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The paramedic profession: disruptive innovation and barriers to further progress

02 April 2020
Volume 12 · Issue 4


The paramedic profession in the UK evolved from a small number of pilot programmes in the early 1970s that focused on training selected NHS ambulance crews in advanced resuscitation techniques. Similar initiatives occurred almost simultaneously in the United States, Australia, New Zealand and Canada. This case study focuses primarily on the UK, and England in particular. The purpose of the initiatives described was to address the unmet needs of patients with serious injury and illness. Over the following decades, paramedics developed a clear identity and became fully professionally recognised and regulated as allied health professionals, becoming an example of the phenomenon termed ‘disruptive Innovation’; this is something that creates a new market and value network while disrupting existing ones. The steep developmental trajectory of paramedics has not been mirrored by a comparable pace of reform and modernisation in NHS ambulance services which, in comparison, have lagged behind and also failed to adapt to significant changes in the pattern, quantity and epidemiological characteristics of patient demand. This has led to a mismatch between the capabilities offered by paramedics and the professional opportunities available to them in ambulance services, and hampered these practitioners' ability to make full use of their skills. The consequence of this has often manifested as low levels of paramedic and other ambulance staff satisfaction, resulting in high rates of staff turnover. Parallel developments in medical personnel deployment have increased the quantity of medical labour available to patients with serious or life-threatening injuries, with medical staff added to helicopter emergency medical crews. While many patients with urgent conditions would have benefited from general practitioners being available out of hours, proportionally fewer doctors are available to fulfil this role today and those that are attracted to working with the ambulance service often prefer to respond to cases involving major injury. For these reasons and given the reality that the ambulance service is morphing into primarily an urgent care organisation, de-emphasising the transport aspect of the service, changes are needed to its model of operation and to staff management and support.

Some inventions can be viewed as ‘disruptive innovations’—a concept that started to enter the managerial lexicon after being devised by Joseph Bower and Clayton Christensen in the Harvard Business Review in 1995 (Bower and Christensen, 1995). These innovations create a new market and value network, disrupting existing ones. This designation is normally applied to new technologies, such as microcomputers, digital cameras, mobile phones and small home photocopiers.

One important feature of this phenomenon is that the new product is initially inferior to established products but, over time, becomes progressively more capable and relatively less expensive. The relationship of film and digital cameras demonstrates this reality.

Disruptive innovation has been applied to many service industries, as exemplified by low-cost airlines or specific groups of workers, particularly if they offer technical capabilities that are broadly equal and effective as those offered by traditional providers but at a lower cost.

Disruptive innovation can be exceptionally powerful when coupled with complementary business models, without which their fortunes and ‘value propositions’ will be subject to the restraining influences of the ‘resources, processes and influences of the existing system’ (Hwang and Christensen, 2008). It is not difficult to see that, in a crystallised and even conservative system like the NHS, these distorting, potentially reforming effects will inevitably (as with disruptive products and services in other sectors) frequently encounter varying levels of resistance from atavistic or protectionist interests.

This short professional case study contends that paramedics provide one of the clearest examples of new practitioners who fulfil the characteristics of a disruptive innovation in modern-day healthcare staffing. It considers some of the barriers, both professional and system-based, in the ability or otherwise of health services to harness the advantages from deploying the power of disruptive innovation. It advances the proposition that evolutionary pressures, in the form of changes in patient demand, have helped by accelerating the professionalising process of many ambulance staff, resulting in them transitioning into skilled providers of emergency healthcare.

Today, a new set of equally evolutionary imperatives require a further development of paramedics and the adoption of a broader clinical skill set, reflecting a necessary greater focus on assessment and management of those presenting with urgent, rather than critical, medical conditions. This has implications for educational programmes, recruitment, development, remuneration and workforce planning.

Historical context

In the UK, paramedics emerged from ambulance staff in the mid-1970s (Baskett et al, 1976; Briggs et al, 1976). They were trained to provide advanced resuscitation using invasive techniques that were almost exclusively the province of medical practitioners at that time. Their purpose was to bring advanced care into the streets and homes of the community they served.

