the role of specialist paramedics in reforming emergency care

SPECIALIST PARAMEDICS

!Prehospital Clinical Fellow review for Health Education Thames Valley!!Pete Roberts - 5 June 2014!!!!!

The Role of Specialist Paramedics in

Reform of Emergency Care

�1PETE ROBERTS, PREHOSPITAL FELLOW


!Contents!!

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Page

Executive Summary 1

1 Review of context 5

2 Approach to this review 6

3 The Specialist Paramedic in Thames Valley 7

4 Contributing to Reform of Emergency Care 12

5 Paramedic Evidence Based Education Project 13

6 Emergency Care Practitioner Survey 14

7 Point of Care Testing 18

8 Common Clinical Pathways 20

9 Regulatory Framework and Professional Body 21

10 The Advanced Paramedic 22

11 Clinical Hubs 25

12 Common Educational Standard 30

13 Towards TAB 35

14 Thames Valley Specialist Paramedic Skills Passport 37

15 Costs 39

16 PESTLE Analysis 49

Appendices

References


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Executive Summary!Thames Valley is at the forefront of modernising emergency care.

Paramedics are treating and transporting seriously ill and injured patients longer distances to specialist centres. Specialist Paramedics working as autonomous clinicians, are able to treat patients at home, or avoid A&E by referring them directly to medical or surgical units.

These approaches are saving lives, improving outcomes, and increasing efficiency.

It is now time to enhance the Specialist Paramedic (S.P.) programme in Thames Valley.!Educating and training S.P.s to direct patients onto the correct Clinical Pathway provides a seamless introduction for the patient; initial relevant clinical tests can be performed and treatment can be started by the S.P., enhancing patient experience by quickening their passage along the pathway. This will enhance efficiency, and provide equity of care across Thames Valley.Cultural and institutional barriers are preventing S.P.s being tasked to the most appropriate calls, and are reducing the ability of existing Emergency Care Practitioners to contribute to operational service delivery.

To support delivery of an enhanced Specialist Paramedic service, and from a wider governance perspective, a new role of Advanced Paramedic is needed. This will provide, for the first time, opportunities for staff to progress their career in a clinical pathway, and ensure South Central Ambulance Service remains the regional employer of choice for aspiring and existing Paramedics.

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!SCAS has embraced a Team-Based approach to operational resourcing, and the benefits to the organisation and individuals that are achieved by this organisational style should not be understated. The dichotomy, however, is that the outcomes expected of the Ambulance service may not reflect either the immediate clinical needs of the patient, or the wider health economy.

These two apparently diverse strands may be woven together for mutual benefit by introducing Clinical Hubs.

In the absence of a national educational standard or agreed set of competencies for Specialist Paramedics, there is an imperative to achieve, and maintain, a programme of common standard of education and practice for S.P.s in Thames Valley.

A baseline set of skills and knowledge is required for S.P.s across Thames Valley. This can be achieved by introduction of the Thames Valley Specialist Paramedic Skills Passport, which will ensure each Clinical Hub of S.P.s practices to a common standard.

To assist the S.P. in maintaining competency, a series of bespoke Continuing Professional Development modules should be designed around the role. These should be maintained as a suite of modules that can be delivered by an appropriate facilitator, such as an Advanced Paramedic, GP, Speciality Doctor, or Advanced Nurse Practitioner.

The Emergency Operations Centre for Berkshire, Oxfordshire, Buckinghamshire, and Milton Keynes, receives around 1,300 emergency and urgent calls every day. Not all of these patients are taken to A&E.

S.P.s either treat people in their own home, or find alternative care pathways for 60% of the calls they attend. The average net saving for the Ambulance Service when a patient is ‘seen-and-treated’ at home is £32, with a wider saving to the local health economy of £70. Increasing the numbers of S.P.s will increase the potential cost-savings.

The argument for rebranding and relaunching the ECP programme, with Specialist Paramedics in Thames Valley is clear.

A radical S.P. strategy fits with the work being undertaken by Sir Bruce Keogh, and prepares SCAS for the budgetary, political, and social demographic challenges that lay ahead.

This is not a time to be timid. It is a time to embrace change and use Specialist and Advanced Paramedics in Clinical Hubs, to create a radical solution to delivering unscheduled and emergency care.



!1 Review of context!This project was motivated by changing healthcare demographics, which are seeing increasing numbers of people accessing unscheduled and emergency care services, leading to strain on the entire emergency care system.

A number of factors are driving increased activity, and in addition, the perception of individual ‘wellness’, public expectations for round-the-clock healthcare, and changes to the social fabric of some sectors of society may be contributory factors.

Recent publicity has been generated by HealthWatch England’s recent YouGov survey of just over 1,000 people, which revealed 18% have used A&E inappropriately, many because they either didn’t know how to access care, or because of a lack of the nearby services. This has been countered by the College of Emergency Medicine, who report that only 25% of people in A&E need not be there. Sir Bruce Keogh suggests pressures on A&E can be reduced by empowering Paramedics to

treat more people at home. Paramedics are a young profession. Having voted for statutory registration in 1999, there are currently 19,960 registered in the UK.

Whilst the majority are employed by NHS Ambulance Trusts, others work in domains of practice as diverse as GP Surgeries, Minor Injury Units, and for the Independent Ambulance Sector.

More than 3,150 Paramedics are members of the professional body, the College of Paramedics.

Paramedics possess a unique skill set, enabling them to undertake dynamic patient assessment and symptom management in a wide range of settings, from the patient’s own bedside, to hostile environments such as Road Traffic Collisions and Civil Disorder.

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!In recent years, Paramedics have transitioned from a historical artisan approach, to professional status, with some demonstrating the ability to practice at an advanced clinical level.

The provision of mobile, urgent, and unscheduled healthcare in England is experiencing a period of rapid and dramatic change, driven by relative shortages of senior doctors working in A&E, increased workload, and public expectation of equitable, round-the-clock care.

Properly trained and equipped Specialist Paramedics will reduce inappropriate A&E visits, assist with GP workload, treat and discharge more people at home, and free-up valuable Ambulance resources to deal with severely ill and critically injured patients.

!!2 Approach to this review!Advice was sought from a variety of sources for this review.

Approaches were made to each Ambulance Service in England and Wales, with site visits and conversations undertaken during January and February. Follow-up contact was also made at a later stage.

Two semi-qualitative surveys of Specialist and Advanced Paramedics were undertaken.

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!One survey was distributed to those working for other Ambulance Services, the other distributed internally to Emergency Care Practitioners working for South Central Ambulance Service.

Conversations were held with General Practitioners, Doctors, and A&E Consultants, and relationships for future collaborative working fostered.

Engagement with Higher Education institutions and Ambulance Service educators informed the educational framework.

A review of the literature added to the evidence-base underpinning the review.

!3 The Specialist Paramedic in Thames Valley!For the purposes of this review, the job title Emergency Care Practitioner (ECP) is replaced with Specialist Paramedic (S.P.), as discussed in section 9 Regulatory Framework and Professional Body.

South Central Ambulance Service NHS Foundation Trust employs 23 S.P.s in the Thames Valley area. Others are employed in the Wessex region.

S.P.s work in ‘pods’ covering loosely-defined geographical localities as follows:

!North Oxfordshire: 3 S.P.s

South Oxfordshire: 2 S.P.s

Milton Keynes: 4 S.P.s

Mid/South Bucks: 4 S.P.s

West Berkshire: 3 S.P.s

East Berkshire: 3 S.P.s

There is a Team Leader responsible for performance management and some clinical development of the S.P.s.

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!S.P.s are educated to a minimum BSc in Paramedic Science, with specific modules covering minor illness and injury; some are studying for the MSc in Advanced Practice. They sit at Level 6 of the NHS Career Framework.

S.P.s are autonomous clinicians, working to the medical model, independently treating and discharging patients who have contacted either the 999 or 111 systems.

They are trained to manage minor injuries in the community, including use of sutures and staples for wound care. Complex cases are referred to A&E.

They are also experienced in community and minor illness management, and can provide patients with appropriate medication through a suite of Patient Group Directions, including analgesia, antibiotics, and local anaesthesia.

Some patients are referred to the GP, or to Medical, Surgical, or Paediatric Assessment Units.

Often crossing the boundaries between emergency medicine, primary care, and community-based care, S.P.s have strong links with local community services, providing catheter care when the District Nurse team is unavailable, and referring people to community teams when medical or surgical admission is not appropriate.

This ability to seamlessly move between autonomy and collaboration with clinical colleagues marks the S.P. as an effective emergency and unscheduled care clinician, with highly-developed skills in communication, teamwork, and leadership (Cooper et al, 2007).

A SCAS review, which grouped calls by type, suggests that 85% of patients have a condition that S.P.s are trained to manage, either in the community, or by referral to the appropriate speciality.

S.P.s play a valuable role in safer non-conveyance of patients to A&E. They consistently send fewer patients to A&E, have few complaints, and high patient satisfaction ratings. A separate internal SCAS review found that a significant proportion (42%) of callers unsuccessfully tried seeking another option prior to calling 999, and the majority of people treated and discharged by S.P.s believed that they would need to go to hospital when they called 999.

The National Audit Office report Transforming Ambulance Services (2011) found little comparable data from Ambulance services in effectiveness of S.P.s, with only one service reported targeting their S.P.s to appropriate calls. This lack of evidence supports a wider reporting system for use of S.P.s, and auditing their effectiveness.

