The first two parts of Andy Newton’s article reviewed the history of ambulance services and the changing profle of demand and identifed a major challenge which up until now has been the subject of several reports but is yet to be fully addressed operationally.
In the concluding part, Andy Newton has tabulated the changes in the dominant concepts of ambulance operations since 1948, identifes the key enabler to meet the challenges of today, and draws conclusions to the three-part article.
Education: the key enabler at both pre and post-registration
The move from training to education for paramedics is one example of the failure to reform ambulance services to meet the changing nature of demand. Education of the workforce is a prerequisite for lasting change and the core enabler for changing clinical behaviour, though it has proved to be slower than some might have expected. This is despite further adverse media attention from BBC’s Panorama (BBC, 2000) and other programmes that have highlighted defciencies in ambulance services’ operations and academic recognition that conventional ambulance paramedic training does not match the demand actually dealt with by paramedics (Lendraum et al, 2000).
Disappointingly, as Armitage notes (Armitage, 2012), the process of professionalising paramedic education and training is far from complete, despite the efforts of many paramedics themselves and the efforts of the College of Paramedics, whose ‘prime directive’ is to develop the paramedic profession and raise the profle of the work paramedics. The role of a strong professional body for paramedics is indeed a key ingredient to success. The College of Paramedics is the primary advocate for paramedics in the UK and in a real sense the guardian of the uniqueness of paramedic practice. The value of a sound professional body has not been lost on other professions and interestingly Peter Neyroud, the former chief of the National Police Improvement Agency has argued for the creation of such a body for police offcers, in a report requested by the Home Secretary. Many of his recommendations for the Police, particularly in respect of the College’s leadership role and its’ work in relation to education and developing the paramedic profession are routine activities for the College.
Even the commitment to move to a universal minimum of a foundation degree for new entrants to the paramedic profession has yet to be implemented, although is now scheduled to happen in 2013, subject to Health Professions Council approval. Quite why the recommendations of the former Ambulance Service Association and Joint Royal Colleges Ambulance Liaison Committee JRCALC, 2000), chaired by Professor Chamberlain, which recommended embracing an educational approach in 2000 were not followed is, uncertain, but represents another example of an opportunity lost or at least not seized in a timely manner. Widespread differences in education funding remain around the country, with an almost unfathomable and unjustifable range of qualifcations, together with inconsistencies in respect to commissioning and access to the NHS bursary scheme.
This position stands in marked contrast to the situation with all other allied health professions (AHPs) despite positive research fndings (Woollard, 2006; Mason et al, 2007) and publications (DH, 2003; 2008) both of which identifed the potential of paramedics. Despite this attention, less than 1 000 operational paramedics have received the additional education, training and skills needed to function at the specialist paramedic level, with only a fraction of these accredited via the formal examination, designed and developed by the profession with support and quality assurance from colleagues at the Royal College of General Practitioners (RCGP), the College of Paramedics and St George’s Hospital, University of London.
Confusion over title, career structure, education and credentialing are now being resolved, however, most ambulance services do not yet have suffcient adequately prepared staff who can effect the necessary change to meet the diverse needs of patients. Nor does a coherent doctrine to drive the necessary philosophical and organisational change in thinking, without which meaning service redesign cannot take place. It seems that the old unconscious dogma continues to hold sway and acts as an invisible, hindering factor.
| 1948-1960 Dominant Concept of Operation/ Priorities | 1970-1980 Dominant Concept of Operation/ Priorities | 1990-2000 Dominant Concept of Operation/ Priorities | 2000-2010 Dominant Concept of Operation/Priorities | 2010-2020? Dominant Concept of Operation/ Priorities |
| Local Authority provided transport. | Transport (ambulance service). | Transport/emergency Ambulance/EMS model | Transport/EMS model, ambulance aid at technician and paramedic-level responsibilities.Some schemes extending the paramedic role (e.g. ‘community paramedics’). | Clinical decision making and triage. Needs-led transport to various facilities. Expansion of mobile healthcare. Progressive integration to wider health economy. Broader range of treatment options. |
| Treatment at the first-aid level | Treatment including gradual development of Advanced Life Support, ALS | Treatment including development of Advanced Life Support, ALS, with some expansion in the scope of paramedic practice | Treatment including paramedic advanced life support with development of paramedic practice. Extension of role with patient assessment/minor illness/injury management. Few schemes prosper. | Regulated paramedics operating at higher education level. Specialist practice in primary care. Critical care paramedic introduced, providing ‘enhanced care teams’ for seriously ill/injured. Paramedic control practitioners. Models of care include ‘hear and treat’/‘see and treat’. |
| Civil defence role | Assessment and triage (usually mass casualty incidents) | Assessment and triage [normally limited to mass casualty incidents] | Recognition that expansion of scope of practice desirable beyond critical care; variable experimental schemes | Incorporation of 111 service |
| Renewed emphasis upon major incident, anti-terrorist and rescue/‘civil defence’ role [emergence of HART capability | Needs-led transport. Full implementation of cardiac, stroke/TIA trauma, vascular and other networks. Increased reliance on care during transport | |||
| Paramedics become registered Allied Health Professionals, leading to higher educational standards and an opportunity to extend practice to meet patient needs. | Emphasis on AS ‘rescue’ role. Paramedic rescue specialist. Promotion of medical sub-speciality in pre-hospital care focused on ‘hyper’ acute patient population, (0.15%-0.5% of 999 calls). |
The ambulance services and the paramedic profession can make a signifcant contribution in providing a more appropriate service to meet the population’s demand. But they can only achieve this through the development of the workforce, which will increasingly become based on the development of paramedics.
