clinical leadership structure aligned to the College of Paramedics framework is the one that's going to be the golden ticket.’
While the consultant paramedics on higher pay bands were referred to as the head of profession, it was also felt by some that more consultant paramedics were required within their organisations. It was suggested that a clinical leadership structure could exist per region within each organisation, with all reporting to the senior consultant paramedic as head of profession.
‘You've got the band 7 advanced practitioner, but then what you've got now is you're [one] consultant paramedic level, there's a gap and what we need is a raft of consultant paramedics aligned to each region, to be the clinical leaders, to be the think tanks.’
Operational management resistance was considered to be a challenge for clinical leadership where territorial issues were seen by general management currently holding power, and in one case preventing a fully clinicalised structure from becoming reality.
‘My original model was that we weren't going to have an operational structure, just a clinical structure with general managers within it. But there was a revolt from operational managers, really I just wanted clinical managers, people who were clinically competent.’
Role expectations.
A number of participants raised the issue of a change from a consultancy function to that of a delivery function. For most this put considerable pressure on their ability to deliver on the four core functions with the cause being mostly attributed to changing organisational expectations and the increasing number of redundancies leaving less staff to deliver objectives.
‘I guess the consultancy and strategic leadership's always been there, what you've seen develop has been the work that I have to deliver on. It's moved from just a consultancy role to actual delivery.’
For some, the delivery aspect often amounted to project management work where a loss of project support staff had been experienced. Where this occurred, these shifting expectations also suggested a lack of organisational support or understanding, potentially placing the role of the consultant paramedic at risk of further blurring with that of management.
Concerns were raised by a number of participants that the approval process for non-medical consultants had been lost with the abolishment of strategic health authorities who previously managed this process, threatening to increase a lack of role clarity through an inconsistency in job specifications that didn't adhere to the four core functions.
‘There is no longer the protected architecture around the discipline of creating the business case for the role that documents in qualitative and financial terms why such a role would be of value, and determines in the work plan what the individual would do, and that's not happening.’
Discussion
This study is the first of its kind using original empirical primary data to review and report on the current position of consultant paramedics in the context of developing clinical leadership in UK ambulance services.
Unsurprisingly, there are differences among the group in relation to qualifications, experience and pay band characteristics, no doubt influenced locally by employers. Furthermore, the variability in undertaking research is consistent with previous non-medical consultant literature (Woodward et al, 2006; Humphreys et al, 2007), which for most was achieved as part of their academic studies. Paramedic confidence and employer support in allowing time to conduct research may be contributory factors.
Early guidance such as Making a Difference (Department of Health, 1999a) provided the catalyst in removing the glass ceiling from the nursing profession's career. This has yet to be achieved for the paramedic profession, with more consultant paramedics required to provide a cohesive link with paramedics on the ground.
But clinical credibility is essential if ambulance clinicians are to view consultant paramedics as their clinical leaders, and not just additional managers. Not only does maintaining regular clinical practice ensure that consultant paramedics are aware of the risks and issues in delivering clinical services and thus provide good governance for the executive board, they are also able to role model, maintain clinical expertise, and convey vision and messages through visibility.
For most of the group, this remained a challenge with 4 out of the 7 consultant paramedics reporting that clinical practice was undertaken only 1 day per month, and recognised by those practicing more frequently as an issue in delivering credible clinical leadership.
At the heart of this study's findings is the emerging concept of the consultant paramedic in slowly clinicalising the organisational structure, which results from the implementation of a clinical leadership framework, enabling what Edmonstone (2005) terms as leadership by clinicians of clinicians. This could be viewed in the paradigm of transformational leadership, enabling paramedics to become more engaged and empowered in issues of clinical development, rather than the traditional focus of operational performance managed by general management structures.
Yet those in this relatively new role must be employed with enough seniority to be heard and affect change among senior management teams. Evidence from nurse consultant studies suggested that operating strategically proved challenging as a result of competing power bases from medical and management colleagues (Woodward et al, 2006; Humphreys et al, 2007).
For those consultant paramedics in the most senior pay bands, this does not appear to be an issue as operating strategically is inherent in their role, ensuring that the voice of the paramedic profession can be adequately heard.
However, operating strategically can also come at a cost for clinicians on the ground, for those unable to regularly undertake clinical practice and lacking visibility may adversely affect the organisation's ability to influence quality among clinical staff. This problem is only exacerbated by the small numbers of consultant paramedics employed by each organisation, and recognised by some participants as one of the drivers in developing a clinical career framework enabling a paramedic structure with more advanced roles to improve visibility and clinical accountability.
Furthermore, until a genuine attempt to remove the glass ceiling from the profession is made, and unless a clinical career framework can be implemented to improve accountability through clinical leadership, then the leap from the senior paramedic to consultant level appears unrealistic and may be viewed as a tokenistic form of career framework at best.
Organisational expectations may also present a challenge to a clinical leadership structure, as operational resistance was recognised in this study as a barrier to successful change management, and may represent a cultural issue involving operational issues that frequently dominate clinical quality.
Previous studies from other non-medical consultants have shown that a degree of skepticism exists regarding any impact directly attributable to these roles. One advantage to the late development of the consultant paramedic role should be the opportunity to learn lessons from the literature of other non-medical consultant research.
Recommendations
Ambulance organisations must consider the methods of implementing clinical leadership structures, as a single consultant paramedic is unlikely to achieve these clinical leadership goals alone.
In order for a clinical leadership framework to effectively improve clinical quality, ambulance services should develop organisational structures that include a full clinical career framework in line with national reports in order to remove the glass ceiling and encourage paramedic empowerment in clinical development.
Ambulance services that employ consultant paramedics must also try to guard against a tokenistic form of clinical leadership that inhibits the ability to perform the four core functions of the non-medical consultant role in addition to enabling regular clinical practice to be undertaken.
Limitations
This study reports on the current position of consultant paramedics using a qualitative methodology and does not take the views of other stakeholders. In addition, future studies will require a quantitative analysis to identify the cost impact and any value added from such roles.
Since the consultant paramedic is just one role in a clinical leadership framework, a review of NHS ambulance services’ leadership frameworks is also warranted.
Conclusions
Consultant paramedics are an exciting development for the paramedic profession, with the potential to affect quality and clinical development in pre-hospital care as part of a wider clinical leadership framework. But the success of this role requires a structured and consistent implementation process that adheres to the original intention of non-medical consultants, which otherwise runs the counter-productive risk of tokenism and excessive blurring with management.