The targeting of S.P.s to appropriate calls is supported by two recent quasi-experimental studies. O’Keefe (2011) compared Specialist Paramedic discharge rates for paediatric patients, compared



!to GPs and Specialist nurses in an Out-of-Hours or Primary Care setting, and reported that S.P.s demonstrated comparatively lower rates of confidence in safely discharging sick children.

Mason et al (2012) compared S.P. discharge rates at the scene of an emergency, compared to within a health care facility. This study found that S.P.s discharged a higher proportion of patients than ambulance crews, especially in Care Facilities such as Nursing Homes, but discharged fewer patients when the S.P. was working in a Primary Care facilities, compared to a GP.

These studies add support to the concept of targeting S.P.s to the calls where they are most likely to have an impact on safe patient care and discharge. They also underline the need for greater clinical support and supervision for S.P.s, and the development of a competency framework.

S.P.s are keen to demonstrate their value in relieving the burden on A&Es. The Milton Keynes S.P. team (consisting of 4 S.P.s) conducted a trial throughout December 2013, during which they “piggy-backed” themselves onto 999 calls that we're already receiving an emergency ambulance, to support safe decision-making by crews, and to positively influence the patient disposition.

Sourcing which calls to attend, was achieved by using a computer on the S.P.'s base station to view the Emergency Operations Centre (EOC) Dispatch Screen (essentially a scrolling list of each 999 call that is being handled by the EOC), and then self-mobilising onto appropriate calls.

The S.P. changed the crew disposition plan from A&E to another plan in 68% of cases - of these, 58% were treated and discharged at the scene, and 12% referred to their GP.

It is clear, that targeting S.P.s to the appropriate caseload reduces inappropriate ambulance referrals to A&E; it is recognised that this was a narrow study, without rigid parameters, and open to corruption of the data. Therefore, extrapolation of the findings to may produce unreliable results.

Other studies have yielded results demonstrating the effectiveness of the S.P. in managing patients via an alternative pathway to the A&E.

A wider SCAS review of 2,127 ambulance calls, found S.P.s conveyed fewer patients to A&E across the 999 call spectrum.

Currently, there are not enough S.P.s to provide sufficient operational cover for a robust and progressive service, and the roster they are working is not fit for purpose across Thames Valley.

In addition, Operational S.P.s are withdrawn from their direct patient contact role, into the Emergency Operations Centre to provide support on the Clinical Support Desk (CSD). This provides enhanced telephone clinical support to junior and inexperienced Paramedics and



!non-clinical community responders, and allows the CSD-based S.P.s to task their operational colleagues to appropriate calls. Due to the infrequent exposure of the majority of S.P.s to working in this environment, it is not possible to demonstrate their competency or professional development in this role, and given the current location of the Emergency Operations Centre in Bicester, Oxfordshire, some S.P.s have much longer travel times for their shift, than others.

Whilst SCAS continually strives to offer an environment for allowing S.P.s opportunities to manage their shifts, the constraints of the existing roster system leave little room for flexibility when providing cover. There is an argument for changing the current roster to provide extended cover.

Expanding each of the existing “pods” to 6 S.P.s will offer the following benefits:

round-the-clock S.P. coverage

more opportunities for enhanced care at the scene of 999 calls

providing safer discharge when A&E is not appropriate

Increased availability of S.P.s

Opportunity for ring-fenced Clinical rotation

Income-generation opportunities by contracting-out S.P. services to GPs, Out-of-Hours, Community services and private event cover

The role of S.P. is perceived as a clinical progression by Level 5 Paramedics - the only other option for clinical progression in SCAS is the Hazardous Area Response Team (HART), based in Eastleigh, Hampshire; there is no Specialist Critical Care Paramedic role.

There is no national strategy for deployment or scope of practice for Level 6 Paramedics, or agreement about what to call them. Some Trusts employ S.P.s as Level 7 clinicians, and there is no common standard of nomenclature, or practice. This may lead to confusion among other healthcare professionals or doctors, especially where there is some degree of - albeit uncommon - cross-border working.

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!The term Emergency Care Practitioner is widely-used, and well understood by Ambulance staff and managers. It is less well-understood by those outside the profession. The organisation that developed and promoted the role of ECP to Ambulance Services, Skills for Health, no longer describes the role.

NHS Careers state that Senior Paramedics “may have a range of job titles, including emergency care practitioner”, and a recent survey of 85 Level 6 Paramedics revealed nine different job titles (see section 6 Emergency Care Practitioner Survey). There is also little agreement of what to call Level 7 Paramedics, however some Ambulance Services are using the term Advanced Paramedic. This reflects Level 7 on the NHS Career Framework, and it would be helpful for Ambulance Trusts to agree a national role title for Level 6 Paramedics.

The term Paramedic Practitioner for Level 6 Paramedics is favoured by some, and crucially, it includes the term Paramedic, which identifies the professional role to the patient and other professionals.

There is not even agreement among S.P.s about their role title, with 46% of SCAS S.P.s wishing to retain the term ECP, and 36% suggesting a change to Paramedic Practitioner.

Ambulance Service websites underline this lack of standardisation, with only 6 out of 11 Ambulance Trusts promoting their Specialist Paramedic role as a career option.

It is recognised that lack of clarity over role description or definition is confusing, and whilst this variety of role titles may be found elsewhere, for example in Nursing, a common thread is inclusion of the term “Nurse”.

With the expected advent of Paramedic Prescribing, it should be considered that there is a requirement for the title of the practitioner’s primary registration to be included in their job title, for example, “Paramedic Practitioner”, or “Specialist Paramedic”. It would also be helpful to the public, and other Medical and Non-Medical Professionals, if the job title of Specialist Paramedics were to include the term Paramedic.

The College of Paramedics no longer promotes or supports use of the title of “Emergency Care Practitioner”.

It is not a registered, protected title, and continued use of this job title cannot be supported.

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!!4 Contributing to Reform of Emergency Care!Thames Valley has been at the forefront of modernising emergency care.

SCAS Paramedics diagnose life threatening conditions, commence treatment, and take the patient to the appropriate specialist unit. This has demanded a steep curve in Paramedic clinical decision-making, is saving lives, and improving outcomes.

There is little evidence about the impact of these reforms on the Ambulance service, and to Paramedics. Certainly, taking seriously injured or ill patients longer distances increases physical and psychological demands on the Paramedic. It also means that a Paramedic Ambulance is engaged on certain types of emergency call for longer than might have been expected if they were to take the patient to their local A&E. Increased rationalisation and regionalisation of specialist services may see this trend continue, and lead to fluctuating levels of available Paramedic resources in local areas. It is difficult to predict when patients will need to be taken to a specialist centre; demographic models are designed to anticipate 999 call volumes, but are not yet sophisticated enough to predict outcomes.

Increasing the numbers of Paramedics will help to an extent, however this is not a long-term solution.

Increasing the numbers of S.P.s, and sending them to appropriate calls, or to relieve Paramedic crews at the scene, will free-up resources to be made available more quickly for patients requiring critical transport.

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!5 Paramedic Evidence-Based Education Project!The Paramedic Evidence Based Education Project (PEEP) study, examines some educational needs for a Level 7 Advanced Paramedic, whilst avoiding discussion about their domain of practice. PEEP has opened debate about in the way Ambulance services are led nationally, and makes a case for establishing the following:

A national lead for education and training of Paramedics

Standardised approach to the “green uniform’ and job titles

A whole-systems approach

Embed multi-professional learning

Defining the scope of practice to inform education

A national Paramedic lead is necessary for driving change in a co-ordinated way. As PEEP describes the myriad funding streams for a multitude of different educational programmes for Paramedics, and the wide variety in existing Paramedic scope of practice, it is clear that without a focal point, Ambulance services will continue on divergent paths.

Standardising who wears the Ambulance service “green uniform”, and their job title is an important consideration. PEEP agrees with the College of Paramedics, and many senior Ambulance managers, in calling for national agreement in terms of what Specialist Paramedics are called. PEEP suggests including the term “Practitioner” may not be helpful when comparing the level of the clinician in relation to the NHS Career Framework, since there, Practitioners sit at Levels 4 or 5.

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6 Emergency Care Practitioner Survey!A semi-qualitative survey of Emergency Care Practitioners in SCAS was undertaken, in order to gauge their perceptions of value to the Trust, and to gain an insight into their role and professional aspirations. The survey was anonymised, and because of the nature of some of the inquiries, respondents were permitted to submit multiple responses for certain questions.

SCAS Emergency Care Practitioner Survey

"Do you think your SCAS role as an operational SP will exist in 5 years’ time?"

S.P.s acknowledge the lack of leadership, focus, and direction about their role in SCAS. Whilst some (14%) are optimistic about the future of S.P.s in the Ambulance service, the same number take the opposite view.

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!"Do you think your PGDs are flexible enough to allow to to care for your patients?"

The majority of S.P.’s are content with their continually-expanding suite of Patient Group Directions, however the effectiveness of a PGD can be reduced by having to refer to other clinicians when patients symptoms fall slightly outside the PGD. This also demonstrates the S.P.'s professionalism and ability to only work within their defined scope of practice.

"Should S.P.s attend all 111 calls, and/or visit HCP Admissions to confirm they need a DMA and can’t find alternative transport?"

Most S.P.s would like to be busier within their scope of practice, and contribute to operational delivery in attending patients who might benefit from their S.P. skills.



!"How would you feel about having a formal, structured competency assessment every 1-3 years?"

S.P.s are aware of taking responsibility for their own development, however, feel this should be undertaken in partnership with SCAS. The majority indicate they would support the introduction of regular competency assessments for their role.