During the 1960s and 1970s, patient needs were often viewed as reflecting the twin plagues of the 20th century: cardiovascular disease, which accounted for more than 300 000 deaths in 1966, often manifesting as acute heart attacks and, sometimes, cardiac arrest (British Heart Foundation, 2011); and traumatic injury which, in terms of mortality from road traffic collisions alone, accounted for 7985 deaths in the same year (Keep, 2013).

Even in the most developed countries at that time, including the UK, advanced resuscitation skills were not generally available to patients in the prehospital setting. In some parts of the UK, a relatively small number of general practitioners operated on a voluntary basis as part of local response schemes, usually under the aegis of the British Association for Immediate Care Service (BASICS), tending to focus their efforts principally on trauma from road traffic accidents (since redesignated road traffic collisions) (Easton, 1969; Hines, 1998). Deaths from blunt trauma caused by road traffic injuries have declined in recent years with the number of deaths down from 3172 in 2006 to 1792 in 2016 (Department of Transport, 2017). General practitioners' involvement in this role has reduced in recent years, often being supplanted by helicopter emergency medical services (HEMS), which deal with <1% of health-related 999 calls (Mackenzie et al, 2009) and employ doctors drawn from hospital medicine working with paramedics.

Today, more than 99% of 999 calls for health reasons are responded to by ambulance staff, 38% of whom are paramedics working in the NHS ambulance service. There has therefore, in effect, been a repurposing of existing ambulance staff, which was both a pragmatic and economically prudent approach advocated by the Rescue and Resuscitation Committee of the Medical Commission on Accident Prevention (MCAP). MCAP recommended that ‘as ambulancemen were usually the first to arrive at the scene, if they were trained in advanced techniques of resuscitation, not only might the mortality be reduced but also the morbidity in the prehospital phase of patient care’ (Lucas, 1979: 9).

Economics have been an important aspect of paramedic development. A landmark economic study, commissioned by the then Department of Health and Social Security Standing Medical Advisory Committee, later sought clarification of the health economics basis for such an approach. Subsequently, a report by the University of York's Institute for Research in the Social Sciences (Wright, 1984) concluded that the saving of between four and five lives each year for every ambulance staffed, 24 hours per day for 365 days per year, with an extended trained personnel would be a reasonable and conservative estimate. This claim was not universally accepted by the medical profession, leading Baskett (1991: 14) to criticise the ‘dog in the manger attitudes’ held by some of his colleagues, describing it as a prejudice best left in the past.

From the perspective of definition, the UK model of ambulance staffing falls under the umbrella category of the ‘Anglo-American model’, which is represented not only in the United States and Canada but also throughout much of the English-speaking world and beyond. Anglo-American and similar terms are used to categorise system configuration. The alternative Franco-German model (Page et al, 2013), in which doctors rather than paramedics work in ambulances, are found in some European countries in addition to France and Germany, including Spain and European Russia. While there have been disputes over which system is more effective (Dick, 2003), a national review on behalf of the Office of Strategic Health Authorities (2009: 46) concluded that ‘neither [system design] outperformed the other’ but recognised that medical staffing models would have a higher operating cost.

In the UK, this has led to a ground-based ambulance service staffed by paramedics rather than doctors, as advocated by Giround (2012), who argued for a French Service d'Aide Medicale Urgente (SAMU)-type operation. Medical input in the UK occurs at both the executive level on ambulance service boards with field input increasingly via HEMS, which has progressively displaced many voluntary general practitioner-staffed immediate care schemes that had existed previously.

Today's paramedics—a term that was formalised only in the 1990s, by which time the role had been pioneered for more than two decades—were, therefore, developed from the first generation of prototype ‘extended trained ambulance staff’. The progressive expansion of paramedics' scope of practice was accompanied by a gradual process of professionalisation which, ultimately, led to the designation of paramedics as allied health professionals (AHPs) and their professional registration in 2000, a process now managed by the Health and Care Professions Council (HCPC).

Adding value to existing personnel in this way led to other advantages, as these staff brought with them an inquisitive willingness to learn, a can-do attitude and an emergency services culture. These attributes are very much in demand today, in an environment of patient demand that has changed, with the proportion of people presenting with life-threatening problems continuing to decrease.

Shift in patient need

In consequence, realisation has been growing that it is illogical to continue to mandate an emergency response to all 999 calls. Since 1996, there have been numerous changes, including many revisions to response time standards and redefinition of categories.

