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The future role and education of paramedic ambulance service personnel (Emerging concepts)

from a subcommittee of The Joint Royal Colleges and Ambulance Liaison Committee and The Ambulance Service Association.

Members of the committee in alphabetical order :Dr Peter Baskett, Prof Douglas Chamberlain (Chairman), Dr Tom Clarke (Joint Hon Secretary), Mr Robert Crouch, Dr Neal Edwards, Mr Martin Flaherty, Mr Alan Howson, Mr Paul Leopold, Mr Andrew Marsden, Mr Don Page, Mr Gron Roberts (Joint Hon Secretary) Dr David Williams, Mr Michael Willis.

5th January 2000

This document has been drawn up by a subcommittee of the Joint Royal Colleges Ambulance Committee (JRCALC) and the Ambulance Service Association (ASA) after a series of broadly based discussions, soundings and meetings. It offers an overview of the emerging concepts in relation to paramedic education and training for the United Kingdom ambulance services of the future. These reflect the important strands of the Governments plans to modernise the National Health Service: improving quality, producing a flexible workforce, creating an ethos of multi-disciplinary team working, and ensuring continuing professional development. [1,2,3,4,5]

Within his guiding framework, the main consideration behind our proposals has been the need to optimise the clinical care and safety of patients in the pre-hospital arena. This must transcend concerns over professional boundaries. A secondary consideration the need to offer educational opportunities that will attract and retain individuals of high academic and practical ability which will in turn improve standards of care. These considerations have led to proposals for a new concept in paramedic education that will complement but not supercede current arrangements. The document, which addresses principally these new proposals, is presented under the following headings:-

- Introduction
Current arrangements
New developments
A pattern for the future
Difficulties and opportunities
An outline model for the education of Practitioners in Emergency Care
Categories of professional and employment possibilities
Cost implications
Summary of recommendations


The future role and education of paramedic ambulance service personnel
(Emerging concepts)

1. Introduction

1.1 Emergency prehospital care can have a profound influence on morbidity and mortality of those critically injured. Whilst ambulance paramedics are expected to treat a wide range of medical, surgical and obstetric emergencies, their additional training (over and above their basic skills and operational experience) is relatively modest, with less than 300 hours initially, followed by a mandatory 16 hour annual refresher course. Moreover, practical experience is also limited. For example on average each paramedic may see one case of serious trauma per month [6] and only a few cases of cardiac arrest each year. Maintaining paramedic skills and improving their continuing education are therefore recognised as areas that present significant challenges.

1.2 The question of whether or not to treat the patient before transporting to hospital can be at least as important as knowing how to treat the patient. The challenge for paramedics to gain adequate knowledge for an accurate assessment of the patient's condition, to acquire the skills for safe management, to maintain both, and to develop sound clinical judgement is already considerable. Wider health care developments are likely to make it increasingly so in the future. Such developments include:-

- Prioritisation and patient help-line services which would offer support on those occasions when, after assessment and treatment, transport of the patient to hospital is deemed to be unnecessary.
- Increased specialisation which often results in longer ambulance journeys during which more extensive care and more sophisticated treatment is required.
- The recognition of a place for "immediate transport" policies, especially for trauma when the over-riding priority may be urgent treatment in hospital. The balance against the need sometimes to spend time wisely at the scene requires careful assessment and sound judgement. [7]
- Equity issues especially in relation to remote and rural communities where conventional emergency services may not be fully effective.
- Changes in the provision of primary care and the diminution in numbers of home visits by general practitioners associated with the establishment of out-of-hours cooperatives.

