Do we really need paramedics on ambulances?

This article is about how we deploy paramedics and emergency medical technicians (EMTs) on frontline ambulances and the ideas in this article are of my own and based on my reflections on frontline ambulance operations.

Academic standard

Since summer 2021, the Health and Care Professions Council (HCPC), supported by the College of Paramedics, mandated that the minimum standard to become a registered paramedic is a Bachelor's degree with Honours. This change ensures that all new paramedics meet a high academic and professional standard to practice within the UK, as outlined here.

Before this mandate, it was acceptable to have a Level 5 Foundation Diploma or equivalent (2 years of university education) and, in some cases, a Level 4 Certificate in Higher Education or equivalent (1 year of university education). Interestingly, there are currently practicing paramedics in the UK who qualified with only a six-week Institute of Healthcare Development (IHCD) Paramedic course.

Those who qualified before the implementation of the new degree requirement in 2021 will retain "Grandfather rights," allowing them to continue practicing as registered paramedics in the UK despite not holding a degree-level qualification. There are many highly experienced and skilled paramedics practicing today who do not hold university degrees.

Expectations vs Reality

The demand on emergency services is ever increasing. The term “emergency services” might suggest a rise in true emergencies, but this is not the case. More 999 calls are for non-critical care emergencies and a diverse range of medical conditions such as chronic health conditions, chest pains, COPD, infections, palliative care, back pain, concern for welfare, and mental health issues, to name a few.

Given this diversity, paramedics are now often seen as “generalist clinicians” rather than specialists in life-threatening emergencies. Many calls are related to primary care issues where patients, after contacting 111 or even 999, receive an “emergency ambulance” response. However, there are still instances where paramedics must handle critical situations, such as imminent childbirth or cardiac arrest, even at the end of their shifts.

Ambulances frequently spend hours queuing outside hospitals with patients, sometimes for the entirety of a shift. This situation, essentially prolonged field care, has paramedics providing extended care outside the hospital environment, akin to "nursing in the car park." This raises concerns about how paramedics are utilising their clinical skills and higher education, especially when student paramedics are also present for their required clinical hours.

Many UK paramedics are leaving ambulance services to work in other clinical roles within the NHS, such as in General Practice surgeries or hospitals. It is estimated that in England alone there are up to 7000 paramedics who have left the ambulance service in 2023, an increase of 51.2% from previous years.

According to this article by the Association of Ambulance Chief Executives (AACE), reasons for this include a perceived lack of value and care for their wellbeing by the ambulance service. Contributing factors include poor mental health from the emotional toll of ambulance work, challenging shift patterns, unpredictable late finishes, work intensification, and lack of control and autonomy. Some paramedics find ambulance work lacks the clinical challenge they seek, and despite efforts to find clinical development and career progression within ambulance services, they often turn to other NHS roles to fulfil these needs.

HCP Admissions

The Health Care Professional (HCP) Admission is a national framework that enables healthcare professionals, including GPs, midwives, and district nursing teams, to use ambulance services for transporting patients to hospitals and community wards. These requests are categorised by urgency, similar to 999 calls from the public, and the ambulance service is expected to respond accordingly. However, much like 999 calls from the public, many of these HCP requests are often misused.

For example, I recently attended a case at an urgent treatment centre where a practitioner requested a HCP Category 2 (a blue light emergency response) for an elderly lady who had arrived with her daughter using their own transport for an ongoing chronic condition and not acute. The practitioner consulted with medics at the receiving hospital, who declined a direct referral, but still requested ambulance transportation to the emergency department. Consequently, paramedic crew was dispatched, effectively serving as a taxi service. No clinical interventions, monitoring, or pharmacology were required. When I explained this to the patient and her daughter, they both agreed it would be more appropriate to make their own way to the hospital in their own transportation, thus keeping an emergency ambulance available for another tasking.

This week, whilst on shift, I spoke with the emergency operations centre (EOC) dispatcher, who mentioned that currently (at the time) has only three emergency ambulances, including mine, available to cover two cities on the south coast.

During one shift, I received four HCP Level 2 requests, none of which required clinical interventions, monitoring, or pharmacology, and subsequently alternative transportation was arranged instead for these patients, in the form of their own transportation or a NHS funded taxi service, thus keeping an emergency ambulance on the road and in a way supporting local businesses.