The most recent revision is the allocation of all 999 calls that appear to be imminently ‘life-threatening’ to the ‘C1’ [category 1] group (the highest tier of response), as part of the ‘ambulance response programme’. This project estimated that only 0.6% of 999 calls concern immediately life-threatening cases, such as cardiac arrest, and only 10% are emergencies (Turner et al, 2017).

Inevitably, even the best triage processes will lead to some level of ‘over-triage’. Therefore, the actual figure of acute emergencies, at least from a purely clinical perspective rather than that of the public, is likely to be in the order of 5%.

Perhaps paradoxically, while resources for the seriously injured and those with acute medical needs have increased, alongside an enthusiasm from the medical profession to become more actively involved (especially in HEMS organisations, of which there are now more than 20 in the UK, operating an increasing number of aircraft), there is often a shortfall in meeting the requirements of those with the next tier of urgent, undifferentiated healthcare problems.

In addition, medical and nursing staffing problems within emergency departments, and in hospitals in general at night and weekends, are commonly reported in the media. Some patients with developing problems in the community will deteriorate and be in a more serious condition unless identified and treated promptly. These patients often require complex diagnostic decision-making, and risk assessment in these cases is arguably more difficult than in people who have well-differentiated major injuries. This has been one issue driving the development of specialist and advanced paramedic roles, which emphasise patient assessment and decision-making, in a way not dissimilar from similar initiatives in nursing and other allied health professions.

Fifty years ago, and indeed more recently in some parts of the UK, patients perceiving an urgent need of care while at home had a 24/7 medically qualified labour force of general practitioners available to respond to their needs, and were often attended by their own doctor. However, these services have progressively reduced over time and been replaced by a range of often less adequate provision with a lower proportion of medical staff. This relative retreat of medical involvement, in contrast to the medical desire to participate as HEMS crew members, has created an opportunity to, once again, reorient paramedics and the ambulance service (although the two are no longer as synonymous as was previously the case) to address this area of service provision. It also offers the prospect of organised interprofessional working between doctors and paramedics.

Care to meet a larger, more diverse and increasingly complex range of need is often accessed through the 999 system. Volumes of such calls have grown tenfold over about half a century, from 1 million in the mid-1960s (Millar, 1966) to 10.7 million calls (including 1.3 million transferred from NHS 111) in 2015–2016 (National Audit Office, 2017). Today's population of patients seen by paramedics is, therefore, much larger than before. It also contains a greater diversity of patients because of a changing and ageing society, where complex health and social care needs are common. Changes in demographics, epidemiology and demand have led some researchers to conclude that ‘paramedicine and the ambulance service in the UK’ is moving from the ‘extreme to the mundane’ (Brewis and Godfrey, 2019).

Some, including Granter et al (2005; 2018) anticipate no reduction in the level of risks to the physical and psychological wellbeing of paramedics, due to the complex societal challenges faced in practice. Peacock et al (2005) found that demographic changes could not account for the doubling of demand for ambulance services their study observed in the 1990s; however, they noted that a rise in the proportion of men needing urgent or emergency attention and an ageing population were significant contributory factors to increased demand.

The precise factors driving these changes remain contested, with some advancing demographic changes. Wrigley et al (2002) identify changes to out-of-hour GP provision as among the most important factors. If it is true that NHS policy leading to a radical change in GPs' working arrangements caused the demand pressures that have plagued the ambulance service and emergency departments, incurring colossal costs, this would constitute a massive own goal for the NHS.

A further review of demand, commissioned by the Association of Ambulance Chief Executives (AACE) fared less well in definitively nailing down the root causes of growth, but added several categories for contention, including the increase in patients with long-term conditions, deprivation, population growth and lifestyle factors, and also agreed that changes to out-of-hours service provision were implicated (Edwards, 2014). These findings were echoed in a comprehensive review of the literature (Radcliffe and Heath, 2010).

Whatever the multifactorial causes, the current scale of demand is a major challenge to service planners who, despite more than a decade of policy initiatives, continue to struggle to keep pace with the need for innovation and change in both service design and workforce planning. These difficulties are exacerbated by the multiplicity of urgent care models, a concern captured by Turner et al (2015) in their evaluation entitled, What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review.

