Gibraltar is a British Overseas Territory located on the southern end of the Iberian Peninsula at the entrance of the Mediterranean. It has an area of 6.8 square kilometres (2.6 sq miles) and a northern border with Andalusia, Spain. The Rock of Gibraltar is the only landmark of the region. At its foot is the densely populated city area, home to almost 30 000 Gibraltarians. Although Gibraltar has a small geographical area, there is a large annual tourist and migratory workforce influx, a naval base, a busy port and airport combined with a more typical elderly community population.
The ambulance service in Gibraltar was provided by the Royal Gibraltar Police up until 1998 after which St John Ambulance service took over pre-hospital provision and adopted the Institute of Health and Care Development standard for Emergency Medical Technicians (EMTs). In 2007, the Gibraltar Health Authority, which delivers primary and secondary healthcare, absorbed the ambulance service and committed to developing a small group of EMTs as paramedics. For the first time in Gibraltar's healthcare history, in November 2013, four students successfully graduated from a Health and Care Professions Council (HCPC) validated paramedic programme in Gibraltar.
‘For the first time in Gibraltar's healthcare history, four students successfully graduated from a Health and Care Professions Council (HCPC) validated paramedic programme in Gibraltar’
Teaching was delivered primarily via a distance learning platform with self-directed online activities such as text material, formative MCQ examinations, discussion board tasks and virtual patients provided for the students to complete. This was accompanied by regular face-to-face teaching visits by lecturers from the Faculty of Health, Social Care and Education (FHSCE) at St George's, University London. Monthly online live-classrooms also provided students with opportunities to discuss current pre-hospital issues with UK and Australian peers.
One of the main challenges faced by both educators and students was how to provide supernumerary placements under paramedic supervision to satisfy the College of Paramedic's and HCPC validation criteria, thus yielding registered paramedics on par with their UK counterparts. Without any local paramedics, the only feasible option was for all Gibraltar students to undertake lengthy placements in a UK ambulance Trust. Initially, all students had to make huge adjustments, both to their systems of work and personal practices. No EMT in Gibraltar had been exposed to EMT work in the UK, let alone paramedic practice. This meant that the students had to reflect and learn just as much from UK EMTs as they did from UK paramedics. This model of mentorship in healthcare is one which has been adopted by the Gibraltar service. Furthermore, referral pathways which are well established in the UK do not exist in the same format in Gibraltar. It was a revelation for all students. As a result, the paramedic students were instrumental in implementing new systems of work in Gibraltar such as falls assessments in the community, cardiac pathways, acute stroke pathways, documentation audits, mentorship programmes and maritime rescue provision.
One advantage of implementing these systems from a ‘blank slate’ was that evidence for change was based on best practice and not on pre-existing structures. This has allowed the local paramedics to design safe and effective systems of work to fit the resources and capacity of a small ambulance service.
One major disadvantage the four students faced was that there were no other paramedics with whom to bounce ideas off. This was offset by regular online classrooms with other international paramedic students but the need for experienced local mentors in pre-hospital healthcare is still a hurdle that is being addressed. Support from other healthcare professions, such as nurses, midwives and anaesthetists, was abundant. This helped bridge many gaps between out-of-hospital and in-hospital care.
As with any pioneers who first start out, the destination is often over the next ridge, and the four paramedics have had to tread through unchartered territory. New equipment has been purchased, new systems of work have been implemented, legislation has been changed and interdepartmental relationships have been developed in order to arrive at the point where paramedic practice is imminently scheduled to go ‘live’ in Gibraltar.