Emergency medical personnel in the United Kingdom

Emergency medical personnel in the United Kingdom are people engaged in the provision of emergency medical services. This includes paramedics, emergency medical technicians and emergency care assistants. 'Paramedic' is a protected title, strictly regulated by the Health and Care Professions Council,[1] although there is tendency for the public to use this term when referring to any member of ambulance staff.

See also: Emergency medical services in the United Kingdom
Emergency medical personnel (green uniforms) and Ambulance care assistants (Blue uniforms) help to load a patient into an air ambulance at Dunoon Stadium. Air ambulance staff are in red flight suits.

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 care assistant), two technicians or a technician with an emergency support worker. Currently only West Midlands Ambulance Service offers a paramedic on every ambulance.

The majority of emergency medical personnel are employed by the public ambulance services of the National Health Service and respond to emergency calls generated by the 999 system. Many are also employed by private ambulance companies and voluntary aid societies such as the British Red Cross and St. John Ambulance, who provide services such as event medical cover or support to some NHS ambulance services in times of need or under contract.[2]

Many NHS trusts are in the process of phasing out the Ambulance Technician/Emergency Medical Technician (Band 5 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 Agenda for Change), and most services are no longer training staff at Technician level.[3][4]

All ambulance services, whether public, private or voluntary, are regulated by the Care Quality Commission, who dictate the expected standard of care.

Notable Individuals

Prof Douglas Chamberlain

In 1970 it was Professor Douglas Chamberlain who pioneered the first recognisable paramedic training programme in the UK, up until this point, only basic ambulance training had been in place nationally, having been rolled out only four years earlier.[5]

Prof Julia Williams

Prof Julia Williams is a pioneer in the area of paramedic led research. She holds a senior post at the University of Hertfordshire and is a senior advisor to the College of Paramedics.

Prof Malcolm Woollard

Over 4 decades, Prof Malcolm Woollard was a leading voice for the paramedic profession. His passion for the development of the profession and was described as a ground-breaker for the paramedic profession[6]. He died in 2018[7] but has a legacy of research that lives on[8].

Skill grades of staff

The specific skills performed by each group of emergency medical personnel will be dictated by a combination of training, the legal framework and the local 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.

Other grades such as Technicians, Emergency Care Support Workers and Emergency Care Assistants do not have a registered or protected role 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.

National clinical standards exist for all ambulance staff, written by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC). The body is made up of representatives from a number of medical, nursing, allied health professional and ambulance committees.[9] JRCALC publishes guidance based on the principles of evidence-based medicine and best practice, but compliance with JRCALC is based on the employing organisations and an individuals' judgement[10].

Emergency Care Assistants (ECA) or Emergency Care Support Workers (ECSW)

Emergency Care Assistants or Emergency Care Support Workers are trained to a basic level of ambulance practice. As a result, they typically work as assistants to a Paramedic, Technician or AAP and do not have clinical autonomy.[11] Their role varies widely between services and as such, their clinical knowledge is typically from that of First Aid up to the FutureQuals Level 3 Diploma in Ambulance Emergency and Urgent Care Support[12].

To reduce costs, many ambulance organisations have tried to reduce the number of Ambulance Technicians, increasing the number of Emergency Care Support Worker or Emergency Care Assistants.[13]

Ambulance Technicians

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. Generally, ambulance Technicians can either work autonomously, making their own clinical decisions within their training and remit, or as assistants to a paramedic.

Technicians within the ambulance services have generally completed the Institute of Healthcare Development (IHCD, now defunct) Ambulance Technician award (awarded by Edexcel, part of Pearson) which was a course lasting around 12 weeks. A 3-week emergency driving programme was available to accompany the Technician award, which was titled Ambulance Aid and Driving. This qualified the person as a 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 training providers. The IHCD emergency driving programme was certificated as a 'stand-alone' qualification.

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.