The appropriateness of demand has also been a topic of interest, with studies describing a range of inappropriate use, a perspective that is often, as Ahl (2006) cautions, defined from the perspective of the professional, not the patient. Estimates of non-appropriate calls were researched during the late 1990s, and were found to vary from 16% reported by Palazzo et al (1998) to 40% by Victor et al (1999). These types of study appear less common today, with perhaps an acceptance of advice offered by Snooks et al (1998), which suggested that services should worry less about appropriateness of demand and devote more effort to providing appropriate care.

The reality is that, while much of the demand routed through the 999 system could be handled by a range of other services, including GPs, out-of-hours community nursing services and other provision, these options are either not available throughout the 24-hour period or, where they are, do not always have the resources or responsiveness expected by the public. Therefore, much of this healthcare demand behaves rather like water or electricity flowing to the line of least resistance which continues, in many cases, to be 999 access and the ambulance service, which acts partly as a safety net for failures and gaps in other parts of the NHS.

Disruptive innovation

After coining the term ‘disruptive innovation’ (Bower and Christensen, 1995), Christensen went on to apply it to healthcare in his book The Innovator's Prescription (Christensen, 2009). He offered some examples of how new professional groups, including those working in healthcare but not specifically citing paramedics, tend to have a more vocational preparation in the United States than those in the UK or Australia.

His key point—that disruption within the healthcare workforce could positively disrupt healthcare systems with constructive clinical and financial consequences—was well made. The size of the cost burden—had the NHS ambulance service followed the Franco-German model as advocated by some, including Beaulieu and Vilain (1992) and Banks (1999)—has not been calculated but the authors understand this would be considerable.

There are many examples of AHPs other than paramedics operating in a positive and disruptive way, including physiotherapists expanding their role as first-contact diagnostic practitioners and taking on independent prescribing roles. Another example is that of radiographers interpreting x-rays, which previously was a role reserved exclusively for medical personnel, especially qualified radiologists.

In this context, paramedics are near-perfect illustrations of disruptive innovation. They have, in effect, always been first-contact practitioners, only more recently becoming better equipped to carry out the complex clinical care associated with undifferentiated patient need. Their precursor role as ambulance men and women, which took root within the comparatively simple operational requirement that emphasised providing first aid and transport, created opportunities for relatively independent practice and required the ability to think on one's feet and adapt.

In terms of disruptive innovation, the developmental pressures placed on paramedics have resulted in several advantageous transformative adaptive responses, which can be highlighted as:

  • Paramedics are the only group of qualified health professionals who, at the point of registration, are specifically trained and educated to meet the full spectrum of patient presentation, although not always the full spectrum of need, in the context of prehospital 999 emergency patient demand. However, as would be expected, newly qualified paramedics require a degree of orientation, supervision and support
  • They are also able to assess and manage situations and determine the most appropriate pathway, such as transfer to a specific hospital or referral to a range of community health services, by exercising clinical judgment. They are educated and trained to operate as part of an emergency ambulance service or—and this is a trend that is on the increase in other settings—as part of the wider healthcare community setting
  • All paramedics undergo specific training and preparation to enable them to both react to and coordinate any response to mass-casualty major incidents and other scenarios that necessitate the use of command and control arrangements in structured collaboration with other emergency services
  • Paramedics are highly economically efficient, operating at a relatively low pay band given the responsibilities they hold and the environmental risks they face.
  • Fifteen years ago, the Bradley reports recognised that the default action taken by many ambulance crews during that period was nearly always ‘transporting most patients to hospital’, and that this was often neither in the patient's, nor the healthcare system's, best interests (Department of Health and Social Care, 2005; AACE, 2011).

    Other commentators suggest that the experience of dealing with large numbers of patients with often seemingly minor problems could create ‘blasé’ attitudes among ambulance crews (Woollard et al, 2010). The implication was that training and educating paramedics to manage these cases more appropriately was the only logical course of action.