1.3 Incomplete data sources, problems of isolating the influence of individual components in a continuum of care, and the short time during which the patient is usually in the care of ambulance personnel are examples of the factors which make prehospital research particularly difficult. Thus, national and international evidence of impact on patient outcome remains inconclusive. A number of recent UK studies [6,8-10] have failed to show any reduction in mortality to hospital discharge as a result of paramedic intervention, at least with regard to trauma. Evidence does exist, however, that morbidity may be influenced favourably. It is not only outcomes that are matters of contention: the evidence base for many pre-hospital practices is generally recognised as seriously deficient. [11]

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2. Current Arrangements

2.1 The United Kingdom benefits from a strong national ambulance infrastructure but it may not have been exploited fully with regard to responsiveness to developments in health care. Professional training is conducted mainly within the service and usually on a single discipline basis. That training includes short periods in various hospital departments and a requirement for prescribed numbers of some practical procedures (such as tracheal intubation). But the time available for hospital experience makes it impossible to integrate paramedics into the routine provision of patient care. Thus far, the emphasis has been on training as opposed to education and there have been few formal academic links with medical institutions. Although training material and operational protocols are developed with medical advice and each ambulance service has a local Paramedic Steering group, the direct involvement of physicians in pre-hospital patient care is limited.

2.2 The perceived need in 1989 to provide in a relatively short time one paramedic on each front line ambulance was a major influence in dictating the early development of their training. There has been growing concern over the years that the desired depth of knowledge may have been sacrificed for speed. Paramedics have recently been granted recognition as a "Profession Supplementary to Medicine" but there is some debate [12] as to the best way of developing their future education and widening their contribution to meet the future needs of patients and the National Health Service.

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3. New Developments

3.1 In recent years a consensus has developed that education and experience needs to be broadened and improved for those personnel involved in pre-hospital care and specifically for paramedics [13]. In response to this perceived need several local schemes have been set up, including degree courses in a number of universities. These schemes, however, have developed independently. They have not been coordinated and tend to have varying objectives. Some are aimed more at providing managerial skills than clinical competence and most recruit existing ambulance staff rather than providing a career foundation.

3.2 Financial and operational pressures on ambulance services have also been changing with increasing emergency demand, grater emphasis on evidence-based medicine, a constant search for better value for money and the need to respond to wider changes in the Health Service. Public expectation of first class emergency health care is also increasing, and the principles of clinical governance support this requirement.

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4. A Pattern for the Future.

4.1 For ambulance personnel to provide optimal care for critical conditions in the important pre-hospital phase, some better method must be found of providing and maintaining the necessary skills and developing clinical judgement. The ability to recognise rapidly severity of any emergency comes mostly from wide experience - urgency or otherwise may not be immediately obvious to those not very familiar with some specific conditions. That skill is vital in deciding the relative priorities of intervention on scene and rapid transport to hospital. Moreover, paramedics in some rural areas have to care for critical patients for an appreciable time even if all delays are minimised.

4.2 There is also an increasing requirement for the ambulance service to be involved in the assessment and treatment of "minor conditions" including those which may not need transport to hospital. Adequate judgement for these roles cannot come from within the ambulance service alone. The dilution of experience is necessarily too great - a limitation that is now widely perceived as weakening paramedics' contribution to safe and effective care.

4.3 One practical solution is to establish an additional level of pre-hospital care provider who would both respond to life-threatening emergencies and attend those cases in which the need for emergency response had not been determined. Their potential for helping those most threatened and for providing triage of those seemingly less threatened is based on real need, and should not be seen as a paradox. The higher-skilled emergency workers would spend much more time in these various environments that can provide experience in a wide range of emergencies and - equally important - exposure to academic training and disciplines. Regular rotations into the hospital and primary care would improve and maintain skills and have other practical advantages for the Health Service.

4.4 In particular, the work load of Accident and Emergency (A&E) Departments continues to increase but staffing resources remain limited. There has been an expansion in the provision of senior medical cover, but a large proportion of medical staff are Senior House Officers. These trainees have a very steep learning curve during their six months in post, and then are replaced by less experienced colleagues. Continuity of experience can be provided by skilled nursing staff but some A&E Departments have difficulty in recruiting and retaining sufficient nurses. Better integration and interchange of ambulance and hospital A&E nursing staff may have the potential for easing this burden, to the considerable benefit of both.