Associate Ambulance Practitioners (AAP)

Associate Ambulance Practitioners work as non-registered healthcare professionals, similar in scope of practice to the now discontinued IHCD Technician qualification. In contrast to the unprotected title of 'Technician', a nationally recognise standard was agreed between the national Ambulance Trusts which is now defined by the FutureQuals Level 4 Diploma for Associate Ambulance Practitioners.[14]

Paramedics

Clinical Grades of Paramedic

The College of Paramedics has published a framework for paramedic education which details the attainable clinical grades of UK paramedics as below[15]

  • Paramedic (BSc (Hons))
  • Specialist Paramedic (PgC/PGDip)
  • Advanced Paramedic (MSc)
  • Consultant Paramedic / Director (PhD)

Paramedics take potentially life-saving decisions about treatment needed and, if appropriate, will then administer the treatment.[16] They work utilising their own clinical knowledge and as registered health care professionals.

The original 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 Qualified Ambulance Man/Woman and, after qualifying, those who wanted to increase their knowledge and skills joined the Association of Emergency Medical Technicians. This was an organisation run by members to promote and train Paramedics. The AEMT was supported by BASICS and large numbers of hospital doctors. Training took place at various locations with members attending off-duty and at their own expense. Trainees followed a wide academic curriculum which led to a written exam and if successful, they became Associates and entered the clinical phase of training. They then attended hospitals to receive their practical skills training. The final examination was designed to put as much pressure on the candidate as possible. The hospital consultant would sign to say that he was happy for a passing candidate to treat their family.

In the early to mid 1980s some ambulance service training departments started offering advanced skill training. In 1986 the NHSTA introduced the certificate in Extended Ambulance Aid. Existing AEMT Paramedics were forced to sit a conversion examination. The curriculum for the new qualification was substantially smaller cutting out a lot of anatomy and physiology as well as pharmacology and obstetrics. In November 1986 the examinations took place with the first certificates issued alphabetically. The candidate with highest score received certificate 177 and was the only Paramedic at Huntingdon. Training was introduced the following year but due to costs the time was kept to a minimum. The AEMT folded in the 1990s as the training offered was no longer recognised by the ambulance services. Equipment owned by the branches was given to hospitals.

The NHS Training Authority, NHSTA, (which became the NHS Training Directorate and then the NHS Training Division, which in turn became the Institute of Health and Care Development. The Institute was acquired by the Edexcel examination board in 1998, and Edexcel was acquired by Pearson in 2004. Pearson continued to operate the IHCD 'brand' until 2016. This 'in-house' paramedic training was a modular programme, usually between 10 and 12 weeks, followed by 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 Council for Professions Supplementary to Medicine (CPSM), which was superseded by the Health and Care Professions Council (HCPC), a regulatory body.

Prior to regulation and closure of the title, the term "paramedic" was used by a variety of people with varying levels of ability. Paramedics could apply to register via a grandfather scheme which ended in 2002.

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.

Amongst the professionals regulated by the Health and Care Professions Council, paramedicine was the only one not to have an extant professional body, until the British Paramedic Association was formed in 2001. This later became the College of Paramedics and now acts as a representative organisation for the paramedic profession. Unlike some other professions, membership of the college is not mandatory in order to be a registered paramedic.

There has been expansion of allied health professions who are regulated, leading to the regulatory body being re-established as the Health and Care Professions Council (HCPC). In 2010, the IHCD route (which by now was jointly badged with BTEC) which as a route to becoming a registered paramedic was largely deprecated, although is still recognised by the HCPC, and anyone successfully completing the BTEC Level 4 qualification is entitled to register as a paramedic. This leaves the university route as the primary pathway for new paramedics, with a number of universities offering qualifications 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 ambulance service) and part-time courses for existing ambulance staff.

Standards of proficiency which every paramedic must meet in order to become registered were first issued in 2003, with the most recent revision issued by HCPC in September 2014.[17]

Academic Grades of Paramedic

Paramedics in the UK are increasingly becoming involved in academic research and education with the move to higher education training being required to enter the national register as a paramedic. There are now paramedics in post as Professors, and senior lecturers in addition to a monthly UK paramedic journal in the form of the Journal of Paramedic Practice. The College of Paramedics has delineated a post-graduate career pathway for paramedics in academia and education;

  • Research Paramedic / Paramedic Lecturer
  • Research Fellow / Senior Lecturer
  • Reader / Principle Lecturer
  • Professor

Other Paramedic Grades

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,[18] critical care paramedics and emergency care practitioners.