    The means to achieve this have been articulated many times over the last two decades, with the fundamental requirement of safe practice stated by Gilhooly (1990) and improved clinical reasoning and patient assessment later becoming a recurrent theme (Charlin et al, 2000). These researchers were clear—and few would disagree with them today—that meeting the prime responsibility of competency for first contact practitioners is assessment to place a patient accurately along the acuity spectrum. This requires a detailed educational process for paramedics, as articulated in the Paramedic Evidence Based Education Project (PEEP) report (Lovegrove and Davis, 2013).

    Any educator will attest to the difficulty of creating learning outcomes that permit a practitioner to assess, treat and discharge safely below undergraduate level, and this is a key reason why the College of Paramedics has placed so much emphasis on educational development for paramedics. This has resulted in a change by the HCPC (2018) to approve only programmes offered at degree level.

    These developments have strengthened the foundations of paramedic practice and helped to prepare the way for its further advancement, such as by increasing postgraduate opportunities for paramedics (College of Paramedics, 2017a). This continues to expand and now incorporates independent prescribing for some paramedics over the next few years (College of Paramedics, 2017b).

    Emergency transport rates across English ambulance services were considered in the National Audit Office (2011) report, Transforming NHS ambulance services and have periodically attracted the attention of ambulance commissioners, although translation into widespread practice remains disappointing. Other reports, which might have been expected to be influential—most notably, Transforming urgent and emergency care services in England. Clinical models for ambulance services (NHS England, 2015)—have offered clear, well-conceived guidance, but to little avail.

    Finding opportunities to reduce the number of patients transported is ever-more important, yet barriers and contradictions to progress remain. Implementing the necessary changes in ambulance services, which often have cultures that are not fully compatible with the needs of patients or paramedics, impede improvement and have often been slower than is necessary. The Carter review into variation in ambulance service performance (NHS Improvement, 2018) has highlighted this issue, which has been considered in previous reports without resolution.

    Unfortunately, the Carter review (NHS Improvement, 2018) was published shortly after the detailed Understanding variation in ambulance service non-conveyance rates study by O'Cathain et al (2018), which presented many pertinent findings. These included the tendency of ambulance services to use different grades of staff to attend emergency calls and significant differences in the perception of risk between services. It also suggested linking ambulance and hospital data; this should be relatively easy in the NHS and would be desirable because giving feedback to staff would facilitate learning, but it is rarely evident in practice.

    The strategic vision, which has gradually become more coherent, has been accompanied by an implementation gap primarily in the system of NHS regulation and at ambulance trust level. This has resulted in a failure to modernise services' model of operation from being transport-dominated to gaining the maximum advantage from the skills and abilities of paramedics. This has led to wide differences in performance, with the National Audit Office (2017) reporting that the number of cases resolved by ambulance trusts using control room-based triage varied between 6.2% and 16.2%; there was an average ‘recontact rate’ (where a further call was received within 24 hours) of 6.3% but, again, there was wide variation. A similar level of variation between ambulance services was apparent in transport rates when crews attended a scene. Recontact rates between trusts also differed markedly, ranging between 8.5% and 29%.

    Fundamentally, the National Audit Office (2017) considered that some services sent out ambulances too frequently when this was not needed, and transported too many patients, often to overcrowded hospitals for what were often clinically unnecessary journeys. These attendances and conveyances were, therefore, frequently inappropriate. The safety of such activity, in terms of the differences in rates of triage and decisions on whether to send an ambulance and the consequent frequent journeys, requires further scrutiny and detailed research.

    Figure 1 (Newton and Hodge, 2012) shows that the transition from transport to clinical decision-making is the best chance of improving services to patients and this relies upon using paramedics and those with specialist, advanced skills to the full.

    Figure 1. Paramedic role transition from transport to clinical decision-making. The left-hand triangle represents the 20th Century model for ambulance services and their staff emphasising a transport role. The right-hand triage represents the change enabled by paramedics and the need for new concept of operation within ambulance services

    It also indicates that ambulance services that remain committed to the traditional model of operation (left triangle in Figure 1) are likely to be less equipped to deal with contemporary challenges in patient demand.

