As registered healthcare professionals, it is important that paramedics in the United Kingdom (UK) demonstrate equality in the care and treatment that they offer to all those who call upon their services. The Health and Care Professions Council (HCPC) clearly state that no registrant should allow their views about a service user's sex, age, colour, race, disability, sexuality, social or economic status, lifestyle, culture, religion or beliefs affect the way in which they deal with them (or the professional advice that they offer). They must treat all service users with respect and dignity (HCPC, 2008).
This basic principle forms part of the National Health Service (NHS) attempts to eliminate discrimination and reduce inequalities in care—this principle is partly dictated by the Equality Act 2010 (c.15). If anything the NHS Constitution goes further than this stating that employees should:
‘…pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population…’
It could be seen as quite simplistic to state that pain is pain, injury is injury and illness is illness—maybe too simplistic if we look closer at the perceived care inequalities relating to specific patient groups, in this case substance users. Other authors have looked at specialist patient groups with non-standard attendance backgrounds—examples such as accident and emergency responses to patients with head injuries as a result of martial arts (Graham et al, 2007), district nurses’ concerns when dealing with long-term drug users (Peckover and Chidlaw, 2007), and the opinions of nurses towards those who have attempted suicide (Sun et al, 2007) all go some way to assuring paramedics that this is not an isolated professional concern but one with multi-professional connotations.
The HCPC acts as the professional regulator for paramedics in the UK in order to protect public interests and safety. They place a direct duty of care for any patient that is assigned (HCPC, 2008). This assignation is normally made by those who receive requests for help, prioritise those requests and then despatch resources—predominantly ambulance trust emergency call centres. This duty of care is broader than just HCPC regulation though. There is also a combination of legal, organisational, professional and moral demands which attempt to ensure that the right care is delivered to the right patients at the right time (Ashman, 2004)—a time that suits that patient's individual circumstances and not a time which is based on a potentially judgemental opinion of how the patient's circumstances came about.
This author suggests that there may well be a number of acceptable rationales for unconventional levels of care quality and some may suggest that variations in the quality of care can be justified by paramedics when the difficult circumstances in which they regularly find themselves operating are considered. But, they also suggest that many paramedics are at risk of being accused of abusing the autonomy that their profession affords them by those who have little or no experience of the world in which they work. As a result of the autonomous decisions that paramedics make to care for and treat some patient groups differently to others they run the risk of being deemed negligent in the eyes of not only the HCPC but also the UK legal system and, at times, the media. This article is intended to offer the opportunity for discussion and consideration of the difficult situations that create the opportunity for this criticism. It highlights some of the real pitfalls of negligent care for those who may be under the influence of alcohol, drugs or both. The author wants to draw upon personal and professional experiences, UK-based literature and anecdotal opinion of other healthcare professionals, public health researchers and substance users alike in order to stimulate further discussions on the difficult topic of equal emergency care for all.
A discussion of the topic is needed; it is suggested that during the educational and development stages of pre-hospital learning more emphasis could be placed on patients who are under the influence of drink or drugs in order to encourage positive behaviours from the start. Surely we can have professional compassion for substance users without actually condoning their actions—but this is difficult when many (through ignorance) continue to view a user's actions as ‘wilful’.
One patient who I spoke to recently told me:
‘…I hate being treated like an addict, people want to constantly ignore me, forget me, lie to me, manipulate me, blame me and punish me for what I am…’
The risk of paramedics not having a positive mind-set when dealing with those who abuse drink or drugs is that patients end up ‘just being treated like drug addicts.’ Sometimes care will be offered with different standards to those who have drugs that are prescribed for them to those who use ‘other’ drugs (legal or not). Is it professional to treat people badly just because many others in society do so? It would be wrong to fall in to this trap which has been identified by so many recovering or recovered ‘users’. Many see drug and alcohol use as a weakness or part of broader criminal behaviour and not necessarily the illness that it can sometimes become. Some see it as a disease and not a character flaw.
What next?
The way in which you talk, the language you use and the level of care and treatment that you start can invariably have a positive effect on the patient's chain of care. You can set the tone for their treatment.
There is no suggestion by this author that clinicians are in any way judgemental or negligent in their duty of care. With the stress and workload involved in emergency care it is sometimes easy to see why certain circumstances lead to treatment being given in certain ways.
But this doesn't mean that it is acceptable to adopt a ‘one size fits all’ model to the treatment of this named vulnerable patient group. This article merely offers an opinion—that when we (as paramedics) deal with patients who are ‘under the influence’ the situation and the patient's social history have a tendency to create disparities in the care and treatment that is offered to them compared to that for other groups. This is not always a bad thing, or done for the wrong reasons—paramedics have to make many decisions based on limited information and difficult situations. At times though, these variables can lead to a decision which is simply wrong. This could be as a result of limited training or education in managing this patient group, limited experience of offering complete care to them or limited onscene information on which to base their decisions—or even a combination of all three.
This author suggests that a prehospital paramedic research study is needed to consider this dilemma. Paramedics are not alone in this, their professional colleagues in both the NHS and the other emergency services continue to be at risk of making judgements based on social appearance of the substance user and the circumstances in which they find themselves. In recent media coverage it has been noted that many police services in the UK have started advertising for ‘custody nurse practitioners’ to care for a further group of patients who are in difficult circumstances and may have specialist needs. So it seems that the questions posed by this author could be directed at the police service and accident and emergency doctors or nurses with potentially similar risky decisions being made on a regular basis. In light of recent high profile reports in to the standards of patient care, all professionals need to be far more aware of the demands placed on them to return to the basics of their roles.
Is it time to ensure that we care for and treat what is found regardless of potentially subjective, judgemental and risky opinions on what actions led to care being required in the first place?