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,
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 Wales1. 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 treatment2.
In 1964, the Millar report3 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 UK4
.
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.
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 Government7. Until 1974, ambulance cover in Scotland was provided by a combination of the British Red Cross and St Andrews Ambulance8. In the financial year 2008–2009, the service employed 3,797 staff across five divisions and attended to 599,052 emergency calls.
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 programme7. 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
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.
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 decision-making 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 registration8.
Table 4 Year 2
Advanced Airway Management Patient assessment
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.
recognised career framework. The governing bodies with responsibility to maintaining standards of paramedic practice are the Health Professionals Council and College of Paramedics11,12.
References
1
"NHS Ambulance Trusts Description". http://www.nhs.uk/England/AuthoritiesTrusts/Ambulance/Default.aspx.
2http://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
4Caple 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=905accessed 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 11http://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’