!A second, similar survey was undertaken of S.P.s working for other Ambulance services, as a means of gauging practice of the wider S.P. community. Again, the survey was anonymised, and multiple responses were permitted for certain enquiries.

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!External Specialist Paramedic Practitioner Survey

"What is your job title?"

Ambulance services have been slow to move away from the original job title of Emergency Care Practitioner. This will need to change with the introduction of Paramedic Prescribing.

!"How do you maintain competency for your role?"

!S.P.s report a varied and inconsistent national approach to maintaining their clinical competency, which reflects a national lack of strategic direction for the role.

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!7 Point of Care Testing!The goal of Point-of-Care testing is to support safer decision-making, and decrease the time it takes for doctors to reach a diagnosis and commence treatment.

These themes underpin good S.P. practice, and it is sensible to examine if Point-of-Care testing by S.P.s can offer benefits in delivery of Emergency Care.

Sir Bruce Keogh suggests that up to 40% of people attend A&E Departments inappropriately, whether self-presenting, or by Ambulance. It is unclear how many of these patients require diagnostic tests to rule out medical conditions that require in-hospital management, although the College of Emergency Medicine suggest up to 75% need to be there, and work by Howerton et al (2005) suggest up to 70% of clinical decisions are made with the support of Point-of-Care testing.

S.P.s refer some patients to either A&E or an ambulatory care unit for further tests when the diagnosis is unclear. Conditions include people with fever who require sepsis screening, or older people with abdominal pain, who may benefit from an abdominal ultrasound scan.

Specialist Paramedic Point-of-Care testing provides rapid and reliable results which can support safer decisions, and Collopy (2014) describes how Point-of-Care testing affects up to 30% of prehospital clinical decisions.

One recognised, and widely-used a point-of-Care system is the i-STAT® from Abbott, marketed to provide accurate prehospital assays comparable with laboratory test results.

By undertaking some of the tests currently performed in A&E, S.P.s may be able to safely manage a higher number of patients outside A&E, or directly refer the patient to a more suitable ward or unit.

The use of Point-of-Care testing should be confined for those patients for whom this will support safe discharge, or expedite rapid flow through the hospital front door.

It has been found that Point-of-Care testing can increase A&E doctors’ decision-time in up to 25% of patients (Asha et al, 2013), although it should be noted that the authors only looked at patients in A&E, and not

at prehospital interventions.

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!Point-of-Care testing of baseline of electrolyte levels and other baseline metabolic readings has a positive beneficial effect on patient flows through A&E, and on the decision-making process for discharge or admission in the prehospital setting. Measurement of Potassium, Sodium and Calcium, for example, are all valuable when managing patients with long-term cardiac conditions, since diuretic medication may alter their basic metabolic levels.

Point-of-Care tests can be performed on acutely unwell patients to assist decisions on medical admission or discharge at home, and also routinely as part of a sub-contracted service that can be offered to GP consortia in the management of their long-term cardiac patients.

The cost of an i-STAT® bundle (the unit, cables, cartridges, etc) is around £7,757.

Use of the i-STAT® would be confined to either confirming a diagnosis to support medical or surgical admission, or to rule-out certain conditions to allow safer discharge at home, and in the absence of reliable evidence, it is expected that they would be used by S.P.s a maximum of 6 times per 24-hour shift period.

Several Ambulance services are exploring the benefits that can be gained from Point-of-Care testing, and each is undertaking work independently, with all the associated duplication of research and increased cost to each Trust.

The opportunity for collaboration should be explored. For example, Frimley Park Hospital are early recipients of funding from Sir Bruce Keogh’s team, and have just commenced the operational field-trial for their “Lab in a Bag” Point-of-Care testing system, designed by their pathology team for use by S.P.s.

Whilst the option of reclaiming the cost of researching and developing Point-of-Care testing from Commissioners should be explored, since it is expected to reduce in-hospital costs, and speed patient flow through the emergency care system, collaboration with other Ambulance services and Hospitals should be considered. If robust and workable systems have already been developed elsewhere, collaboration with them should be explored, since, although this is likely to incur licence fees, or lease agreements, it will allow SCAS to buy-in to a proven Point-of-Care process.

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!8 Common Clinical Pathways!Clinicians in Thames Valley operate similar, methods of patient streaming and management, but there is not an agreed approach for managing distinct presentations.

For example, patients presenting with acute of urinary retention may undergo primary catheterisation by GPs or S.P.s in their own home, based on clinical features; the same patient may receive bladder ultrasound if managed in A&E.

An S.P. in Milton Keynes will refer a patient with acute appendicitis directly to the Surgical Assessment Unit; in other areas of Thames Valley, S.P.s have no option but to send these patients through the A&E common front-door.

Implementing Common Clinical Pathways for a specified set of conditions allows a standard best-practice approach, reduces duplication, and ensures treatment is started as soon as possible.Designing such pathways requires multidisciplinary input. Consensus on pathway design requires initial agreement from each A&E Department, and from each speciality involved in managing the patient.Gaining buy-in from each department is a challenge, since it is rare to find specialities with sufficient flexibility in their schedule to provide dedicated appointments or time-slots for a Common Pathway that may not receive sufficient patients during the allocated period for it to remain sustainable.Educating and training S.P.s to direct patients onto the correct Clinical Pathway provides a seamless introduction for the patient; initial relevant clinical tests can be performed and treatment can be started by the S.P., enhancing patient experience by quickening their passage along the pathway.!S.P.s have engaged a “whole systems approach” towards their practice for several years. It is standard for them to discuss patients with GPs, Medical Registrars, on-call Surgeons, and Community and District Nursing teams. They also refer people to community service teams for care packages in their own homes.

Given the unique perspective afforded from seeing patients in their own homes, S.P.s are well-versed in the difficulties and frustrations of not being able to implement prompt and appropriate care packages - particularly older people. It is not unusual for an S.P. to refer an older person for medical admission simply because no social or intermediate care package can be obtained within a safe timescale.



!Defining the scope of practice to inform education is woven into the concept of the Common Clinical Pathway. It may be necessary to undertake PESTLE analysis to ensure the scope of practice is not defined too narrowly, which may have been the case during education of Emergency Care Practitioners in recent years.

Using the example of minor injury management, many thought it was only necessary to train them to close simple wounds, with no requirement to be able to request or interpret x-rays. It is now apparent that many wounds encountered by S.P.s require advanced closure.

Suspected fractures could be referred directly for x-ray, and if the S.P. is working from a Minor Injuries Unit, they should be expected to interpret the x-ray themselves, and initiate a treatment plan, avoiding duplication, and ensuring patient care is started as soon as possible in the management pathway.

Work already under way by a collaboration of A&E doctors in Thames Valley, is exploring how to design common clinical pathways that ensure the first clinician to see the patient commences the appropriate pathway care as early as possible.

In the case of urinary retention, this requires the S.P. to be proficient in performing and interpreting ultrasound scans of the bladder, the licence to prescribe the correct medication, and access to urology follow-up.

This requires the S.P. to receive training in managing these pathways, a means of demonstrating their continuing professional development in the pathway, the equipment to safely diagnose and exclude other pathologies, and access to hitherto closed specialities, such as ultrasound clinics.

!!!9 Regulatory Framework and Professional Body!The term Emergency Care Practitioner came from work undertaken by the Modernisation Agency and Skills for Health. ECPs were part of the National Practitioner Programme, where traditional job boundaries were challenged, and the concept of the multidisciplinary health professional was encouraged. Applicants were encouraged from physiotherapists, Occupational Therapists, Nurses, and other allied health professionals, in recognition of the multidisciplinary nature of the role. !!



!Many Ambulance services implemented ECP programmes, but in the absence of a coherent national strategy or guaranteed funding stream, Ambulance services and their commissioners reconsidered their priorities, and many withdrew investment from their ECP programmes.SCAS was one of a handful of Ambulance services who persisted with - and continued to develop - ECP provision; other notable examples are the South East Coast Ambulance service (who are leading the way nationally), and the South West Ambulance service. Others have redesigned their ECP programmes, with Ambulance services in the East of England, and Yorkshire, both embarking on ambitious recruitment drives.There is consensus among many Ambulance services that the term “Emergency Care Practitioner” is no longer fit for purpose.Many favour a direction of repositioning the role as embedded in managing acute illness and injury within the 999 system, with some emphasis on managing long-term conditions.Recruitment to the role of S.P. is predominantly from the service’s own Level 6 Paramedics.!S.P.’s are regulated by the Health and Care Professions Council. The term “Paramedic” is a protected title, and as already discussed, should be present in the job title. The Professional Body is the College of Paramedics. The CoP Career Framework mirrors that of NHS Careers, with S.P.’s at Level 6, and Advanced Paramedics at Level 7.!!!10 The Advanced Paramedic!To support the S.P.s clinically, and to benefit the Ambulance service from a wider governance perspective, a new role, that of the Advanced Paramedic is needed.

Having either achieved an MSc - or be working towards it - the Advanced Paramedic will provide a senior tier of clinical advice to all clinical grades of staff. They will act as the fulcrum of local Clinical Hubs, overseeing all governance issues in their area; they are not intended to replace or dilute the role of operational Team Leaders, Clinical Mentors, or Emergency Service Managers, since their job role is specific and distinct from these managers.

