Emergency medical personnel in the United Kingdom are people engaged in the provision of emergency medical services and include paramedics, emergency medical technicians and emergency care support workers. Although there is tendency for the public to refer to all ambulance staff as 'paramedics', the term is protected by law and strictly regulated by the Health Professions Council.[1]
Emergency medical personnel most often work in an ambulance alongside another member of staff. Typically, an ambulance will be crewed by either a paramedic with another crew member (technician or emergency support worker), two technicians or a technician with an emergency support worker. No NHS ambulance trust in the country currently offers a paramedic on every ambulance, although some trusts are moving towards this.[2]
The majority of emergency medical personnel are employed by the public ambulance services of the National Health Services, although many are also employed by private ambulance companies and the two voluntary aid societies (British Red Cross and St John Ambulance), either providing private services such as event medical cover, or providing support to the NHS ambulance services under contract.[3]
As part of a cost-saving exercise NHS is in the process of phasing out the ambulance technician/emergency medical technician (Band 4 on the Agenda for Change) role from the services and replacing it with the Emergency Care Support Worker or Emergency Care Assistant roles (Band 3 on the A4C), and most services are no longer training staff at technician level,[4][5] although a large proportion of staff in the trusts remain at technician level.
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The specific skills performed by each group of emergency medical personnel will be dictated by a combination of training, the legal framework and the policies of their employer. The most homogenous group is the paramedics, as the framework of practice is largely dictated by their status as registered healthcare professionals, although local policy differences are still in effect.
The other grades, including technicians, support workers and emergency care assistants do not have legal status as health care professionals, and their skill sets and permitted interventions are governed by their employer. This has led to significant differences in training and skill between staff in different services with the same or similar job titles, especially within the private sector.
There are standards in place for all ambulance staff, written by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC), which is a body made up of representatives from a number of expert organisations including medical, nursing, allied health professional and ambulance communities.[6] JRCALC publishes guidance based on the principles of evidence based medicine and best practice, but adherence to JRCALC is not mandatory, and organisations and individuals can choose to deviate from it.
All ambulances services, as well as the provision of treatment by health care professionals (paramedics), whether public, private or voluntary are regulated by the Care Quality Commission, and they control the operation of all services.
Paramedics are expected to work utilising their own clinical knowledge to make decisions,[7] and as registered health care professionals, carry full responsibility for their actions.
Traditionally the only route to becoming a paramedic was to join an NHS ambulance service and work towards the position from non-emergency patient transport roles through to the emergency division as a technician, and after a period of time, it was possible to internally apply for paramedic training.
Although offered at ambulance service training departments, the curriculum and certification were awarded by an organisation affiliated with the Edexcel examination board, called the Institute of Healthcare Development (IHCD). Such paramedic training was usually a 10 to 12 week course with some of this time spent in a hospital emergency department, coronary care centre and operating theatre, assisting the anaesthetist and performing airway management techniques such as endotracheal intubation. Completion of the course allowed the paramedic to register with the then legislative body.
It was nearly impossible for non-NHS employees to access such courses, some private ambulance companies provided their own training. Prior to regulation and closure of the title, the term "paramedic" was used by a variety of people with varying levels of ability. After the incorporation of the Health Professions Council (HPC), the term became legally defined and applicants to the paramedic register were given an opportunity to have their training and experience reviewed against the new standards. Existing paramedics applied to the register via a grandparenting scheme which ended in 2007.
Eventually the IHCD began to accredit a few non-NHS training establishments, allowing them to teach their curriculum. In the mid 1990s some universities started to offer para-medicine diplomas and degrees, in association with local Ambulance Trusts. By necessity these included all of the practical skills found in the IHCD curriculum and allowed applicants to apply for registration with the HPC.
Within the professions regulated by the Health Professions Council, paramedicine was the only one not to have an extant professional body, and the British Paramedic Association was formed in 2001. This later became the College of Paramedics and this is now an important representative group for the paramedic profession. Unlike some other professions, membership of the college is not mandatory in order to be a registered paramedic.
In 2010, the IHCD route to becoming a registered paramedic was largely deprecated, although is still recognised by the Health Professions Council, and anyone successfully completing the BTEC Level 5 qualification will be entitled to register as a paramedic. This leaves the university route as the primary training method for new paramedics, with a number of universities offering qualificaitons which can lead to registration, both as full time courses for new students (although they must also be accepted for the practical element of the training by an ambulanceservice) and part time courses for existing ambulance staff.