4.5 Rotation and placements would provide an increasing resource of skilled practitioners who would eventually provide experience counted in years rather than months. Such an arrangement would offer job satisfaction, assist career development, raise standards of care, make the transition from pre-hospital care to hospital care increasingly "seamless", avoid unnecessary delays in repeated triage, and favourably influence other emergency medical personnel. It would also be entirely in keeping with the current NHS philosophy of developing a flexible multi-skilled workforce with opportunities for life long learning.

4.6 A health care professional with a degree and commitment to long term development of skills and education by working both in hospital and ambulance environments would be in a category different from any that exist today. This should clearly be recognised by an appropriate title. As an interim measure, we suggest the provisional use of the designation "Practitioner in Emergency Care" (PEC). The name is deliberately generic, because we foresee the need to have individuals with appropriate experience and skill to fill a variety of roles in addition to those already mentioned.

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5. Difficulties and Opportunities

5.1 One major difficulty must be recognised, but can be readily overcome. Nurses play a crucial role in Accident and Emergency Departments as elsewhere in hospitals. If they were to regard PEC's as specifically ambulance personnel with allegiance only to another profession they may have grave misgivings about the long term effects of the scheme. Important aspects of care, facilitated in a unique manner by nursing education, may be - or be perceived to be - threatened. Such attitudes would be less likely to arise if education of these pre-hospital care providers very visibly had some shred components with that of the nursing profession.

5.2 The new emphasis on academic ability also presents challenges and opportunities. Trends already established should ensure that many who are recruited into the ambulance service will have been high achievers at school, but care must be taken to ensure that they can have confidence in their future career prospects. Increasingly, entrants will want not only a role that fulfils their immediate aspirations but also a qualification that has value in it's own right - and this implies a growing need for appropriate University courses. Whilst all degrees have intrinsic value, the committee urges that University education for PEC's should be focussed on the practical needs of the service yet also offer the flexibility that will be required if an adequate number of academically gifted and ambitious people are to be attracted into the profession.

5.3 These two considerations lead to the promotion of an educational programme that is University based with a strong academic component coupled with instruction and experience in practical skills, delivered by members of the nursing, medical, and new paramedical (ambulance) professions. The course must be modelled around the needs of the patients in the community - both pre-hospital and non-hospital - whilst providing an educational experience that has value outside as well as within ambulance services.

5.4 We believe that this can best be achieved by a programme that has an initial component that will be common to a variety of health care professionals, followed by modules that will be specific to emergency pre-hospital and non-hospital care.

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6. An Outline Model for the Education of PEC's

6.1 Having regard to the principles outlined above, we suggest the following model for a three year PEC University course.

6.2 Year 1. This will be integrated into the new core education for the nursing profession (currently 18 months, but likely to be reduced to 12 months). It will provide underpinning knowledge that is needed by entrants into the nursing and paramedical professions and will be delivered predominantly by members of the nursing profession.

6.3 Years 2 & 3. These will be directed primarily towards pre-hospital care, but will be modular, with some modules having wider applicability. The modules should include

- Continued theoretical learning with medical, nursing, managerial, and ethical components as well as background knowledge of the history, ethos, and aspirations of all the emergency services;
- Practical training and hospital experience (as appropriate) in Accident and Emergency Units, Intensive Care Units, Cardiac care Units, Paediatric Intensive Care Units, Anaesthetic and recovery Rooms, other High Dependency areas and Obstetric Units;
- Brief observational experience in operating theatres and other relevant specialist units;
- Observational and practical experience within primary care, in liaison with general practitioner units, midwives, health visitors, and the psychiatric and general social services;
- Practical training and experience within the ambulance service, with all the components (including driving, radio, and telemetry skills) that will be appropriate for the future needs of PEC's.

6.4 Appropriate assessment methods and arrangements will be developed to ensure the participation of assessors from the medical, nursing and ambulance professions.

6.5 Registration will occur after the satisfactory completion of year 3, but Practitioners will still lack experience. An additional probationary period is therefore recommended in which clinical and ambulance experience will be broadened but some hospital contact maintained.