Considering the 4 Pillars of Advanced Practice, the typical Advanced Paramedic will:

Spend 75% of their time in clinical practice (including time as clinical support in the Emergency Operations Centre or local Resource Centre to rationalise operational resources and provide telephone support to S.P.s and other Ambulance staff)



Undertake education and training of S.P.s and other staff

Participate in - and contribute to - audit and research

Demonstrate leadership to S.P.s and other staff through clinical support at incidents, and finding innovative ways of working

There is evidence to suggest that current 999 call prioritisation systems are not sophisticated enough to appropriately task S.P.s to the correct type of calls, which may continue system inefficiency, or cause loss of belief in the ability of S.P.s to contribute to service delivery.

Poor utilisation of existing Emergency Care Practitioners has been demonstrated by an audit of 999 calls to the SCAS Emergency Operations Centre (February-March 2014), where the main complaint was either a minor injury, or a head injury; both conditions fall into the scope-of-practice of existing ECPs.

Of 142 incidents, an ECP was only dispatched as the primary response in 1.4% of cases, and crews on scene only referred 2.3% of patients for ECP review.

Ambulance crews transported 65.5% of minor injuries, or head injuries to A&E, and it is suspected that a number of these patients could have been managed at the scene by an ECP. The reasons for poor referral to ECPs is unclear, however, anecdotal evidence supports the argument that an inverse of supply-induced demand comes into play, in that patchy provision of ECP cover results in Ambulance crews becoming disinclined to attempt referral to them.

It might be argued that cultural or institutional barriers that prevent ECPs being tasked to the most appropriate calls, are hampering the ability of the existing model to contribute to operational service delivery.

Rebranding the delivery strategy, changing their title to Specialist Paramedic, increasing their numbers, enhancing their availability for Ambulance crew referrals, and expanding their clinical scope of practice may stimulate supply-induced demand for their services, with subsequent benefits for the Ambulance service and the local health economy.

This would be reinforced by the Advanced Paramedic. They will devote a proportion of their shift to working in the Emergency Operations Centre, or at an Ambulance Resource Centre, directing the S.P. to appropriate calls, and providing clinical support to operational crews, and colleagues in the EOC.

The Advanced Paramedic would fulfil other operational duties, and respond to appropriate calls as necessary; for example, undertaking Bronze Officer Incident Management responsibilities when necessary.



!Advanced Paramedics will form a natural step between S.P.s, and the Prehospital / Paramedic Consultant, providing a pool of high-quality candidates for this senior role, and supporting the Consultant in some aspects of their role.

Advanced Paramedics will provide specific clinical leadership to the S.P.s, and also support Operational line management in clinical aspects of their role.

In order to meet external partners and attend internal meetings, a proportion of their time will be spent working ‘in-hours’, however there is a need to provide some unsocial hours’ cover.

The nature of the role requires flexibility, and a roster that contains a mixture of fixed clinical shifts, with relief and self-rostering may provide Advanced Paramedics with a practical work pattern.

To achieve the basic level of clinical cover, and to allow time to undertake other aspects of the role, there should be an absolute minimum of 6 Advanced Paramedics, which provides at least one per Clinical Hub every day.

It is recognised that the business model for Advanced Paramedics is not yet proven, therefore a pragmatic approach may be for the Ambulance service to undertake a 12-month pilot scheme, where one or two suitable applicants are appointed to the role of Advanced Paramedic for a fixed 12-month secondment, overseeing a Hub of 6 S.P.s, working to the described model.

There are currently insufficient S.P.s at any single Resource Centre in the Thames Valley region to provide a convenient cohort for the trial, however it may be possible for some to temporarily move Resource Centres, in order to form a working Clinical Hub for 12 months.

For example, two recently-qualified S.P.s from Milton Keynes have moved to work in other areas because there are no vacancies in their local S.P. team of 4. These two S.P.s could be offered a 12-month temporary stay at their original Resource Centre, and with the existing S.P.s, they would form the six clinicians for the Clinical Hub.

In Berkshire, a dynamic and high-performing team of S.P.s are spread across a number of locations, working to a roster which provides variable cover; there are sufficient numbers of S.P.s to undertake a trial, however this will require them to change their working pattern, and probably base station, which is rarely a positive experience for staff who are struggling to maintain a favourable work-life balance.

Data generated by the trial will inform a business case for stakeholder investment, and roll-out of S.P. Clinical Hubs and Advanced Paramedics across Thames Valley.



!The role of Advanced Paramedic provides, for the first time, the opportunity for Paramedics to progress their career in a clinical pathway, rather than follow the traditional Operational Management route. This will ensure South Central Ambulance Service remains the regional employer of choice for aspiring and existing Paramedics, and will support recruitment and retention of high calibre applicants.

!!!11 Clinical Hubs!The concept of team working has been embraced by SCAS. Frontline ambulance staff are grouped into distinct teams, performance-managed and clinically-led by one Team Leader, and one Clinical Mentor.

There are many organisational advantages to the team-based approach, including:

increased operational efficiency

devolution of senior management decisions to local Team Leaders

emphasis on team performance, rather than individual focus

local resolution to staff-side performance issues

robust clinical supervision and support

Proponents of the organisational benefits achieved by team working suggest it offers indirect improvements to patient care, via increased operational efficiency and adherence to governance structures.

Rigid, inflexible team-based approaches fit uneasily into the modern Ambulance service, which still relies heavily on a centralised hierarchical structure. Motivation of each team-member is difficult when their individual contribution to performance is negated by third-party factors, such as poor performance of another team-member, or environmental factors.

The benefits to the organisation and individuals that are achieved by team working should not be understated. The dichotomy, however, is that the outcomes expected of the Ambulance service may not reflect either the immediate clinical needs of the patient, or the wider health economy. These two apparently diverse strands may be woven together for mutual benefit by introducing Clinical Hubs.



!The Clinical Hub sits like an onion-skin beneath the team structure, and should be implicitly structured for local need. The design of the Clinical Hub requires the Ambulance service to analyse the surrounding landscape of social care, A&E provision, GP services, Community services, and population demographics.

Future planning should include conversations with local Council officials, Urban Planners, Clinical Commissioning Groups, and local Chambers of Commerce.

Pivotal to Clinical Hubs are the Advanced Paramedics. They have already been described, and their role within the Clinical Hub is vital.

Operational teams - and therefore the Organisation - function efficiently, in large part, because of high calibre Team Leaders.

Student Paramedics are developed - and local standards of care are improved - by the dedicated and skilled Clinical Mentors.

Clinical Hubs will improve patient experience and outcomes - and positively contribute to local health economies - because of S.P.s and Advanced Paramedics.

This triumvirate of senior Paramedics from different sub-specialisms of the role, can invigorate unscheduled and emergency care across Thames Valley, as SCAS strives to position itself as a class-leading Ambulance service.

Emergency Ambulance responses to serious and life-threatening calls will continue regardless of the Clinical Hub, achieved through the existing team-based operational structure. This function will be supported and enhanced by the Clinical Hub.

The Advanced Paramedic will act as the fulcrum of the Clinical Hub, dynamically dispatching S.P.s to emergency and urgent calls, and providing clinical support in the Emergency Operations Centre. They will take an active role in forecasting and analysing the clinical needs of the Hub, and with the support of the Consultant Paramedic, design and implement strategies to ensure the best patient care and outcomes are achieved.

Achieving appropriate levels of shift cover whilst allowing the S.P. to maintain a satisfactory work-life balance is challenging. It is a physically and mentally demanding role, requiring lone working in difficult situations. Working unsocial hours attracts increased financial benefits under the national Agenda for Change agreement, however the reduced volume of 999 calls reduces after 01:00 am, and there is not a proven need for S.P. cover overnight.

!



!The example shown (below), will lead to reduced monthly percentage unsocial hours’ payment for the S.P. - compared to their frontline emergency colleagues - since they will not be working overnight; however any shift roster should aim to reflect appropriate workloads, and not be designed to attract higher pay.

There may be an argument for providing overnight S.P. cover at weekends, because of the relatively higher call volumes on Friday and Saturday nights, however, the case has not been conclusively proven.

There is a strong an argument for including relief into the roster, since this will provide increased resilience for covering annual leave and sickness absence.

!!!!



!Given the specialist nature of the role, it is also advisable to build clinical training time into the roster pattern, which the S.P. will self-direct towards their individual needs; this will be agreed with the Advanced Paramedic.

The option for a cohort of S.P.s to manage their own operational cover through use of limited self-roster changes should be considered. Self-rostering offers benefits to individual S.P.s in terms of increased control and flexibility over their working pattern, however this needs to be balanced against the organisational disruption this frequently brings (Bailyn et al, 2006).

Using the example roster (above), the scope for complete self-rostering of S.P.s is limited, but may offer occasional opportunities for self-directed study, reduced need for short-notice carer’s leave, and enhance their work-life balance.

The example roster shown does not provide enough capacity for the S.P. to be sub-contracted to provide services for partner organisations, such as Nursing Home visits, running Minor Injury Units, or undertaking home visits on behalf of General Practice consortia. The relief line could be used for these undertakings, however that will impact on the availability of the S.P. to benefit SCAS’ core service.

It is anticipated, that by demonstrating the success of the S.P. programme, SCAS will be able to provide demonstrable benefits to the Commissioning Groups, and attract increased funding to recruit more Specialist Paramedics.

These new members of staff could either work as a distinct team within the Clinical Hub on a separate six-week roster, or join their existing colleagues on a 12-line roster (created by repeating lines 1-6), either option providing capacity for sub-contracting the S.P. to partner organisations.

The successful, and dynamic Clinical Hub may use the S.P.s to undertake healthcare functions that are not traditionally considered the remit of the Ambulance service.

!!