Paramedics have been subject to regulation since 2000 and are an example of a ‘disruptive technology (Cheristensen, 2009). Essentially, this means that paramedics, like other AHPs, and in common with some well known technological developments, such as the digital camera or mobile phone, become more effective, more able and yet relatively cheaper than available alternatives over time.
Well-trained fexible paramedics are, therefore, both a ‘game changer’ and a bargain for any health economy and a key ingredient of any efforts to produce high quality mobile health care.
Somewhat paradoxically, the establishment of a new medical sub-speciality in pre-hospital care to address the relatively small number of patients presenting with major injuries seems surprising and options appraisals detailing what advantage such services may bring are awaited. It may yet be possible to determine an economic arrangement that fuses the roles of paramedics and medical staff from this new sub-specialty and the effect on those physicians who give of their own time to provide this role, many of whom will be holding the purse strings in the new Clinical Commissioning Groups, is equally uncertain. Perhaps charitably funded Helicopter Emergency Medical Services, being a potential model, but as Rawlins notes ‘innovation [if] cost ineffective cannot—so far as the NHS is concerned—be innovation.’ (Rawlins, 2012)
This lack of consensus has been noted by Mackenzie (2009) asking how to serve the small number of critically ill patients through the most effective combination of paramedics and doctors. Discussions continue as to how a relevant, cost effective and harmonious set of arrangement might best be achieved. Equally, the opportunities associated with the wider use of paramedics, who are already in funded positions operating as a ‘disruptive’ technology have undoubtedly yet to be fully exploited and it will be essential to complete the professionalising process, matching the educational standards of other AHPs, implementing the AHP career structure and fully embracing specialist practice in order to deploy the full benefts.
Conclusion
The steps and considerations identifed above, especially when combined with the necessary organisational development, will ensure that ambulance services will be able to deliver an increasing range of services across a wider spectrum of patient need. Including advanced ‘hear and treat’ triage services to patients, using specialist paramedic control room paramedics. More ‘see and treat’ services, by deploying specialist paramedic practitioners, who have passed the pioneering Paramedic Practitioner examination, quality assured by colleagues from the RCGP/College of Paramedics and more critical care paramedics providing enhanced care teams targeted at the most acutely ill and injured end of the patient acuity spectrum, as recommended in the NHS Confederations review (Jashapara, 2011). But none of these capabilities can be put to best effect without a change in philosophy and concept of operation, slicker implementation and a sharper emphasis upon paramedic education and development.
In health care only two things really matter, the outcome for patients and the cost at which these outcomes are achieved (Barker, 2010). For the ambulance sector, paramedics and the taxpayer, the world has changed and the need to deliver health care in lower cost centres is now well established, but not yet routinely refected in ambulance services or in urgent or non-urgent pre-hospital care in general. The question as to which of the two alternative models, either relatively straightforward transport based, or one with a focus on clinical assessment and decision-making, provides the best value and the most positive impact for patients is clear. But the price of achieving greater workforce productivity is an unwavering commitment to offering paramedics the same educational opportunities as other AHPs, together with a need for joined up leadership between policy makers, system leaders and the College of Paramedics.
As to whether there is an appetite to implement the new doctrine and a new concept of operation, or provide the educational opportunities in the ambulance services and amongst commissioners and service leaders is however somewhat less certain. The answer to this question will decide how relevant, fexible and adaptive both the ambulance services and the paramedic profession become in regard to the needs of patients and the public purse in the 21st century.