Across the country the scope of practice of each advanced paramedic varies, however many can be found offering unscheduled care in situations where the patient does not need to travel to hospital, when the practitioner decides care can be provided without needing to see 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.[19]

Many paramedics choose to progress their career by qualifying to further levels, such as by doing additional diplomas in critical (intensive) care.

Paramedics or pre-hospital care providers in the UK may also use other titles such as:

Scope of practice

Ambulance Technicians or Associate Ambulance Practitioners

Drugs

The drugs administered by Technicians or AAPs are given under provision of The Human Medicines Regulations 2012[29] and under direction of the JRCALC Clinical Practice Guidelines. They include General Sales List (GSL), Pharmacy (P) and Prescription Only (PO) medicines.

Interventions

Procedures carried out by Technicians or AAPs can include:[14]

Paramedics

Drugs

The drugs paramedics are allowed to administer are regulated in UK Law and include Controlled Drugs (CD). The Joint Royal Colleges Ambulance Liaison Committee provide clinical guidelines on when they should be used.[30][31][32][33] Paramedics can administer drugs that are available to Technicians/AAPs (above) as well as:

A number of other drugs are given by Paramedics with advanced training, either by utilising a Patient Group Direction (PGD) or simply because they are classified as over the counter (OTC) medicines which are available to anyone.[30][34][35]

Interventions

Procedures carried out by Paramedics include that of Technicians/AAPs as well as potentially:

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[42] 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.

Advanced Paramedics

Advanced Paramedics typically hold an MSc in Paramedic Science and can deliver care in a pre-hospital environment that has traditionally only been performed by doctors.[43]

Drugs Interventions Skills Equipment
Ketamine

Midazolam

Haloperidol

Magnesium

Calcium Chloride

Lidocaine

Salbutamol (IV)

Adenosine

Enhanced analgesia

Advanced thoracocentesis

Advanced asthma management

Advanced management of acute behavioural disturbance

Enhanced post-ROSC care

Fracture/dislocation manipulation

 Thoracostomy (cardiac arrest)

Surgical airway (cardiac arrest)

Mechanical CPR

CPAP

Cardiac ultrasound (cardiac arrest)

Intubation

Cardiac pacing

Synchronised cardioversion

 Mechnical ventilator + CPAP

Lucas 2

Ultrasound

Benecast splints

Video laryngoscope

Driver skills

The majority of NHS, private, and voluntary providers, who undertake emergency response, provide training in the form of FutureQuals Level 3 Certificate in Emergency Response Ambulance Driving[44]. This replaced the IHCD D1 (Non emergency driving), IHCD D2 (Emergency driving) and BTEC Level 3 in Emergency Response Driving.[45][46][47][48][49][50]

There is currently no legal requirement for emergency response drivers to undergo any additional training to claim exemptions such as use of blue lights, exceeding the speed limit, or passing through red traffic lights.

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See also

References
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  4. "Pay for ambulance service staff". NHS Careers.
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  6. "Professor Malcolm Woollard". collegeofparamedics.co.uk. 2018-07-19.
  7. "Professor Malcolm Woollard died after morphine overdose". BBC. 2019-01-09.
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  10. "JRCALC Q&A's - aace.org.uk". aace.org.uk. Retrieved 2020-02-10.
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  22. "Connexions-direct".
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  31. "Archived copy" (PDF). Archived from the original (PDF) on 2010-03-03. Retrieved 2010-02-18.CS1 maint: archived copy as title (link)
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  34. "Archived copy" (PDF). Archived from the original (PDF) on 2007-10-18. Retrieved 2010-02-18.CS1 maint: archived copy as title (link)
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Sources
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