Just over a decade ago, when I first registered with the Health and Care Professions Council (HCPC) (then the Health Professions Council), I did not picture a career outside of the back of an ambulance—unless I ceased to be a paramedic entirely. Yet, over the last 10 years, one of the main components that has catalysed the development of the profession is the idea that paramedics could capitalise their generalist unique selling point (USP) to work to an enhanced clinical level. The development of the paramedic profession itself is not new—we have continuously developed since our inception from working clinically within the constraints of providing life support under the supervision of cardiologists, to being autonomous clinicians in our own right. However, the progression to working within advanced practice has been something new—and I think we have the changing model of care delivery within the ambulance service to thank for this. Ambulance services were historically based on a retrieval model of care, where ambulances are dispatched to patients and convey them to further care, perhaps with some emergency treatment en route. However, based on changing healthcare demands and the oft-touted 5% of 999 calls constituting an emergency (NHS England, 2014), UK ambulance services have had to adapt their model to focus on delivering care to a more urgent, less emergent, group of patients. One way to help meet rising service demand is by developing a workforce that can adapt and respond, maximising existing roles and expanding clinical practice. I think that it was through the various schemes developed to respond to this ‘new’ group of patients in the ambulance service, in which the clinical skills and capabilities of the paramedic were enhanced beyond what was considered traditional paramedic practice, that paramedics proved their worth in being able to operate at an advanced level of clinical practice— and, more latterly, within different clinical settings entirely.
Now, the ability for a paramedic to work within an expanded scope of practice, at different clinical levels, is recognised in national guidance (National Institute for Health and Care Excellence (NICE), 2017; 2018) as well as in professional policy (College of Paramedics, 2018). Indeed, all nations within the UK have outlined the value of paramedics working to enhanced levels of practice within their health policy. In 2017, these levels practice were formalised and defined into what we see today as advanced practice. This definition, which has become widely adopted across the UK, sets out advanced practitioners as health professionals who are educated to Master's level or equivalent, with the skills and knowledge to allow them to expand their scope of practice to better meet the needs of the people they care for (Health Education England, 2017).
I think it is therefore safe to say that advanced practice has catalysed the development of paramedic career prospects. Prospects that were once limited to a career working on an ambulance, or perhaps within a management role, have now expanded to where paramedics are responsible for managing whole care episodes—from investigation, diagnosis, and definitive management. More excitingly, this is across a range of clinical settings, from primary care, to emergency medicine, to surgery—as well as within the ambulance service. The very definition enables advanced practitioners to work within every corner of healthcare. Another part of the beauty of advanced practice is its multidisciplinary nature. As long as the health professional (whether that be paramedic, physiotherapist or podiatrist) has undertaken their Master's degree (or equivalent) and has expanded their clinical skills to work within their setting of employment, they are an advanced practitioner.
But what about their base profession? If advanced practice is a level of practice, how can they still be pharmacist, physiotherapist or paramedic? I heard some years ago, at a Health Education England conference, Beverly Harden (the National Allied Health Professional lead) describe advanced practice as an egg: the yolk is the base profession of the practitioner—and all the USP that involves. I think part of our USP as paramedics is our generalist nature and ability to problem solve. The white is the clinical skills and competencies that are characterised by the clinical setting in which paramedics work, where there may way be cross-over with other professionals. When frying or poaching an egg, while the egg white may mix with others, the yolk stays central. When scrambling an egg, it all gets mixed up, where the yolk and white are inseparable. That is okay too—the yolk is still a central component to that mix. Difficulties exist, however, where the yolk and white become separated—where the need for one is favoured over another. We are starting to see this documented in the research literature, where advance clinical practitioners experience the loss of their professional identity in advanced practice roles (having lost their yolk) (Stewart-Lord et al, 2020), or experience dissatisfaction and inability to clinically progress when the role centres too much on the base profession (like a meringue) (Wood et al, 2021). The panacea is the clinical setting where advanced practitioners are encouraged to progress their clinical expertise, while accepting the USP developed through their experiences in their base profession— and this is all to the benefit of the patients we serve.
Something I particularly like about advanced practice is that it is not limited to the clinical domain. Although most paramedics may enter advanced practice through development of their clinical expertise, advanced practice is defined by four equal pillars of research, education, leadership, and clinical practice. It has something for everyone. Crucially, advanced practitioners must operate across these four pillars, though it is accepted that this may be in varying degrees—like a four-pan scale—and we can pick the bits that fit us best at one time, with the option to change at a later time. Whichever pillars we operate to a more or lesser degree within, the focus must be on the betterment of patient care.
However, advanced practice for paramedics is not without its cracks. It is commonly held that the ability to independently prescribe medicines makes an advanced paramedic. However, this is not true. Independent prescribing may be one part of working with an expanded clinical skill set, but it is not the only part—indeed, without the clinical education from a Master's degree (or equivalent clinical experience), it is perhaps not going to better meet the needs of patients, which makes the whole ethos of working to a level of advanced practice rather devoid.
On another note, it is highly likely that advanced practice needs further consideration by ambulance services. While plenty of advanced paramedics exist within ambulance services across the country, the ability to retain them is paramount. Across the wider NHS, advanced practitioner roles are commonly reimbursed at a salary equivalent to Agenda for Change (AfC) 8a (£48k–£54k) and advanced practitioners who can prescribe would commonly see AfC 8b (£56k–65k). Such clinical pay grades within ambulance services are largely unheard of, with a majority of programmes paying their advanced practice workforce between £41k and £47k (AfC Band 7). The Welsh Ambulance Service NHS Trust is leading the way in this regard, where their advanced paramedics can expect a salary of 8a once they have successfully completed their Master's degree and independent prescribing. I hope other Trusts across the UK are watching with interest. While the provision of unsocial hours allowances may increase the AfC Band 7 wage somewhat, it is not beyond the realm of possibility that advanced paramedics in these services may seek to practise where they are remunerated at a scale that is commensurate with the clinical level at which they operate. This is problematic for ambulance services who risk losing their most educated and experienced staff who not only deliver care for patients, but who also act as clinical leaders and role models within their respective services.
So, as we look to celebrate advanced practice week, and those paramedics who work as advanced practitioners across various settings, let us look to the future. When I registered as a paramedic over a decade ago, I did not consider being anything other than a paramedic on ambulance—much less leading the development of advanced paramedics. We should be proud of the growth our profession has seen since its inception, and none more so than in the last decade which has continued to see paramedics push through clinical boundaries across a range of clinical settings, working to an advanced level of practice.
So, where do we go next? The limit should not be considered in terms of what the profession can do—we can do pretty much anything—but in the context of what the patient needs. Where the definition of advanced practice has the needs of patients firmly at its core, so too should the ongoing development of our profession.