    Other significant leadership and human resource inadequacies exacerbate deficiencies. Wankhade (2012) identifies problems such as a target-driven culture, suggesting that this hinders service improvement and the processes of professionalisation. These factors exacerbate staff turnover and hamper efforts to retain the most skilled paramedics, who are better prepared to seek opportunities outside the ambulance service. High sickness rates and staff dissatisfaction have been repeatedly noted and featured in the National Audit Office (2017) report and have attracted media interest (Wakefield, 2014a; 2014b), as have instances of bullying (Twist, 2015) and sexual harassment (Lewis, 2017). Excessive rates of self-referral to the HCPC (van der Gaag, 2018) are also suggestive of poor working conditions and a lack of support.

    All of these factors allude to a culture that has toxic elements and which exists in a harsh regulatory environment that relies upon inspection for data gathering; this approach has often been criticised as outmoded, ineffective and a waste of money (Gerd Flodgren et al, 2016), including by the prolific healthcare commentator and former NHS chair, Roy Lilley (2019).

    McCann et al (2012) echo similar themes and make it clear that paramedics are still ‘blue-collar workers’ in some ways, largely because of the constraints placed upon their practice as well as a lack of opportunities to develop because of managerial failings. These constraints originate from a variety of sources, including governmental targets and poor leadership within the ambulance sector. It is hard to imagine that there has been much positive progress in recent years given the lacklustre results of NHS ambulance service staff surveys. The College of Paramedics (2017c) has published a career framework making the link between paramedic education and service delivery clear, but implementation at individual service level is lagging.

    It appears that, while disruptive innovation is a powerful force and one that, in this professional case study, offers at least a substantial part of any explanation about the success of paramedics over the past few decades, it does have its limitations. It is also important to recognise that innovation and disruption tend to occur when a variety of factors are present together.

    The change in thinking that brought about the paramedic profession was certainly assisted by technological developments, including the creation of portable defibrillators. Equally important was a recognition by a small number of senior doctors of the potential of ambulance personnel, which occurred almost simultaneously in the UK and Australia, as well as with fire service personnel in the United States. This was coupled by a willingness on the part of these individuals to take on more advanced training and education.

    In the UK, paramedics provide a significant level of support to patients seeking care via the 999 system. However, they have not replaced medical practitioners in prehospital care for many seriously injured patients. This is in contrast to both the United States and Australia and, indeed, much of the English-speaking world, where critical care has become a largely delegated phenomenon. In that sense, the Anglo-American model, although increasingly widespread, is playing out differently and becoming more hybridised.

    The advent of a medical subspecialty in prehospital care within the UK might be said to be an innovation notwithstanding Rawlins (2012) observing that innovation, if cost-ineffective, cannot be considered an innovation at all as far as the NHS is concerned, and Barker (2010) cautioning against new specialties.

    Attempts to qualify the relative merits and cost of lifesaving by professional groups has been attempted. In a King's Fund publication a quarter of a century ago, New (1992) commented on the overprovision of medical teams and underuse of paramedics. Jashapara (2011) reached similar conclusions when considering the role of critical care paramedics.

    Other commentators question the evidence of the value of paramedics operating in the advanced critical care role in England (Von Vopelius-Feldt et al, 2014). There seems to be a divide in medical opinion in the United States, Australia, Canada, New Zealand and South Africa, where prehospital advanced life support and critical care roles tend to be delegated to paramedics, perhaps partly influenced by national cultural differences, the preferences of medical professionals themselves and medical staff planning. In contrast, in the UK, Europe and Russia, the scope of paramedic practice is more constrained, with certain skills remaining exclusively within the domain of medical practitioners, who greatly prefer to be directly involved in what might be perceived as the more glamorous aspects of prehospital care. These commentaries have not gone undisputed and a multiprofessional consensus as to the optimal arrangements or ratios of staff (medical or paramedical) for prehospital care remains elusive.

    The fact is that, despite more than 70 years of the NHS, nobody really knows how many ambulances, paramedics, helicopters or doctors are required. Consequently, what evidence does exist is often at risk of being interpreted in a partisan manner. These ambiguities are unhelpful, especially given that the British Medical Association (BMA) (2017) and the Royal College of Emergency Medicine (2017) have reported that shortages of medical labour are particularly acute in emergency medicine. With press reports, including those published in the Lancet (Black, 2016) and others, implying a lack of medical staff in areas including emergency care, it raises the question of whether medical staff should be diverted into prehospital activities and, if so, in what numbers, both now and in the future.

