Developing the paramedic profession is at the heart of the mission for the College of Paramedics. As any profession develops it evolves to take leadership and responsibility for a growing body of knowledge that informs practice. Back in 2008 the College published the second edition of the curriculum framework for paramedics clearly outlining the need for the development of roles at a variety of clinical levels. Having these levels populated creates a clinical framework that will deliver patient benefit and develop future paramedic practice. At its recent Council meeting the College outlined the need to develop education standards, clinical guidelines, and voluntary regulation for these emerging elements on the career framework, and is set to do this over the coming year. In this article Andy Swinburn the College Council representative for NW region outlines how the North West Ambulance Service NHS Trust has put into place a structured career development spanning the professional roles from first registration to consultant practice.
Paramedic clinical leadership within the North West region
What is clinical leadership?
The role of the supervisor and team leader is well documented to be integral in ensuring a team can deliver quality in whatever it does (Glenapp, 2008; Parsons, 2009). In the context of ambulance service out-of-hospital care, the importance of this supervisory/leadership role is no different. For the correct quality of care to be delivered within the unplanned and complicated environment of unscheduled care, it could be argued that the importance of strong leadership, supervision, and coordination is greater than many other more conventional healthcare environments. It is with this challenge in mind that this article has been formulated, to offer an element of understanding to a situation now prevalent within the UK's NHS ambulance services; clinical leadership, and more specifically that of front-line clinical leadership and supervision.
In ‘Taking Healthcare to the Patient’ (Department of Health (DH), 2005) a number of recommendations were made, but specifically the document highlighted the need for transformational leadership within ambulance trusts. Clinical leadership is regarded as a process by which an individual infuences others to set standards, accomplish objectives and directs the organization to greater consistency. Leaders are generally identified by a number of key characteristics; knowledge, skills, and attributes. Therefore clinical leadership that covers a range of areas will encourage clinicians to inform strategy, improve and drive quality, service design, and resource utilization. This work will prove critical to boards, executives, and clinical teams to ensure their organizations are developed and shaped appropriately. Clinical leadership in the ambulance services is designed to provide a framework that will support ambulance trusts as they move forward in the 21st century. Although good clinical leadership is vital for ‘today’, ambulance trusts must also ensure they look forward to the medium–longer term with reference to succession planning and talent management.
The report also identified a potentially more pressing need for changes to the workforce at this level. In recent years call volume and subsequent attendance has shown a 4–5% increase year on year (NHS Information Centre, June 2010). Conversely, the number of life threatening calls requiring an immediate response have not seen this rise and remained static at around 10% of total call volume. It is increased demand for urgent primary and social care that now makes up the bulk of the calls received by ambulance services. Traditional ambulance training has focused on the need to manage life threatening emergencies, leaving many situations where paramedical staff can offer no more than transport to the emergency department. To safely address this ever increasing demand, ambulance services also need to invest in education and not just training, a view shared by Lendrum et al (2000). The College of Paramedics (2008) suggest that a practitioner working at this level, making decisions to refer to other sources and not transport, should be educated to a minimum of HE level 6, a view shared by the Government's own ‘Skills for Health Career Framework (2010)’.
What has NWAS been developing in terms of its clinical leadership?
Following the merger and subsequent re-organization of the North West Ambulance Service's (NWAS) general management structures some years ago, there has been development of clinical roles and responsibilities and implementation of a robust model of clinical leadership and supervision across the organization. In ‘Taking Healthcare to the Patient,’ Peter Bradley discussed at length the need to establish a tiered system of clinical leadership throughout the ambulance services and to also create an aspirational career pathway within the paramedic profession. This is further emphasized in many other related policy documents both locally and nationally.
Clinical leadership within NWAS is leading to a network of clinical leaders across the organization, educated over and above that of registrant level (academic levels 6, 7 and 8), providing a tiered system of clinical leadership to the practitioners working within the teams they clinically lead. In conjunction with this clinical leadership, all the extended role paramedics will practice at a level above that of base registrant with the ability to offer a greater degree of assessment, diagnosis, treatment and referral capabilities than that of current paramedics. These practitioners will have the following titles:
‘…competent clinicians have been forced to develop their careers away from patient care…’
The NWAS’ current development processes have also led to an increased clinical presence within the emergency control centres, with the creation of a specialist paramedic role to manage low acuity calls.
What will be the benefits of delivering this strategy?
Enhancing the clinical skills of all staff will inevitably lead to a growth in clinical standards. From specific interventions through to clinical documentation, improved education and an aspirational career framework coupled with a tiered level of clinical supervision, will undoubtedly lead to ongoing improvements in clinical care. Clinical leadership will become the cornerstone of quality assurance in patient care. Developing the educational profile and professional competencies of all staff, in conjunction with tiered supervision of these skills will allow staff to develop their proficiency in assessing and diagnosing patients’ conditions, thus allowing for the increased opportunity to ‘treat and refer.’
By creating a tiered level of clinical leadership, the organization will have the ability to ensure that review and appraisal of all clinical staff competencies and clinical performance indicators are conducted in a timely and effective manner. These clinical leaders will also ensure that staff are bestowed with the most up-to-date knowledge base and supported towards developing their own continuing professional development and thus overall professionalism. Increasing the clinical competence of senior and advanced paramedics will eventually see only those patients with a direct clinical need that cannot be supported and cared for within a community setting being transported to emergency departments.
Too many times within the profession, highly competent clinicians have been forced to develop their careers away from patient care and in positions with a restricted clinical focus, leading to a perpetual migration of experienced clinicians towards other areas of career progression. By removing this ceiling within clinical practice and allowing staff to progress within their careers without being forced to choose between patient care delivery or role progression, the NWAS will develop its profile as an employer of choice for all its staff, improving morale, attendance, and staff retention.