Paramedic training programmes and scope of practice: A UK perspective Paul Gowens MCPara, AASI, Dip IMC RCSEd, MCMI Head of Clinical Governance, Quality and Patient Safety Scottish Ambulance Service, National Headquarters, Gyle Square 1 South Gyle Crescent, Edinburgh EH12 9EB, UK Alasdair Gray, MBCHB, MD, FRCS. FCEM, Consultant in Emergency Medicine, College Professor of Emergency Medicine, Department of Emergency Medicine, Royal Infirmary of Edinburgh, UK. Honorary Reader, University of Edinburgh, Address for correspondence: Paul Gowens Head of Clinical Governance, Quality and Patient Safety Scottish Ambulance Service, Medical Directorate Gyle Square 1 South Gyle Crescent, Edinburgh EH12 9EB E-mail: pgowens@nhs.net 1 of 9
Introduction Emergency care in the United Kingdom is predominantly provided by four publicly funded health care systems: the National Health Service (for England), Health and Social Care in Northern Ireland, NHS Scotland and NHS Wales 1. These health care systems include prehospital care and transport delivered by 14 regional ambulance services in England and national ambulance services in Scotland, Northern Ireland and Wales. The National Health Services Act (1946) identified that local authorities were required to provide ambulances 'where necessary'. Prior to 1946, the chance of being transferred to hospital in an ambulance depended upon where you lived. Ambulances were mostly available in cities and large towns. Initially, ambulances were staffed by volunteers transporting the sick and injured to hospital for treatment 2. In 1964, the Millar report 3 recommended that ambulance services should provide treatment in addition to transporting patients. Ambulance services began to provide clinical care, including life saving procedures such as haemorrhage control, spinal injury care, cardiopulmonary resuscitation and fluid, drug and oxygen therapy. The requirement to deliver on scene clinical care led to the introduction and development of Paramedics in the mid 1980 s across the UK 4. Clinical guidelines were subsequently developed by individual ambulance services to support paramedic clinical practice. However, this led to significant variations in clinical care and scope of paramedic practice across the UK. In 2000, a set of nationally applicable clinical practice guidelines were produced by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) 5. The guidelines are evidence based and regularly reviewed and updated. 2 of 9
Ambulance Service Demand The demand on ambulance services across the United Kingdom has increased, dramatically over the last 20 years (see table 1 for English figures) 6. Table 1 3)Year Emergency Calls 1994/5 2.61 million 2004/5 5.62 million 2006/7 6.3 million When the public in the UK require an emergency ambulance they contact the UK wide 999 system. These calls are then connected to the most appropriate emergency service. Within the Emergency Medical Dispatch Centres, the triaging of the call is predominantly by systems using computer algorithms such as the Medical Priority Dispatch System, NHS Pathways or equivalent. On ambulance arrival, the patient receives face-to-face triage and clinical assessment from the paramedic and treatment if required. This may include the use of patient care pathways for conditions such as elderly falls, seizures or hypoglycaemic episodes in insulin dependent diabetics, providing the option for these patient groups not to automatically be transported to hospital. The Scottish Ambulance Service is a Special Health Board of the NHS in Scotland. It is funded directly by the Health Department of the Scottish Government 7. Until 1974, ambulance cover in Scotland was provided by a combination of the British Red Cross and St Andrews Ambulance 8. In the financial year 2008 2009, the service employed 3,797 staff across five divisions and attended to 599,052 emergency calls. 3 of 9
The Paramedic Programme Today, paramedic training programmes can be entered either via a university degree course directly from school or after employment with the ambulance service. The latter group is trained by an apprentice model with the ambulance service supporting educational development to enable subsequent entry into a university programme 7. A small number of ambulance services still provide in-house paramedic training which is not affiliated with a university. Historically, entry into paramedic training was achieved by working in various roles within a specific NHS ambulance service. Prospective paramedics often initially worked in the nonemergency Patient Transport Service, before moving to frontline emergency work by qualifying as an ambulance technician. Then, following a period of clinical experience in this role, candidates would sit entry exams covering oral and written communication and a practical patient assessment, including a mandatory medical and traumatic scenario. If successfully completed, they would then, begin the paramedic programme. Driving Emergency Vehicles In addition to registration with the Health Professions Council as a paramedic, most NHS Ambulance services require students to achieve a category C1 driving licence (vehicles weight 3,500-7,500 kg) to ensure safe driving of an ambulance under emergency conditions. In addition they are required to pass an advanced emergency driving course coordinated by the local ambulance service. Foundation paramedic The foundation programme consists of a seven-week residential period during which time students learn the basic principles of prehospital care. Assessments consist of both short written, multiple choice question and objectively structured clinical examinations (OSCE). These introductory sessions will be further supplemented by learning materials and tutorials provided by the Practice Placement Educator during the students first year. Learning outcomes for these topic areas are taken from the Institute of Health Care Development (IHCD) module J learning outcomes 8. 4 of 9