!Some of these activities may generate income, secondary to contractual or reciprocal agreements, whilst other services may offer wider benefits to the patient, or the local health and social care economy:

Treating more people at home, or delaying transfer time to A&E

Mutual working agreements, allowing the S.P. to spend a portion of their time working in the local A&E Department

Establishing Paramedic-led First Aid Units, similar to the one at Chipping Norton, Oxfordshire

Running a minor illness Urgent Care list in a GP surgery

Undertaking in-hours home visits on behalf of a consortia of GP surgeries!Supporting early discharge from hospital with home visits and assessments

Undertaking routine and urgent visits to residents living in Nursing and Care homes

Collaborating with Intermediate Care services to help people stay at home safely, and arranging community respite care when appropriate

Providing contracted S.P. cover for neighbouring Ambulance services who do not maintain a robust Specialist Paramedic programme, specifically, East of England Ambulance Service, East Midlands Ambulance Service, and the London Ambulance Service

Engaging in cross-border collaboration with neighbouring Ambulance services who maintain similar S.P. programmes to SCAS, specifically, South West Ambulance Service, and South East Coast Ambulance Service

Providing a forensic medical service for Thames Valley Police and other secure institutions

Collaboration with private Occupational Health providers

Providing bespoke and enhanced Event Cover at sporting events and large social gatherings

The Clinical Hub will allow the Ambulance service to support the Royal College of General Practitioners’ Centre for Commissioning, which requires an “Integrated Approach” to commissioning of health services.

!!



!

12 Common Educational Standard!Specialist Paramedics in Thames Valley share broadly common learning outcomes for minor illness and minor injury, and are only reassessed as competent in these areas if they self-identify a learning need, or are involved in a clinical adverse incident. They are most effective at see-and-treat - or referral through correct clinical pathways - when their training and education is focused on the type of clinical presentations they will encounter (Cooper et al, 2007).

In the absence of a national educational standard or agreed set of competencies for S.P.s, there is an imperative to achieve, and maintain, a programme of common standard of education and practice for Specialist Paramedics in Thames Valley.

The programme should have a clearly-articulated purpose that describes the role, scope of practice, and clinical standards required of the Specialist Paramedic.

Flexibility to adapt to local requirements will be provided as bespoke bolt-ons to the programme.

Enhanced technological methodologies should be engaged, with elements of the programme delivered as eLearning, and as work-based learning.



!Pastoral care of the S.P. during their training, and post-qualification, will be undertaken by the Advanced Paramedic, and other frameworks provided by the Ambulance Service, HE Institutions, and Health Education Thames Valley.

The programme will meet the competencies of the Specialist Paramedic Skills Passport, and link to the strategic direction of both SCAS, and NHS England.

A common educational and training baseline for existing S.P.s should include recognition of their experience and prior learning, and should be included in a database of their clinical competence. Access to the S.P. competence database should be restricted to include the Team Leader, the Advanced Paramedic, and the individual themselves. This database will include the Skills Passport, the individual’s Team Assessment of Behaviour portfolio, records of attendance at 60-minute Essentials sessions, and competency re-certification sessions, such as the Annual Wound Care Re-certification.

Aspiring S.P.s will already be working as Paramedics, educated to Level 6 BSc in an appropriate and relevant field of study, and it is likely that their studies will have included teaching in minor illness and minor injury. These modules should be viewed as an introduction to this area of practice within the context of the Paramedic’s role, and not as a licence to work as a S.P.

Undergraduate Paramedic Science minor illness and injury modules usually require practice placements, and these should be undertaken with a S.P., rather than with a GP, or Minor Injury Unit.

This will provide the student with an insight into the unique role of the S.P., and help their decision-making processes for referring patients to them. This also allows the S.P. to foster closer working relationships with their colleagues, improve referral rates from Paramedics to S.P.s, and inform the S.P.s Team Assessment of Behaviour portfolio (see section 13 Towards TAB).

The transition from Paramedic to Specialist is not for everyone. Most Paramedics find their role sufficiently varied, challenging, and rewarding, that they remain committed to that role for the duration of their career. Others seek career progression through operational management roles, or education, whilst some focus on developing their skills in Critical Care.

Increasingly distinct Paramedic roles, such as Specialist Paramedic, offer wider career choice, and for some individuals, higher job satisfaction. Paramedics who wish to work as S.P.s should undertake additional higher education modules in minor illness and injury, at Level 6, which have been designed specifically for their role.

!



!Oxford Brookes University and Bucks New University are able to deliver relevant modules, in collaboration with the SCAS Education Department. Some delivery may be undertaken by the Advanced Paramedic, or by S.P.s with an area of special interest.

Aspiring S.P.s should also undertake the Applied Knowledge Test and Clinical Skills Assessment (see below), to prepare them for running clinics in GP surgeries, and undertaking GP home visits.

There is a need for developing a framework for continuing the education of S.P.s, and this should have a dual focus of maintaining their competency in their current role, but also prepare them for the anticipated introduction of Paramedic Prescribing, and for undertaking the role of Advanced Paramedic.

To achieve this, S.P.s should be encouraged to study a minimum of one Level 7 / Postgraduate MSc module in areas such as: Advanced Patient Assessment and History Taking, Advanced Minor Injury and Illness Management, or Advanced Diagnostic Therapeutics, any of which can be taken as stand-alone modules, or as a pathway towards an MSc.

There are a number of benefits to this approach:

Provides a framework for clinical progression

Supports the bridge from Level 6 Paramedic to Level 8 Consultant roles

Preparation for the Paramedic Prescribing Course

Provides a common grounding in the knowledge required for the S.P. role

Demonstrates a commitment from SCAS to the S.P. programme

Makes SCAS a more attractive employer to potential applicants

Health Education Thames Valley have commissioned two bespoke Level 7 (40 credit) modules “Minor Illness: developing competency through work-based learning” and “Minor Injuries: developing competence through work-based learning”, both of which are designed for S.P.s, and cover the competencies required to practice effectively as an independent, autonomous S.P. across a range of settings.

The modules are HE accredited through the University of West London, and have clinical placements built-in, targeting a spectrum of learning outcomes, and delivered to meet Ambulance service needs, these modules prepare the S.P. for independent practice, and to undertake the role of Paramedic Prescriber.



!Delivery of the taught-elements can be flexible enough to meet SCAS operational requirements, with the practice placements timetabled to meet the needs of both the student, and the organisation.

These modules equip the S.P. with the advanced skills required for their expanded role, link into the Thames Valley Specialist Paramedic Skills Passport, and are recommended modules for S.P.s wishing to work in the Oxford Health Community service Minor Injuries Units, or the Hospital-at-Home Service.

Whichever method or educational provider is chosen, it is essential for HETV and SCAS to share ‘ownership’ of the module content, to ensure it will produce S.P.s and Advanced Paramedics who are fit for purpose.

S.P.s working for the Ambulance service differ from their colleagues in formal settings, such as A&E, or Minor Injuries Units.

They practice unsupervised, without the opportunity to seek immediate peer advice. They are expected to reflect on, and monitor their own professional standards; however SCAS has no formal means of monitoring their performance, which raises questions about clinical oversight and governance.

To address these concerns, the skills of the S.P. in wound assessment and closure, should be formally assessed annually, during a 1-day Clinical Update (appendix 4).

The Clinical Update should include topics required for managing a range of wounds in a range of environments, such as in the patient's own home, in the patient compartment of an ambulance, and in a public place. The S.P. should also be competent in assessing and managing presentations that may be seen more commonly in GP surgeries, or Minor Injuries Units, such as infected wounds, abscesses, and more complicated wounds.

The ability of the S.P. to manage wounds to the required standard requires input from experts in this field, therefore, the Wound Care Certification should be facilitated by an experienced Advanced or Emergency Nurse Practitioner from a local A&E Department or Minor Injuries Unit. Using a local Nurse ensures continuity of practice in the Clinical Hub.

!


Specialist Paramedic Wound Care Certification 14th December 2014

Health Authority Regulations and Medico-legal duties, responsibilities and Informed consent Introduction to surgical materials, instruments, basic surgical technique, what not to touch !Local anaesthetic !Digital nerve blocks

Live Demonstration of Suture Techniques Removal of Subcutaneous Lesions, Dirty Wounds

Troubleshooting – getting out of trouble! !Excision and drainage of pus!Practical Group Work !Excisions and basic suturingtechnique!Cysts!Advanced / difficult closure!Practical work divided intogroups according to level ofexpertise !!!

Programme to include:


!In addition to common standards in wound care, a baseline set of skills and knowledge is required for S.P.s across Thames Valley.

This may be achieved by the introduction of the Thames Valley Specialist Paramedic Skills Passport (explained in more detail in the next section), which will support each S.P. to practice to a common standard. This will be monitored locally by the individual S.P., and by the Advanced Paramedic.

Areas for professional development will be agreed on an individual basis.

There are other advantages to developing the Skills Passport, beyond mapping individual competence and areas for development. It will provide a common clinical standard, to be recognised by each organisation in the region, reinforcing credibility of the S.P.s

The Passport - as it’s name suggests - will facilitate movement of S.P.s across organisations, providing each with the ability to assist one another during times of operational stress. Neighbouring Ambulance services, with whom SCAS shares a common border, can be offered the opportunity to adopt the Skills Passport - perhaps in a different format to meet their needs - to underpin commonality of care across boundaries. This will also allow Ambulance services to call upon the services of S.P.s from their neighbours during periods of unforeseen and severe operational pressure; examples may include terrorist attack, local clusters during epidemics, or major incidents.