    Would opportunities to work in the prehospital environment increase medical recruitment and what are the implications for patient outcomes? There is, therefore, an arguable case for giving more thought, as was suggested in The Economist (2012), as to just how the unique capabilities that medicine offers can be deployed to best clinical and financial effect.

    Nevertheless, many doctors and paramedics enjoy working in the systems that have been developed in the UK, and it is doubtful that services that are more centrally directed and influenced by health economics would find favour in the UK, particularly among HEMS providers. There are some advantages to independence and diversity, including the agility derived from having small, focused, charitable-minded HEMS operators, just as there are probably disadvantages in duplication and heavily doctor-oriented staffing patterns, but separating these factors out is not straightforward. It is also doubtful that ground-based NHS ambulance services would have the ability, influence or inclination to contribute to discussions on how to make future service design theoretically more efficient, given the many challenges in basic service delivery they experience.

    Benefits from the wider deployment and expanding role of paramedics, both financially and in terms of being able to reach much of the community, are therefore more likely to occur in the foreseeable future in mobile urgent care services than in those for patients with the most serious injuries. This is an area of indisputable unmet need and where cooperation, partnerships and other forms of collaboration have great potential to improve patient experience and possibly outcomes. Ambulance services, at least for now, retain the advantage of employing the highest numbers of paramedic staff, but the ratio is changing as an increasing number of paramedics develop their careers outside the ambulance service, whether inside or outside the NHS.

    One reason for the high staff turnover in the NHS ambulance service is a culture that is less than conducive to meeting the aspirations of paramedics, particularly those with postgraduate education, who have more opportunities to migrate to primary, hospital or other care sectors. Ambulance services' slow adaption of their model of operation to take account of changing patterns of demographics and demand means they are continuing to offer a primarily transport-based model rather than one that emphasises mobile healthcare in collaboration.

    The Carter report makes for disturbing reading and indicates that the fitness for purpose of many organisations is open to some degree of questioning (NHS Improvement, 2018). This finding, when considered in the context of the well-documented high rates of bullying reported in the ambulance service which are corrosive for staff, especially when accompanied by a restrictive, target-driven culture, indicates that urgent action is required. A toxic culture contributes towards a lack of satisfaction within the workplace and a desire to find more enlightened employers in other parts of the health economy. If not addressed energetically, these problems will reduce the changes of any meaningful modernisation of the ambulance service. Attention to leadership (Newton and Harris, 2015) system design and possibly the structure of the ambulance service (Newton, 2019) is urgently required.


    In an artificial market such as the NHS, the power of disruptive innovation will always be attenuated. It is therefore disappointing but not entirely surprising that, despite the solid foundations and building blocks for the paramedic profession which are now largely in place, after half a century of development, achieving the full potential of paramedics remains elusive.

    Nevertheless, the hard-won successes, including national regulation, undergraduate preparation, postgraduate opportunities, career choices and independent prescribing, are certainly solid foundations for the future of the profession. Where shortfalls are evident, they are largely a function of organisational weakness and remaining professional barriers.

    At the critical care end of the patient care spectrum, a compromise has resulted in a form of ambulance delivery system that, despite its Anglo-American designation, exists as a hybrid influenced by the Franco-German model, with heavy medical practitioner involvement, especially in air ambulance provision. Combined crewing provides opportunities for medical staff to experience and contribute to prehospital care, with both paramedics and doctors gaining insights that are valuable for direct care delivery teaching and research. This may divert medical labour away from other essential areas of practice in a manner that would not occur in the United States or many other countries that follow the Anglo-American model of prehospital care staffing. Nevertheless, for the foreseeable future, preference for some doctors to work in prehospital care, finding this work more stimulating than other duties, is not likely to change unless the financial or clinical evidence become clearer or, most importantly, until the preferences of the medical profession itself result in a change in attitude.

    At the urgent care end of the spectrum, the ambulance service has not adjusted its operating model to account for demographic changes, nor moved with the times to create a more integrated offer for patients, despite much encouragement in policy terms to do so. While this will result in a continuing change in patient demand from the ‘extreme to the mundane’, the work will remain physically and psychologically demanding, as well as unpredictable.