Although 'paramedic' is the only protected title for the profession, some paramedics undertake further training or higher educational programs in order to work as advanced practitioners. These may be known as community paramedics, paramedic practitioners,[8] critical care paramedics and emergency care practitioners.
These advanced paramedics vary in the scope of their practice throughout the country but can be found offering unscheduled care where the patient does not require transport to hospital, instead of summoning a GP. Some of these roles are very similar to those carried out by specialist nurses, thus, blurring professional boundaries. Some roles like advanced practitioner courses and the emergency care practitioner courses are offered to both professions as interchangeable skills are present.[9]
The College of Paramedics has published a framework for paramedic education which details the attainable clinical grades of UK paramedics as below:[10]
Ambulance technicians, or emergency medical technicians form a large proportion of the workforce in emergency medical care, although the title lacks formal definition or protection, and there is no restriction who can use it. Generally, ambulance technicians can work either autonomously, making their own clinical decisions within their training and remit, or as assistants to a higher skilled paramedic.
As part of a cost-saving exercise, the NHS is in the process of phasing out the ambulance technician/emergency medical technician role (Band 4 on the Agenda for Change) and replacing it with the Emergency Care Support Worker or Emergency Care Assistant roles (Band 3 on the A4C), and most services are no longer training staff at technician level,[4] although large numbers remain operational.
Technicians within the ambulance services generally completed the Institute of Healthcare Development (IHCD) ambulance technician award (awarded by Edexcel) which is a course lasting around 12 weeks, including 3 weeks of emergency driving. This qualifies the person as an trainee technician, and after a period (usually around a year) on the road, a plenary examination is taken to complete the training and become a qualified ambulance technician (QAT). Whilst now deprecated by the NHS services, the qualification is still available as a BTEC level 4, and can be trained by the ambulance services or a number of private providers.
Alternative qualifications exist, especially in the private sector, although there is no set standard between qualifications. Other qualifications include the Emergency Care Technician award from the Royal College of Surgeons of Edinburgh and numerous in-house qualification courses offered by individual providers.
Emergency care support workers or emergency care assistants are trained to a basic level, and do not have clinical autonomy, relying on a paramedic or technician to make clinical decisions. Their role varies widely between services, but they are normally expected to perform driving duties, and to assist the clinician in their work.[11]
Paramedics or pre-hospital care providers in the UK may also use other titles such as:
There is currently no single organisation representing the interests of pre-hospital workers in the UK, although a number a organisations represent different interest groups. The College of Paramedics represents paramedics on a number of fronts, including with other professional bodies and setting training standards, although a large number of paramedics are not members, and their representation of other ambulance workers is limited.
The British Association for Immediate Care (BASICS) and its constituent bodies also accept paramedic members, although it is primarily focused on pre-hospital care by doctors and nurses.
The Ambulance Service Institute (ASI) is an independent institute whose membership is open to all operational employees of NHS ambulance services as well as voluntary sector groups or individuals involved in pre-hospital care.
The private sector has two bodies, although membership of both is very low, the British Ambulance Association and the National Association of Private Ambulance Services (NAPAS).
The drugs paramedics are allowed to administer are regulated in UK Law with other bodies, such as JRCALC, providing clinical guidance on when they should be used.
Drug list:[23]
Midazolam
Drugs given utilising a Patient Group Directive (PGDs) by Paramedics with advanced training.[23][26][27]
Paramedics and EMTs in some parts of the country are now able to diagnose ST-Elevation Myocardial Infarctions and bypass the closest Accident and Emergency Department to transport the patient to a hospital able to provide percutaneous coronary intervention.[31]
All paramedics in the UK able to legally carry and autonomously administer thrombolytic medication to patients suffering ST elevation myocadial infarction in the pre-hospital environment. This is known as Pre-Hospital Thrombolysis.
In some parts of the country paramedics and EMTs are able to bypass Accident and Emergency Departments for specialist units with patients suffering from a stroke. Currently the FAST-Test[32] is used to determine a patient's suitability to be transported directly to a specialist unit. On admission to the specialist hospital the patient should rapidly receive a CT scan of their head, to guide treatment. Paramedics may routinely assess transient ischaemic attacks (TIAs or "mini-strokes") for clinical risk, treat and refer direct to TIA clinics or Emergency Departments as appropriate or give advice and leave the patient at home.
Currently all NHS paramedics in the United Kingdom generally receive advanced driver training to drive vehicle under emergency conditions. In spite of this, road traffic collisions do occasionally occur which involve ambulances and other blue light vehicles.[33][34][35][36][37][38]
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