6.6 PEC's will enjoy flexibility within their own profession, with employment opportunities in the ambulance services, within some hospital areas, and in some community based posts. The new pattern of education and raining will also permit wider flexibility. The first "core-studies" year will be common to several health related professions, including nursing. The second and third years will be modular with credits apportioned to each module. This approach will provide for the ability of staff educated and trained under these arrangements to acquire academic credits for their previous education, providing the potential for movement into other professions through the accreditation of prior learning arrangements (APL).

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7.Categories of Professionals and Employment Possibilities

7.1 We should anticipate that most of those trained as PEC's will wish to work for most of their time in pre-hospital emergency care, with some mandatory rotations into hospitals. But such employment will not suit all, and over time preferences and physical capacity may call for change. Opportunities may well exist in primary care. Moreover there will be many openings within the community for professional health care workers whose interests have been directed to emergency care. Such scope would provide a degree of flexibility in employment not available for those in the ambulance service.

7.2 The introduction of PEC's would provide a new tier of expertise, but would not be intended to replace the Paramedic. We envisage they would share the new professional status and registration system of existing ambulance paramedics, but be regarded as advanced practitioners within the discipline. A modern emergency medical system requires that all professionals responsible for emergency care be highly trained. Every service would need a smaller number of PEC's who may not necessarily serve as regular crew of ambulances but would be deployed for higher category calls, and serious emergencies. Of at least equal importance they should be of special value for triage and to calls that are unlikely to need a full ambulance response. The favourable resource implications of such a system should not be overlooked.

7.3 For the foreseeable future, paramedics who are not PEC's would be expected to have much the same level of skill as now, perhaps with the exception of some procedures such as cricothyrotomy which are rarely practiced. Existing paramedics with the necessary aptitudes should be encouraged to progress to PEC status and conversion courses would therefore be required. In the same way as the introduction of paramedics raised the standard of the whole service by virtue of on-site training and shred experience, so the PEC would be expected to enhance the skills of all manning emergency vehicles. Experience and altering requirements in the longer term will doubtless dictate the need for changes - local and national - in the ratio of PEC's to conventional paramedics.

7.4 We anticipate that the new development will provide an opportunity for other health professionals to move into the pre-hospital sector as PEC's, taking advantage of APL and the proposed core training arrangements. Equally we hope that these arrangements will facilitate the movement of PEC's in other directions as a reciprocal arrangement.

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8. Cost Implications

8.1 For historical reasons, the cost of training ambulance staff is currently excluded from the Non-Medical Education Training (NMET) levy which covers the education of nurses and most other non-medical professions in England. Their training therefore falls outside the remit of Regional Education Strategy Groups. Whilst in training ambulance staff are currently employed by their respective Trust, with salary and raining costs borne directly by each employer.

8.2 A cohort of ambulance staff trained to higher levels than existing paramedics has cost implications that require careful consideration. The extent will depend mainly on the numbers required, their employment status whilst training, pay differentials on completion, and the initial costs of developing suitable academic courses. The costs will be offset in part by savings in ambulance service training budgets, better utilisation of currently unproductive time, and also from a range of wider potential benefits in the wider health care system. These will include reduced attendance at Accident Emergency Departments that will result from better working flexibility and improved clinical judgement. Not all of any such savings would accrue to ambulance services, but in the broader context would still be seen as advantageous. The balance of this complex equation cannot yet be calculated in detail, but some of the important principles can be outlined.

8.3 With the introduction of call prioritisation, the development of rapid response units and the search for alternative ways of delivering emergency care it has been estimated that approximately 20-30% of the current workforce (comprising 8000 practicing paramedics) could potentially be employed as PEC's in the future. Local variation is to be expected depending on circumstances and specific needs. Currently about 500 new paramedics are trained annually, but new national performance standards are likely to lead to increased recruitment. Thus, the actual number of PEC's required can be truly established only by considering manpower plans on a service by service basis and in the context of their local healthcare systems.