Table 2 Year 1 Human development Resuscitation Acute and chronic medical conditions Mental health Obstetric emergencies Paediatric education for pre-hospital professionals Trauma life support Moving and handling Conflict resolution Major incident management Infection Control Sociology Psychology Clinical decision making Ethics and law Health promotion and audit and research After completion of the core academic elements of the paramedic training programme outlined in table 2 candidates progress to clinical practice placement. A supporting manual details the expected core skills and competencies. In addition to the practice placement portfolio the students receive a clinical placement folder detailing specific skills to be demonstrated within the clinical environment. Under direct supervision and having obtained patient consent when possible students will be able to practise clinical skills within the prehospital environment in addition to those afforded by hospital placement. Placement areas may consist of any of the following listed in Table 3, but should be directly representative of the local environment the student will operate within, as well as affording opportunities for the achievement of learning outcomes. 5 of 9
Table 3 Emergency Ambulance Paramedic Response Unit Medical Assessment Unit Emergency Department Mental Health Coronary Care Operating Theatres Midwifery EMDC Critical Care Networks Primary Care Out of Hours Primary Care The second year is divided into three terms with the final written assignment on clinical decisionmaking presented at the end of term two. Successful completion of all elements of the practice placement and academic components of the programme will ensure the Standards of Proficiency required by the Health Professions Council are met, enabling students to formally apply for registration 8. Table 4 Year 2 Advanced Airway Management Patient assessment Advanced Life Support Pharmacology International Trauma Life Support (Advanced) Paediatric Education of Pre-Hospital Professionals (Advanced) Obstetric Emergencies Clinical decision making including see and treat and see and refer 6 of 9
At the end of a 2-year foundation paramedic programme they will be competent across a wide range of practical skills including the administration of drugs, detailed in table 4. Post registration opportunities As outlined in "Paramedic Curriculum Guidance and Competence Framework" 9, the College of Paramedics supports an increase in the threshold entry level for paramedics to a minimum of a Diploma of Higher Education. However some university based paramedic courses are set higher than this at BSc (Hons) level and paramedics are increasingly studying postgraduate qualifications after their initial registration. Until recently, the prospects for paramedics wishing to develop were limited to in-house ambulance service training or management roles. In recent years however, many paramedics have developed their clinical practice into specialist and advanced roles in areas such as primary and critical care. Increasingly paramedics are delivering clinical care in other urgent care environments such as out of hours primary care centres and minor injuries units. Similar to other health care professionals, paramedics are required to have attained additional training and qualifications to deliver these roles. Table 5 Career Frameworks 10 Paramedics career frameworks described in table 5 have been brought into line with other Healthcare Professionals, allowing for career development and progression to that of consultant or director. This allows opportunities for paramedics to develop in several ways; clinically, within management, educational or research roles and allows them to be recognised within a nationally 7 of 9
recognised career framework. The governing bodies with responsibility to maintaining standards of paramedic practice are the Health Professionals Council and College of Paramedics 11,12. 8 of 9
References 1 "NHS Ambulance Trusts Description". http://www.nhs.uk/england/authoritiestrusts/ambulance/default.aspx. 2 http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/history-copy/ accessed on 01/10/11 3 Ministry of Health, Scottish Home and Health Department. Report by the working party on ambulance training and equipment: part 1 training. London: HMSO, 1966 4 Caple L. A concise history of ambulance services in Great Britain. Ambulance UK 2001 5 http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/history-copy/ accessed 03/10/11 6 "Emergency ambulance calls 'peak'". BBC News. 21 June 2007. http://news.bbc.co.uk/1/hi/health/6227034.stm 7 http://www.nhscareers.nhs.uk/details/default.aspx?id=905 accessed 04/10/11 8 http://www.hpc-uk.org/assets/documents/1000051cstandards_of_proficiency_paramedics.pdf accessed 12/10/2011 9 College of Paramedics (2008) Paramedic Curriculum Guidance and Competence Framework (Second Edition), College of Paramedics, Derbyshire 10 http://www.nhscareers.nhs.uk/images/table-diagram.jpg accessed 17/10/2011 11 http://www.hpc-uk.org/aboutus/ accessed 17/10/2011 12 https://www.collegeofparamedics.co.uk/about_us/ accessed 17/10/2011 List of Tables Table 1 Ambulance Service Demand Table 2 Foundation paramedic programme year 1 Table 3 Learning Outcomes Table 4 Foundation paramedic programme year 2 Table 5 Career Frameworks 9 of 9