The evolving role of paramedics – a NICE problem to have?

Background

Although the term ‘paramedic’ started to emerge only in the 1960s, non-medically qualified personnel trained to provide emergency medical care have been established since ancient times. ¹ Paramedics have long been considered a vital part of the medical team, providing emergency care to patients when, and where, it is most needed. In the National Health Service (NHS) in the UK, most paramedics apply their skills in the ambulance service, working alongside other emergency care staff.

However, while historically associated with life support and other advanced skills for dealing with emergencies, the role of the current paramedic has evolved rapidly since 2000. Paramedics in the UK now provide far more than just emergency care and are expected to manage a broad range of conditions in the out-of-hospital environment.^2,3 These extended roles have emerged, at least in part, out of necessity. In England, only 8% of calls to the national emergency telephone line 999 are from people with life-threatening illnesses or injuries. ⁴ Therefore, it appears that substantial numbers of patients seeking assistance from ambulance services may have conditions that are able to be assessed and managed within the community, without transportation to hospital.^2,3

In this brief essay, we undertake to explain recent UK consultations concerning the use of paramedics within the wider health service^2,3 and look to address the issues this raises within this health system. Presenting these to an international audience, we aim to outline the versatility of the modern paramedic and their emerging uses in the health service.

A contemporary workforce

Many UK ambulance services now position themselves as mobile health care providers. This means rather than providing transportation to the nearest emergency department they provide virtual care through hear-and-treat services, out-of-hospital care through on scene assessment and treatment or case completion through triage and transportation to specialized health care services. ⁵ Thus, paramedics need to be skilled in managing acute exacerbations of chronic long-term conditions (such as heart failure or pulmonary disease), assessing (and referring) acute presentations of mental ill-health, social care needs assessment and referral, for example, to community falls teams for older patients who fall, and transfers between hospitals. With changing demands on the ambulance service ⁴ and a dependence of this service due to busy hospital systems in the UK, ⁶ the 21st-century paramedic is expected to be nothing if not a generalist.

A key driver of the transformation of paramedics in care provision in the UK has been their level of autonomy as allied health professionals. Unlike in the United States, Canada and other parts of the world, UK paramedics are required to register with the Health and Care Profession Council, the statutory regulator of professionals from 16 health and care professions. This can be seen to have empowered the profession to innovate and challenge health care provision. Data from NHS employers show movement of paramedics from their traditional employer, the NHS ambulance services, to other health care settings in non-traditional sectors. ⁷ Such settings offer paramedics opportunities to practice in increasingly diverse non-traditional areas, such as acute hospital trusts, forensic health care, primary and community care services, minor injury units and urgent care centres.^8,9

Opportunities for paramedics to work within other sectors are articulated in the 2017 draft consultations by the National Institute for Health and Care Excellence (NICE), which recognize the evolving role of paramedics.^2,3 The consultations are the first step within the overall draft guidance that places emphasis on the effect of paramedics with enhanced competencies in patient care. This is predicted to reduce demands in emergency departments, reduce hospital admissions and improve patient outcomes overall.^2–4 The consultations are aimed particularly at paramedics with sufficient postqualification experience and enhanced education, with development based on supervised practice in their speciality, similar to other advanced professionals within medicine, physiotherapy and nursing. A cohort of paramedics performing a more traditional ambulance paramedic role would still be required, and the guidance discusses enhancements to this as an opportunity for paramedics to develop and progress while avoiding professional attrition.

The draft guidance^2,3 suggests that enhanced education and training would not be appropriate for the entire workforce, but crucial for the development of specialist and advanced paramedics. It is therefore highly likely that the evolving role of paramedics will need new pathways for education and training. The traditional education of paramedics has been very different from that of their nursing and allied health colleagues. In the UK, the current education threshold for professional registration has remained equivalent to a higher education qualification, despite professional advocacy that it should be enhanced to Bachelor’s degree. ¹⁰ The professional body for paramedics in the UK, the College of Paramedics, has produced guidance describing the higher educational level as a fundamental tenet of enhanced paramedic practice and career trajectory, particularly as future roles expand. ¹¹ However, it is not clear if all paramedic employers are stipulating such educational guidance as a requirement for enhanced paramedic roles across the UK, resulting in a nationwide mismatch of entry requirements, titles and skill sets. Research into the most appropriate educational background that enables paramedics to successfully deliver the wide range of care expected of them in contemporary health care settings is crucial to the development of the profession.

While the broader extended role for paramedics may be innovative, it may have potential consequences. Many ambulance services face an unprecedented retention challenge, as other health care providers target their most experienced and best-educated paramedics, who typically work as specialist paramedics (previously known as emergency care practitioners), having undertaken postgraduate or postregistration education. ¹¹ In an attempt to tackle this, the UK Department of Health launched, in 2016, a nationally coordinated initiative, which has seen increased financial rewards for paramedics. ¹² This is laudable and reflects the changing demand and the recognition of efficiency and effectiveness within the paramedical practice.

As the professional stature of paramedics is increasing and the variety of practice settings evolving, current opportunities for employment in these different domains still require careful evaluation for clinical impact, value and satisfaction.^2,3,13 However, the evidence suggests that their contribution may be considerable. ¹⁴ A study published in 2004 estimated that a specialist paramedic working in community urgent care could save the NHS £72,000 per year. ¹⁵ These savings were projected on the basis of their impact on relieving the pressure of unnecessary attendance in emergency departments and hospitals as well as preventing admissions or improved triage. More recent studies have echoed these findings, alongside enhanced patient satisfaction with specialist paramedics treating patients on scene, compared with hospital conveyance in a traditional 999 service. ¹⁶ While more contemporaneous research on the cost effectiveness and service impact of specialist paramedics is required, available evidence suggests that this group of paramedics can have positive effects for both patient experience and financial performance within the health system as a whole.

Recommendation

We advocate that the paramedic profession should lead the evolving roles for paramedics, but delivered with an interprofessional approach. Members of the paramedical profession should undertake research, particularly leading service reviews and evaluating delivery implementation as well as evidencing the profession’s contributions to new models of care. The primary care environment is an obvious choice for this.^2,3,13,15 Paramedics must work with patients, primary care clinical staff, academics, commissioners and policymakers to define and shape these integrated roles. An immediate need is to identify the key measures and indicators around quality of communication, clinical excellence and integration into primary care. As the role of the paramedic evolves, learning together and working alongside their medical colleagues will be paramount to the safety and success of paramedics as they enter this environment.