Within paramedic unscheduled care, there has become a fixation on delivering urgent care provision to the patient. Whilst this has its roots in one very familiar Bradley Report (Department of Health 2006), the well quoted Keogh Report also sets out that ambulance services should develop into ‘mobile urgent treatment services capable of dealing with more people at scene, and avoiding unnecessary journeys to hospital’ (NHS England 2013: 8). In essence, delivering care to the patient. The accessible literature shows that across the World, community paramedic programmes follow similar notions. Canada (Reust et al 2012), Australia (Blacker et al, 2009) and certain states within the USA (Jensen et al, 2016) offer community schemes where paramedics work in collaboration with other community services to meet community-defined needs. Although differing in their individual approaches, the general principle is the same: paramedics are reaching out into the community to provide care which often reduces emergency department attendances and results in cost savings, both to the patient and the health provider (Nolan et al, 2012; Jensen et al, 2016). Some patients will always require care to be delivered to them due to various mobility, co-morbidity and access issues. Equally, many patients do not have these issues and are able to travel. What many current healthcare models do seem to miss, is the responsibility this report offers. Keogh explicitly states that the ‘report sets out some principles. How they are developed locally will, and must, vary to suit local circumstances and wishes. We will need different approaches in metropolitan, rural or remote areas. The majority of people needing urgent care do not have life threatening problems so we must focus our attention on bringing the best care to people as close to home as possible, wherever they live’ (NHS England 2013: 9).
I am grateful to have an NHS employer who took this element from the report to heart, and has built a relationship with a local clinical commissioning group to improve the patient experience in one of their most rural areas. Since 2011, South Central Ambulance NHS Foundation Trust and Oxford CCG have worked in partnership to develop and successfully run a First Aid Unit in Chipping Norton, rural West Oxfordshire. A first aid unit is exactly what it says in the title: it is a small unit that can treat a wide variety of minor illnesses and injuries. It was set up to provide out-of-hours first aid cover to the local area as well as relieve the stresses within nearby Minor Injury Units or Emergency Departments. With the usual range of urgent care tools and patient group directives available, the unit is equipped to manage most unscheduled complaints frequently encountered in practice. The obvious difference between this and the mobile Specialist Practitioners in Urgent Care is that patients self-present at the unit. Manned by one specialist practitioner (plus sometimes a trainee), it has become an integral part of health services within the local area and works closely with the local clinical commissioning group. Working autonomously means a background within emergency care is essential, as patients have been known to self-present with heart attacks, strokes, fractured long bones as well as obstetric emergencies. The ability to provide the first emergency treatment steps for such patients, as well as the ability to manage and treat minor ailments, means specialist paramedics are perfectly placed to run the unit and provide care. The current agreement in West Oxfordshire also sees the specialist paramedic respond to red category calls in the immediate area when they are not patient-committed in the unit. To be able to initiate treatment for life-threatening emergencies in a rural area is a key bonus, and one that also offers a financial incentive for NHS stakeholders.
Another benefit of such a unit is the sustained patient contact. Service users in the local area are able to re-attend for wound reviews when occupations or other social factors don't permit in-hours appointments. Similarly, ongoing minor illness review and management means local patients can easily re-attend if and when their illness deteriorates, aligning with the Antibiotic Guardian public health initiative. These provisions are simply not feasible when working to demand in an emergency service, but can readily be offered with a community initiative where the patient self attends.
While the concept of a community paramedic is not new either in the UK or abroad, the idea of paramedicled static service is. Perhaps this is the direction that services should start to take. With the regionalisation of hospitals and the downgrading or closure of old ‘general hospitals’ across the UK, patients are required to travel further to access primary care, especially out-of-hours. Rurality therefore increases with this principle (even for those living in towns) and the health services need to be proactive in their response. Additionally, the ageing population has been well documented (Thompson, 2015). It is estimated that by 2020, the general population will have risen by 3% and the age of the population with it: those aged over 65 are expected to increase by 12% (1.1 million); those aged over 85 by 18% (300 000); and the number of centenarians by 40% (7 000). Combine a new-found rurality with an ageing population, and once again community pockets are formed that may not be able to access regionalised health services due to the aforementioned mobility, co-morbidity and access issues. Community paramedicine will become more important for these patients, but not all services need to be mobile.
Successful community paramedic programmes across the world appear to feature three common elements: meeting the community need; ensuring the service provided is tailored to that locality; and engaging local stakeholders to ensure the programme runs seamlessly with other health services (Bigham et al, 2013). Chipping Norton First Aid Unit is absolutely tailored to the community it serves and its success hinges on the fact that this is not a service run in isolation, but in a relationship between the local clinical commissioning group and the ambulance service. The integration of the service into the community speaks for itself, with the unit seeing its 10 000th patient since opening in April this year.
‘Successful community paramedic programmes feature three common elements.’
So, what is the future of community paramedicine? Specialist paramedics are perfectly positioned to provide community care to augment frontline emergency services, but perhaps there needs to be more exploration across the UK whereby these services are offered strategically at static points within communities, taking healthcare to the community rather than to the patient.