A database of common standards will be maintained by the Advanced Paramedic, and reviewed at the S.P.s Annual Performance Development Review.

To assist the S.P. in maintaining competency, a series of Continuing Professional Development sessions should be designed specifically for their role (Cooper et al, 2007). These should be maintained by the Advanced Paramedic as a suite of off-the-shelf sessions that can be delivered by an appropriate facilitator, for example an Advanced Paramedic, S.P., or where appropriate a GP, Speciality Doctor, or Advanced Nurse Practitioner.

Branded 60-minute Essentials, the sessions should be designed to cover all the main elements required for the topic (appendix 3), and be deliverable in one hour. This will allow the S.P. to receive a 60-minute Essentials session during their shift if necessary, or for a one-day workshop to be scheduled, where the S.P. can attend several sessions in the day.


Specialist Paramedic 60-minute Essentials

14th December 2014

!A 1-hour update providing expert specialist clinical training and essential information on pain management.!The session will focus on essential information, practical tips and take-home messages that will help you improve your practice and patient outcome. !!!!!!!

We will cover: Latest updates on new national painguidance and pain commissioning Pain management in children and theelderly!Pain management versus addiction:addressing the balance!Techniques in the self management ofchronic pain Include in your CPD portfolio inpreparation for your TAB feedback andannual appraisal

Pain Management


!Attendance of a 60-minute Essentials session will generate a Certificate, for inclusion in the S.P.'s Team Assessment of Behaviour Portfolio (summarised in the following section Towards TAB), and other portfolios of Continuing Professional Development.

A bespoke Paramedic Practitioner (PP) examination, which assesses the ability to recognise and manage a range of primary care presentations, has been developed by South East Coast

Ambulance Service, in association with St. George’s University Medical School and The Royal College of General Practitioners.

There are two elements: the Paramedic Practitioner Applied Knowledge Test (AKT) consists of a 3-hour written paper focusing on clinical application of theoretical knowledge, and the Clinical Skills Assessment (CSA) is made up of 15 separate Observed Structured Clinical Examinations, focusing on practical aspects of the role.

The AKT offers a credible means of assessing the S.P.'s knowledge across the range of minor illness, can be used as a baseline measure, and also as a means of re-certification for S.P.s.

It is underwritten by the RCGP, and provides a robust standard for clinical governance. It is heavily weighted towards Primary Care, General Practice, and Out-of-Hours provision, and promotes the use of S.P.s to support their GP colleagues.

Successful completion of the AKT exam may be supported by a period of focused clinical placement in General Practice. The support of the Oxford Deanery is essential for sourcing high-quality clinical placements with GPs, both during normal surgery times, and Out-of-Hours. This will ensure credibility of the S.P. among General Practitioners, and will underpin continuing safe practice.

Post-examination, the team provide in-depth feedback for every candidate, which allows individuals to recognise their own personal learning needs, and tailor their Continuing Professional Development accordingly.

!

13 Towards TAB!Medical students in the UK are assessed using the Team Assessment of Behaviour (TAB) approach. TAB uses multi-source feedback to inform both the student, and their educators, about their progress, and may offer an opportunity for S.P.s to reflect on the relationship between their



education and their practice. An example of elements for an S.P.'s TAB portfolio is summarised below:

RCGP/St. George’s Medical School Applied Knowledge Test (Clinical Evaluation Exercise)

RCGP/St. George’s Medical School Clinical Skills Assessment (Clinical Evaluation Exercise & Direct Observation of Procedural Skills)

Annual Wound Care re-certification (Direct Observation of Procedural Skills)

S.P. required to nominate 4 “Raters” who will be invited to complete feedback summaries. A minimum of 3 replies is expected. The raters should be a blend of other S.P.s, Advanced Paramedics, Level 5 Paramedics, Doctors, or Specialist Nurses, although this list is not exhaustive.

Case-Based Discussions (Continuing Medical Education)

Attendance on a minimum of two 60-minute Essentials sessions (Continuing Medical Education)

Clinical Rotational Placements (Clinical Evaluation Exercise) and (Direct Observation of Procedural Skills)

!

!Each S.P. will maintain their individual TAB portfolio, which will support their evidence of Continuing Professional Development. Individuals who struggle to maintain TAB, or have areas for improvement, will be supported in this respect by the Advanced Paramedic.

Activity Competency

Applied Knowledge Test Clinical Evaluation Exercise

Clinical Skills Assessment Clinical Evaluation Exercise Direct Observation of Procedural Skills

Annual Wound Care Re-certification Direct Observation of Procedural Skills

Rater feedback summaries Direct Observation of Procedural Skills

Case-Based Discussions Continuing Medical Education

60-minute Essentials Continuing Medical Education

Clinical Rotational Placements Clinical Evaluation Exercise Direct Observation of Procedural Skills



!Clinical Rotational Placements are essential for maintaining competence and developing relationships with Doctors and non-medical Professionals, however there is no consensus about the optimum time required for S.P. placements, as a percentage of their clinical practice hours. Indeed, a prescriptive timescale would not allow clinical progression at the individual’s own pace, and should therefore be avoided.

14 Specialist Paramedic Skills Passport!S.P.s are expected to practice across a variety of healthcare settings, predominantly working in the domains of emergency care, minor illness, and minor injuries. Each S.P. possesses a variety of personal and professional attributes that enable them to operate effectively and safely in their sphere of practice. Presentations that the S.P. is not confident with, or competent to manage, are referred to another professional.

Despite their collaborative approach, there is a risk that Ambulance service S.P.s can become entrenched in their current role, and lack the skills necessary to work seamlessly in other spheres of practice, such as Minor Injury Units or GP surgeries. Similarly, S.P.s working for Community services will experience rapid skill decay in major illness or injury.

This reinforces ‘silo-working’, reduces the career portfolio of the S.P., and reduces the ability of organisational sharing of resources.

A Skills Passport allows all S.P.s in Thames Valley to share a common baseline of practice, and ensures a minimum standard of practice across the region.

It will allow a S.P. to seamlessly move from working for the Ambulance service, to Community services, and back again, without the need for extended clinical supervision in their new role. This enhances the career prospects of the S.P., and provides partner organisations with a baseline of standards to demonstrate clinical governance of their autonomous clinicians.



!Skills for Health have invested £400,000 to develop a national Skills Passport, aimed primarily at nursing staff, with a goal to reach 10% of the NHS workforce. The Thames Valley S.P. Skills Passport should complement other national initiatives, be in the format of a Clinical Skills Workbook, and contain each element considered necessary to work as a S.P. across Thames Valley.

It should preferably be maintained as an electronic copy, with the option for retention of a hard copy by the individual. The Passport should feature a concise introductory section, allowing an at-a-glance skills review for the reader, with more detail contained inside.

Collaboration with neighbouring Ambulance services who operate a variety of Specialist Paramedic and Paramedic Practitioner services (SWAST, SECAmb, EEAS, and EMAS) will allow for development of a common format for the Passport, reinforcing - and increasing - transferability and portability.

The Passport should exist in a format that is easily portable, and transferable, whilst remaining current, relevant, and accessible for purposes of governance. It should also have elements that can be tailored for the individual S.P., allowing for their special interests and scope of practice. The Passport should be easy to update, for both the individual, and their clinical supervisors.

For these reasons, maintaining this type of portfolio in hard-copy format may prove difficult, and discussions are underway with colleagues from Health Education Wessex, to explore the feasibility of developing an electronic version.

Credibility for the Passport should be sought by seeking support and guidance from:

College of Paramedics

College of Emergency Medicine

Royal College of General Practitioners

Seeking underwrite from these organisations may increase the visibility and availability of the passport to the wider S.P. community, outside of Thames Valley.

!!!



!15 Costs!Emergency Care Practitioners are at Level 6 of the NHS Career Framework, which is reflected by the Agenda for Change banding (6) of the majority of Ambulance services. S.P.s working for Community and Out-of-Hours services are often attracted by Band 7 salaries; these have usually been traditional in these spheres, since the early workforce consisted of senior nurses, usually Ward Sisters, who were already paid at Band 7.

It is not recommended that S.P.s be uplifted to AfC Band 7 at this stage, although this should be reviewed once their true value to Ambulance services becomes evident, and the risk of losing them to better-paid jobs elsewhere increases.

Replacing S.P.s with agency staff, or contracting them from the independent ambulance sector will cost considerably more than paying them at Band 7.

Myriad opportunities exist for S.P.s to take their expertise outside the Ambulance service, with recruitment agencies advertising for S.P.s to work in various locations across the region, and offering hourly pay rates between £33 and £50.

It might be argued that these jobs are transient, with no guarantee of full-time hours, and none of the associated benefits and security of working for an NHS Ambulance service. However, if a S.P. were to contract to a number of these agencies, and only be offered work for three 8-hour shifts per week, they could expect to earn between £3,100 and £5,280 per month.

S.P.s have demonstrated the ability to provide alternative services to the traditional Ambulance service response-transport model.

The Chipping Norton First Aid Unit in Oxfordshire is staffed by a single S.P., and provides minor illness and injury care for walk-in patients. The S.P. also provides a 999 Paramedic response to life-threatening emergencies in the local area.

Last year, 1,210 patients attended the Chipping Norton Specialist Paramedic First Aid Unit, which compares favourably with ENP-led double-staffed units in Bicester (1,152), and Wallingford (1,498).

It is essential that SCAS retains it’s S.P.s, and prevents them being lured by the apparent high wages on offer elsewhere. Failure to do so, may prove more costly to both SCAS, and the local health economy in the long-term.

!