    Diagnostic complexity in this group of patients is often high and, arguably, much more complex decision-making is required here than for the majority of seriously ill and injured patients where well-established treatment algorithms are available, and all patients go to hospital. For patients where non-transport or referral options can be contemplated, risks that are not always fully appreciated abound. Considerable benefit could be achieved from higher levels of medical input, thus enabling paramedics and others to manage a greater number of patients without transfer to hospital.

    In England and elsewhere, the matter is being addressed by two related developments. First is the decisions of many paramedics to move to primary care for better-supported working conditions. Second is encouragement provided by changes to the GP contract that will help fund paramedics in primary care settings in the future (NHS England and BMA, 2019). Publications such as Paramedic specialist in primary and urgent care core capabilities framework (Skills for Health and College of Paramedics, 2017) and positive case studies (NHS England, 2020) helped lead the way to these current developments.

    In the ambulance service, there is an increasing implementation gap between the opportunities offered by having a more capable workforce that can exploit the power of disruptive innovation to create higher quality at a lower cost. Some positive efforts by Health Education England and the College of Paramedics have advocated a ‘rotational’ model where paramedics spend time in a variety of settings to improve effectiveness and job satisfaction (Health Education England, 2018). However, widespread change can be achieved only with leadership that appreciates the potential benefits and opportunities.

    The situation is exacerbated by the sometimes-poor working conditions that paramedics experience in ambulance services, where hierarchical, target-driving cultures, frequently accompanied by bullying, often compel staff to seek other opportunities. These failures can be countered if employers demonstrate more imagination and confidence, and work to remove the distorting and demotivating behaviours that are all too common. Failure to do so will lead to a continuation of the low levels of paramedic staff satisfaction, high turnover rates and an increasing flow of paramedics out of the ambulance service to other destinations both inside and outside the NHS. All of these trends are observable today.

    Ultimately, coherent national policy and doctrine have a role to play, with upgraded leadership preparation, improved system design and more radical organisational change—all worthy of consideration. At the critical care end of the spectrum, an absence of clarity in terms of policy can result in professional opinion determining approaches to service design and staffing.

    As for urgent care, policy and other factors have reduced medical involvement and, while clear policy has been available to guide the development of the ambulance service to act more imaginatively when delivering services to patients, progress in translating these ideas into tangible service improvement for patients has been limited. A more enlightened approach is necessary—one that emphasises assessment, treatment, referral and limiting transport to cases where this is clinically necessary. This is a goal that should be aspired to and is also eminently attainable, given the right managerial focus.

    The current circumstances illustrate that the emerging paramedic profession must deal with an environment where the advantages associated with being a disruptive force for positive change exist within a multitude of often conflicting, paradoxical and illogical artificial barriers, sometimes professionally-oriented but often also organisational in nature. These factors have reduced the benefits of a new, dynamic and versatile group of AHPs that paramedics have become over recent decades.

    Of particular concern to all paramedics, the public and policy makers, must be that a serious gap remains between the capabilities offered by paramedics and the opportunities available at ambulance services; many if not all ambulance services have not been able to match the potential attributes presented by a growing and more capable paramedic profession with organisational changes that would enable many benefits to patient care. This is an unnecessary waste and one that can be ill-afforded at a time when healthcare resources are likely to remain under pressure and efficiencies and innovative thinking are required. It is time to seize the opportunities that exist and release the full potential of paramedics.

    Key points

  • The paramedic profession can be viewed as a classic example of disruptive innovation in healthcare
  • The power of disruptive innovation to improve healthcare and drive down costs is often limited by conventions, professional attitudes, a lack of imagination and resistance to change
  • The profile of patients who use ambulance services has changed in recent decades, so how ambulance services operate needs to keep pace with a changing world
  • The paramedic profession has adapted to change more rapidly than ambulance services, leading to tensions and paramedics moving to other parts of the NHS and beyond
  • Despite research into the design and role of ambulance services and improved policy guidance, gaps remain in the evidence to support best practice
  • CPD Reflection Questions

  • When considering your own education and training, do you feel that you have be fully prepared for the realities of current and changing clinical practice? How so or why not?
  • If you feel that there are any gaps in your knowledge or practice, consider how you would develop an action plan to address these
  • How fit for purpose is the organisation you work for? Can you suggest how it might adapt to be more relevant and effective to meet changing patient demands?