I often reflect on my early days as a newly qualified paramedic. Just three months into the job, I drove 26 miles on blue lights to a cardiac arrest, being the only paramedic available and the senior clinician on scene, faced with a difficult airway that needed intubation. I felt ready for that job as my training was still fresh. This example highlights how stretched the services are.

Nowadays, I spend more time using my Bluetooth headset and tablet. While I might look like a BMW M3 driver wearing Oakley sunglasses, often stereotyped negatively, I'm constantly on my phone and tablet arranging alternative pathways and transportation to keep emergency ambulances more readily available.

Before the National Ambulance Response Programme (NARP) was introduced, One particular Trust had a dedicated HCP line staffed by EMTs. This role primarily involved responding to HCP requests/admissions, thus freeing up frontline ambulances and paramedics. The HCP line held a particular allure for those nearing retirement, or those who wanted a steady pace of work away from the frontline chaos, unofficially, and was a role very welcomed by everyone in the Trust.

Since this role was abolished after the NARP was implemented, paramedics are routinely being sent to HCP admissions, which are low-acuity transfers at normal road speeds. However, these tasks often require paramedics to drive with blue lights and sirens due to elapsed response times. HCP admissions does have its own place within the ambulance service, but paramedics are finding themselves attending these lower-acuity of calls which the majority doesn't require any clinical interventions, monitoring or pharmacology. Those that do, can be utilised within the scope of practice of an EMT, which has been done previously.

FREC/AAP

First Response Emergency Care (FREC) is a Level 5 diploma, while Associate Ambulance Practitioner (AAP) is a Level 4 diploma. In theory, FREC5 represents a higher level of qualification. However, some ambulance trusts do not accept FREC5 and only recognise AAP. Consequently, individuals with FREC5 must transition to the lower AAP qualification to work as EMTs, even though both roles are essentially regarded as such. Although AAP has its own title, it is still unofficially seen as an EMT.

Examining the learning criteria for the modern EMT reveals that EMTs undergo extensive practical and theoretical training, making them highly competent for frontline ambulance work. My point is that more ambulances should be staffed by EMTs, allowing more paramedics to dually operate between rapid response vehicles (RRV) and dual manned ambulances (DMA) where they can better utilise their higher education. Not referring back to the "clock-stopping" previous response model before the new ARP, but utilising the clinical skills and decision making of paramedics.

There are many Ambulance and Emergency Care Assistants (ACA/ECA) who would like to progress upwards in their ambulance career, and training to be an EMT is a great way to set the foundations of practice for all ambulance clinicians. Plus, not everyone wants to be a paramedic and like the "happy medium".

This approach could enhance control and autonomy, support clinical development and career progression, and potentially improve paramedic retention within ambulance services.

Currently, trials are underway utilising Community First Responders (CFR) volunteers to administer Penthrox, a prescription-only medicine (POM) for strong pain relief. Meanwhile, certain members of Mountain Rescue volunteers are permitted to use controlled drugs (CDs) such as morphine. In contrast, our EMTs working on ambulances, generally, are limited to paracetamol, ibuprofen, and entonox for analgesia. Go figure.

Summary

I've pretty much rambled on in this article because I needed to get it off my chest (as opposed to "getting on the chest" - paramedic dad joke) whilst nursing a hot cup of coffee. While I'm all for education and training, does the ambulance service really require all paramedics to have a Bachelors degree?

It's no wonder paramedics are leaving for other opportunities to utilise their skills and qualifications, and are voting with their feet, where they are of more value and achieving a sense of job satisfaction, and more importantly, a sense of identity. Something I feel the ambulance service did not cater for in terms of the new educational standard being implemented and leaving a large void within the service.

Let's not underestimate the importance of EMTs—they are more than competent to handle 80% of the cases I deal with on a daily basis, leaving only 20% requiring a paramedic (following the 80/20 rule).

The ambulance service urgently requires a comprehensive overhaul in its service provision. While there is widespread criticism advocating for the acceptance of change, it is essential to acknowledge the underlying facts and statistics that explain the high staff turnover rate and poor retention within the service.

I'm ready for the incoming criticism.