!S.P.s are not easily lured simply by lucrative salaries - although, of course, their loyalty is not infinite - and surveys suggest that current S.P.s place a high value on job satisfaction.

The aim, therefore, should be to provide a job role that meets the expectation of the S.P., at a reasonable cost to the employer. Retaining the S.P.s in Band 6 may achieve both these objectives.

A basic costing exercise has been undertaken for one Clinical Hub of six S.P.s, as follows:

Specialist Paramedic annual basic pay at AfC Pay Point 29 (£34,531 + unsocial hours supplement @21% £7,251) + (pension @14% £5,849) + (National Insurance contributions £3,556)

Monthly cost per whole time equivalent at top of Band 6 = £4,266

multiplied by six S.P.s = £25,594

Monthly cost of Clinical Hub of six S.P.s = £25,594

!Calculating the annual cost is achieved as monthly costs multiplied by 12:

Annual cost of each whole time equivalent S.P. = £51,188

Annual cost of six S.P.s = £307,128

!Cost of including the Advanced Paramedic paid at Band 6:

Monthly cost of Clinical Hub of one Advanced Paramedic and six S.P.s = £29,862

Annual cost of one Advanced Paramedics and six S.P.s = £358,316

!There is an argument for uplifting the Advanced Paramedic to Band 7, since this follows the NHS Career Framework, and reflects the additional tasks required of the Advanced Paramedic. This would change the costs as follows:

!



!Advanced Paramedic annual basic pay at AfC Pay Point 34 (£40,558 + unsocial hours supplement @21% £8,517) + (pension @14% £6,870) + (National Insurance contributions £3,556)

Monthly cost per whole time equivalent at top of Band 7 = £4,958

Monthly cost of Clinical Hub of one Advanced Paramedic and six S.P.s = £30,552

!Calculating the annual cost is achieved as monthly costs multiplied by 12:

!Annual cost of each whole time equivalent Advanced Paramedic = £59,501

Annual cost of one Advanced Paramedics and six S.P.s = £366,62

!*These Calculations only include the cost to SCAS of the S.P.'s basic salary, and do not take into

consideration uniform, equipment, or abstraction for statutory training.

!Whether to uplift the Advanced Paramedic to Pay Band 7, is a strategic decision for the organisation, and since the direct benefits of the role are not yet quantifiable, it might be difficult to justify the increased expenditure at this stage.

An alternative approach might be to package the Advanced Paramedic role as a secondment into a professional development opportunity, and therefore retain the individual at Band 6. Whilst there may be several elements of their role that would ordinarily uplift them to Band 7, such as education, audit, research, and supervision, this needs to be balanced against the financial constraints currently faced by all NHS Trusts.

The annual cost of a secondment of one S.P. to Advanced Paramedic is £51,188 at Band 6, and £59,501 at Band 7.

!!!



!Demonstrating the benefits of the Advanced Paramedic can be achieved by implementing the role as a 12-month pilot scheme, using a set of semi-quantifiable outcomes such as:

The Response Cars and equipment already exist and are budgeted for, however there will be additional fleet and estate costs for the Advanced Paramedic, which have not been possible to source.

There are other, additional costs that may be added to provide the optimum service, as follows:

The i-STAT Point-of-Care test machine has already been discussed in the previous section on Point-of-Care testing and it is provisionally suggested that up to four cartridges may be used in any 24-hour period.

Abbot have provided two quotes (expire July 2014) for both a single i-STAT and accessories for a pilot site, and a separate quote for seven i-STATs, to provide one per Clinical Hub:

!!!

Outcome to be demonstrated Method of measurement

Increased usage of S.P.s Monthly audit of number of calls attended

Reduced patient conveyance to A&E Monthly statistical audit

Improved 999 response times Monthly statistical audit

Patient satisfaction Feedback survey for patients to return

S.P. education Record of Skills Passport, 60-minute Essentials sessions, and Team Assessment of Behaviour

Improved operational resource management

Monthly statistical audit

Increased referrals to medical/surgical teams

Monthly statistical audit

Medical Device Single unit cost Supplementary and accessory costs

Total Medical Equipment costs

i-STAT Point-of-Care Machine

£7,065 £692.78 £7,757.78



!Widening the use of Point-of-Care testing to six Clinical Hubs will incur capital outlay of £40,600 for the units, and £953.42 for the cartridges. This includes a £9,000 discount for bulk purchase.

*The above quote represents a cost saving of £9,000 compared to purchase of a single unit

!

!It is anticipated that the Advanced Paramedic will task each S.P. to a minimum of four 999 calls per 12-hour shift. This takes into consideration that the Advanced Paramedic will have other responsibilities, other than managing S.P. resources, whilst spending no more than six hours of their shift in the Ambulance service Emergency Operations Centre, or at a Resource Centre using remote access to the 999 call lists.

It is also expected that the S.P.s will self-mobilise to appropriate calls.

There will be no more than two S.P.s on duty at one time in each Clinical Hub.

!The hourly rate per S.P.s is £26.18 (calculated as):

£52,188 / 52.14 = £981.74

divided by 37.5

£981.74 / 37.5 = £26.18

The hourly rate per Advanced Paramedic is £30.43 (calculated as):

£59,501 / 52.14 = £1,141.17

divided by 37.5

£1,141.17 / 37.5 = £30.43

i-STAT cartridge Pack of 25 Per cartridge Daily cost

Costs £133 £5.32 £21.28



!It is suggested that the average time taken for an existing S.P. to cycle a call is 90 minutes. If tasked to the call by the Advanced Paramedic, a reasonable assumption is that the Advanced Paramedic may spend a maximum of 15 minutes triaging and sifting the call, therefore the cost of that call may be calculated as:

Advanced Paramedic input £30.43 x 0.25 = £7.61

S.P. input £26.18 x 1.5 = £39.27

Total cost for a call lasting 90 minutes = £46.88

There will be occasions when the Advanced Paramedic is unavailable, or not managing resources in the Emergency Operations Centre. On these occasions the S.P. will self-mobilise to calls, either by selecting incidents from the iNetViewer facility on their Resource Centre PC (which gives a near real-time indication of incoming and ongoing 999 calls), or after being contacted directly by Ambulance colleagues from the patient’s bedside. In these cases, the cost per 90-minute call is calculated as:

S.P. self-mobilisation £26.18 x 1.5 = £39.27

It is recognised that not all S.P. calls take 90 minutes, some take less time, and a small number take longer. Sometimes this extended time is spent awaiting ambulance transport to hospital; sometimes it is because the geographical location of the call is a long distance from the S.P.. Occasionally it is because the S.P. is engaged on a clinically time-consuming procedure, such as wound closure, or urinary catheterisation.

Achieving the target of the Advanced Paramedic sending the S.P. to a minimum of four patients is calculated as costing the following:

Advanced Paramedic @ 15 minutes £7.61 x 4 = £30.44

+

S.P. @ 90 minutes £39.27 x 4 = £157.08

total = £187.52

Self-mobilisation by the S.P. to four patients is calculated as:

£39.27 x 4 = £157.08



!It is recognised that overall costs are higher with Advanced Paramedic involvement, however the S.P. is only able to self-select calls from the iNetViewer system when on their Resource Centre, whereas the Advanced Paramedic will able to divert them to calls when they have cleared from the incident they are dealing with. The Advanced Paramedic can bounce the S.P. from call-to-call, without them having to return to their Resource Centre, unless it is to restock, or to use facilities.

The average number of calls attended by an S.P. during their shift differs among the cohort, and is dependant on a number of variables, some of which may be modifiable with the input of the Advanced Paramedic. These variables include:

The skill set of the S.P.

The type of call attended

Geographical location of the calls

Ability of Clinical Support Practitioners to prioritise S.P. dispatch within workload

Appropriate call-types during shift

Ambulance crew referrals

Some of these factors can be modified by introduction of the Skills Passport, Point-of-Care testing, and increasing coverage to two S.P.s per Clinical Hub each day. This will increase the range of presentations the S.P. can have a positive impact upon, and the total number of patients that can be seen.

There is scant research evaluating the direct cost-benefits of an enhanced Specialist Paramedic programme, consequently this review requires some assumptions and estimates to be made; where this is necessary, examples will be quoted using best-case and worst-case scenarios, for example:

!It is anticipated that S.P.s will treat and discharge a minimum of three patients per shift, send a minimum of one patient into hospital via alternative care pathways, and send a maximum of two patients to A&E.

The best-case scenario is that they will treat all of these patients at home, or in association with the patient’s own GP.

The worst-case scenario is that the S.P. will send all their patients to A&E.



!A 12-month pilot to evaluate an enhanced S.P. programme will provide sufficient information to formulate more accurate and meaningful data, across the time-of-day, and day-of-the-week continuum.

Analysing Advanced Paramedic input will also yield evidence to support - or refute - continuing their use for sourcing appropriate calls and mobilisation of the S.P.s in their Clinical Hub.

There is little evidence to demonstrate definitive cost-savings where S.P.s are deployed (Hill et al, 2013). This is complicated by the range of arenas where S.P.s are deployed, such as in Ambulance services, A&E Units, and GP surgeries.

Funding issues have also blurred the picture; it is Ambulance Services who bear the financial burden of the S.P. service, and although they benefit from some direct cost savings, the wider health community also enjoys secondary cost savings. Studies have varied in their estimates of actual cost benefits from S.P. encounters, ranging from £31 to £291 (Mason, et al, 2007).

The larger savings are demonstrated where the S.P. attends the patient through the 999 system and referral to A&E is avoided; smaller savings result when the patient sees an S.P. at a Walk-in-Centre or GP Surgery.