8.4 The primary Degree in Emergency Care would not necessarily be the responsibility of Ambulance Trusts or indeed the Health Service, but the supplementary training to full operational capability would be. It will be additional to and not replacing some current commitments. Conversion courses for existing paramedics would be a further cost.

8.5 Using nurse training as a model, student PEC's would not become employees until qualification. Tuition costs could amount to 5,000 per student per annum, with an additional sum of 5500 to cover the cost of a bursary. The three year total of 31500 should be considered against the current estimated cost of training from recruitment to paramedic qualification of 18500 which includes salary whilst on training courses together with other expenses.

8.6 We can reasonably assume that the additional staff required for rotation into Accident and Emergency Departments would be covered by contractual arrangements with Hospital Trusts which will benefit from services of personnel experienced in both pre-hospital and in-hospital emergency care.

8.7 The cost of developing the proposed academic course is expected to be modest as much of the content is already used in other areas. There will be some additional costs associated with practical/supervised training in the fourth year and the additional costs of offering conversion courses to existing paramedics may need to be considered. Some additional pay costs must also be anticipated and it would seem opportune to factor a higher qualified grade of emergency care provider into the wider national examination of pay structures which is currently the subject of discussion and consultation.

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Summary of Proposals and Recommendations

Emergency pre-hospital care can have a profound influence on morbidity and mortality of those critically ill or injured.

The ambulance service has had considerable success in training and deploying paramedics to play a key role in the provision of pre-hospital care. The objective of having one such individual with advanced skills on every emergency ambulance has largely been met. But further developments are now needed to achieve the full potential of skilled pre-hospital care. In particular, the experience of paramedics in attending medical and surgical emergencies is limited. Moreover, present training and professional development do not provide the underpinning education for sound clinical judgement to be exercised or indeed expected.

The needs for effective prioritisation, safe triage, utilisation of new opportunities for effective immediate care, and judgement to recognise when prompt transport is the over-riding priority all call for a level of education and expertise that cannot be provided at present by the established paramedic courses. This widely perceived requirement has engendered many local schemes, some involving degree courses. Whilst these offer excellent opportunities, they are variously targeted, not co-ordinated and offer no official career structure.

We believe that the needs of patient care and of the service could best be met by a higher level of paramedics, perhaps 30% of the total, who are given a three year education in emergency care leading to a university degree - followed by a further probationary year of service training. These Practitioners in Emergency Care (PEC's) would achieve continuing professional development based on employment both in appropriate pre-hospital and in-hospital environments.

The education would be modular, and flexible, using some components that are already available. Ultimately almost all wishing to pursue such a course will be school-leavers whose ambitions lead them in this direction. But initially there must also be provision for existing paramedics with the necessary ability and motivation to make the transition to the new grade, with due allowance for prior learning.

The scope of the employment of PEC's in the ambulance service will need to be determined by individual trusts in conjunction with other partners in the local health economy. Their advanced skills and increased knowledge are likely to make them particularly useful for rapid response to life-threatening emergencies and - importantly - for triage of cases where the need for transport has not been fully established. Thus, they will not replace existing paramedics but complement them as advanced practitioners within the discipline. We anticipate that the knowledge, expertise and judgement will have a favourable influence on the standard of care provided by all ambulance personnel.

Many opportunities will also exist in hospitals (especially within Accident and Emergency departments) for taking advantage of the experience and skills of PEC's, where indeed they would be expected to work for a portion of the year. They could also expect to have valuable roles within primary care.

The cost of the scheme cannot be calculated in detail at this stage, but the principles and figures outlined above suggest that it will be relatively modest in proportion to the needs that are recognised and the gains that are to be expected. Some savings will accrue and only a proportion of the costs will be the responsibility of the ambulance service.

We are thus proposing a new echelon of generic health care worker as part of the Paramedic Profession with a broad-based University education provided by the nursing, medical and ambulance personnel - and continuing professional development with academic and practical components. They will have diverse roles both within the ambulance service and within wider contexts of primary and emergency care.

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