Authors suggest there is no cost saving when S.P.s are tasked to see patients following GP referral (Gray & Walker, 2009), however their study only considered the actual cost of attending the patient. There is no reference to the greater cost-benefit from increased admission-avoidance rates when S.P.s are involved.

Where S.P.s are used instead of a GP, greater savings are realised (O’Keefe, 2011) and (Mason et al, 2012).

It has not been possible to obtain data relating to the financial costs per operational S.P. unit. Consequently, it has been necessary to obtain costings from other sources, which may not be directly transferrable to SCAS expenditure. Variable efficiency of service delivery between Ambulance services makes extrapolation of third-party data unreliable, however, the following figures provide an interesting guide.

Figures published by Deloitte and The National Audit Office (2011), show that in 2010 the cost per call in SCAS was £251, the highest in the country. It is worth noting that extensive work has been undertaken to streamline and develop a model of delivery in line with anticipated demand, since these figures were published.

!



!The average net saving for the Ambulance service when a patient is ‘seen-and-treated’ at the scene is £32.32, with a wider saving to the local health economy of £70.44.

The net saving for taking the patient through an Alternative Care Pathway is £15.61.

Clearly, the preferred option, both in cost-savings, and resource management, is for treatment at the scene.

After combined analysis with Ambulance services, Deloitte described minimum and maximum scenarios of how an increase in ‘see-and-treat’ rates can prove financially beneficial:

Increasing see-and-treat to 37% will yield savings of more than £20 million annually, with the additional benefits that will be realised from rebranding and reorganising the SCAS Emergency Care Practitioner programme.

SCAS were the most optimistic of Ambulance services, providing a target of increasing see-and-treat to 41%, achievement of which, will provide even higher savings. This should be viewed in the context of current S.P. see-and-treat rates, which are around 55%-to-60%.

As already described, increasing the numbers of S.P.s may provoke supply-induced demand, and actually increase the overall S.P. workload, thereby allowing SCAS to exceed it’s own projection of 41% see-and-treat rates.

Many 999 calls result in multiple resources being sent to a single emergency call. Examples include cardiac arrest, and serious trauma, where it is anticipated that patient care may be enhanced with a higher level of response. This also occurs in the case of emergencies that probably will result in transport to an appropriate facility, and the nearest resource is a solo Paramedic in a Response Car.

The solo responder will arrive within Government targets and commence treatment, whilst the ambulance is en-route. Examples include stroke, or heart attack; there is no evidence, however, that sending multiple resources to 999 calls improves patient outcomes.

It is not uncommon for either a responder, or a Paramedic crew to arrive at the scene of an incident, and subsequently decide the patient may benefit from management by an S.P..

In these cases, it is possible for multiple resources to all attend the same incident. It is not usually necessary to send all these resources to a single incident, however, given the vagaries of 999 caller communications with Emergency Call Takers, and the AMPDS Prioritisation system, such



!overuse cannot be avoided unless there is additional clinical oversight of each call (Gray & Walker, 2008).

Implementation of Specialist Paramedic Clinical Hubs, overseen by Advanced Paramedics, will yield cost-savings through reduced use of multiple resources.

The new NHS Pathways system will go some way to reducing unnecessary use of multiple resources, however, eliminating it completely in a safe manner will be difficult.

Allowing S.P.s to manage their own workload, and use of Advanced Paramedics, may be of additional benefit, ensuring S.P.s are tasked to the most appropriate call types.

An internal review of call and demand processes is underway in SCAS, to review how resource demand is managed, and whether the most appropriate response is being sent in the majority of cases. This is a large, and complex piece of work, and aspects may inevitably dovetail with some findings from this review.

The benefits from rebranding and relaunching the current patchy Emergency Care Practitioner programme, with Specialist Paramedic Clinical Hubs in Thames Valley are clear. It is a natural fit with the work being undertaken by Sir Bruce Keogh, and will prepare SCAS for the budgetary, political, and social demographic challenges that lay ahead.

This is not a time to be timid - it is a time for change; a time to use Specialist Paramedics and Advanced Paramedics in Clinical Hubs, as a radical solution to the modern challenges facing delivery of unscheduled and emergency care.

!!!!!!!!



16 PESTLE Analysis!Undertaking full PESTLE analysis is beyond the scope of this review, however a summary covering each element has been prepared.

Political:

The political future in the UK is uncertain.

Mainstream political parties have migrated towards common ground during the last few years, reinforced by poor voter turnout and increased influence of corporate lobbyists.

It is not possible to predict which of the four major parties may form coalition after the next General Election, however they all advocate varying degrees of competition and choice in the NHS. Unless the Green Party (who oppose all competition in the NHS) enjoy an unexpected surge in support to form coalition, Ambulance services should prepare to engage in competitive tendering for their own traditional service domains, and other areas of healthcare delivery.

S.P.s are an asset in this respect, and will allow SCAS to demonstrate innovation and efficiency as they fend off Independent Ambulance sector bids for their core 999 service.

A Conservative government will offer an EU “in/out” referendum, and populist tightening of immigration policies may reduce the ability of the NHS to employ foreign nationals. This will strangulate the NHS workforce, leading to staff shortages, and increase pressure on Ambulance services.

Political tensions in Eastern Europe and across the Middle East, may result in fuel restrictions, increasing direct operational and estate costs.

Presidential elections in the United States are due in 2016; victory for Barack Obama will strengthen his Healthcare Reforms, and may encourage Private Healthcare companies to divert their operations into the UK.

The Transatlantic Trade and Investment Partnership (currently under negotiation) - if signed into legislature by the US and EU - will allow for increased competition in the NHS, and invite predatory moves by large multinationals, such as the Danish company Falck.

A dynamic and successful S.P. programme will place the Ambulance service in a strong position to navigate these stormy political waters, reduce pressure on GPs and A&Es, and fend off predatory moves for its core service.

!



!Economic:

Fiscal security does not rely solely on the so-called ring-fenced NHS budget.

There are calls for a Living Wage to be paid across the UK, which may require salary uplift of the lowest paid NHS staff.

Foundation Trusts have the option of entering into local pay bargaining, and abandoning Agenda for Change; this may cause imbalance in pay rates at neighbouring Trusts, leading to higher staff turnover, and difficulty in retaining or attracting staff.

Government fiscal policies may lead to increase in fuel duty, causing a spike in the running-costs of the Ambulance fleet.

If the UK were to leave the EU, this may have a detrimental impact on the purchasing power of the NHS, and if UK departure leads to fragmentation of the EU, it is not possible to predict the impact this financial instability may have for the NHS.

S.P.s will insulate the Ambulance service against economic turbulence.

Social:

Society is becoming increasingly fragmented.

This may continue, since calls for amalgamation of the Health and Social Care budgets may lead to reduction in spending on social care as a proportion of national Gross Domestic Product.

Withdrawal from the EU may lead to a review of domiciliary agreements for British citizens living in Spain, France, Italy, and Greece, and force many of the 2.2 million Britons who currently live in the EU, to return home. Estimates of the number of British pensioners living in Spain vary from 125,000 to 300,000, and in the event of a loss of residency rights, these people would probably return to the UK; this would lead to pressure on the social, and health systems in Britain.

S.P.s would be at the forefront of delivering unscheduled care to this population.

Technological:

Technology is rapidly changing how we deliver healthcare.

Increased use of smartphones and cloud-based computing may allow remote health consultations to be conducted by the Independent sector, and possibly even Ambulance services.



!It should be expected that devices will become available in large shopping centres, which can provide health telemetry, analyse basic metabolic levels, and undertake basic body scans.

These may become alternatives for the worried-well, allowing them to avoid consulting their GP, and for busy GPs to send their patients to obtain a set of baseline results.

S.P.s can be utilised to help patients navigate this domain.

Legal:

Withdrawal from the EU will allow employers to abdicate from the European Working Time Directive, and other EU employment laws. It is not possible to predict how these may affect Ambulance services.

Environmental:

Climate change is having a dramatic effect on our weather, and this will continue during the next decade.

The Ambulance service must be prepared to operate in extreme weather, in particular floods, high winds, and heavy snow storms.

This requires a change in the traditional response-transport model of service delivery, since it will not always be possible to send a resource to reach a patient, let alone take them to hospital.

Heat waves may cause public health crises, especially among the elderly populations, and dehydration may increase morbidity and mortality in an otherwise healthy group of people.

The risk of parasitic disease, such as malaria and dengue is growing, with climate change and the migration of insects towards northern countries, such as the UK.

We have recent experience of pandemic viral illness, such as H5N1 influenza, and in the event of similar outbreaks, the Ambulance service will be at the forefront of delivering unscheduled care, and acting as gatekeepers for medical admission to hospital.

Food and water shortages, drought, and floods, in southern Europe, Asia and Africa, may result in large-scale migration of peoples into northern european countries, leading to strain on UK health and social care systems.

S.P.s are more mobile than traditional ambulances, and can be used to treat people in their own homes. They can provide mass immunisation clinics and health screening in shopping centres.



!S.P.s can buffer the Ambulance service from the impact of many of the emerging threats. Failure to invest, and engage with a S.P. programme will heighten vulnerability to new and emerging threats.

Moreover, S.P.s will drive SCAS forwards in promoting positive patient outcomes, delivering their core emergency service model, and improving efficiency.

SCAS will continue to be regarded as the regional employer of choice for student Paramedics, and existing high-calibre Paramedics seeking career progression.


the role of specialist paramedics in reforming emergency care

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