An Important Role of Paramedics in the National Health Service
The aim of this essay will be to explore the role of paramedics in relation to the national health service (NHS) unscheduled care agenda. It will also consider the scope of practice of paramedics within the multidisciplinary team and the key drivers for change within the paramedic profession, supported by evidence-based practice. A contemporary issue within the unscheduled care agenda will then be identified and its impact on paramedic practice and emergency care will be discussed.
Unscheduled care refers to care given to members of the public by health and social care professionals for injuries or illnesses which are unplanned. It is a fundamental part of the NHS and encompasses services such as urgent walk-in centers, minor injury units, and the emergency ambulance service. Unscheduled care services are accessible by anyone, at any time, and for paramedics, this often means working in environments which are unplanned and attending jobs which have not been pre-booked and can therefore be unpredictable.
The publication of the Five Year Forward View in 2014 included as one of its priorities the redesign of urgent and emergency care services to integrate A&E departments, GP out-of-hours services, urgent care centers, NHS 111, and ambulance services with the introduction of new models of care. This was followed in 2015 by the publication of Transforming Urgent and Emergency Care in the NHS in England which outlined how these new models of care would be achieved through a “fundamental shift in the way urgent and emergency care services are provided” to ensure a service which was safe, sustainable and provided consistently high-quality care. More recently, Lord Carter published his findings of a review into the operational productivity of the ten NHS ambulance trusts in England. This review considered best practices and variations in service delivery across England. The report concluded with nine recommendations aimed at improving patient care, efficiency, and support for frontline staff. These documents have been key drivers in the recent move to reform ambulance services to ensure they are able to meet increasing demand and deliver the highest quality care for patients.
The paramedic profession has changed considerably since it was first introduced in 1946. Paramedics were once considered as clinically-skilled emergency ambulance staff whose role was to transport seriously ill patients with a range of trauma and serious medical conditions speedily to the hospital, but the paramedic role has evolved to deal not only with acutely and chronically ill patients but also with lesser emergency situations which require an even greater set of skills. The Department of Health has recognized this change from the once traditional role of stabilizing patients before rapidly transporting them to the hospital to one where paramedics treat all urgent care cases. Paramedics are regulated through the HCPC who has rigorous standards regarding the skills and knowledge required to assess emergency situations and determine their severity and to be able to provide the necessary care appropriately and promptly. These developments have led to increased responsibility and the need to make complex decisions, as paramedics are often the first port of call for patients so their decisions and responses have a huge influence on each patient’s care pathway.
Today’s paramedics are autonomous practitioners meaning they have the authority to make decisions on the most appropriate care for patients using their clinical knowledge and skills. They are expected to have the clinical expertise to be able to provide care for all and the knowledge to work in all practice areas such as emergency care, acute care, and primary care. However, this does not mean they work in isolation, paramedics are an integral part of a multidisciplinary team and must have an understanding of the individual roles and responsibilities within the team and their scope of practice so that they can interact and communicate with them effectively and respect each team member’s roles and limitations. By working together, the wider team can maintain patient safety and positively influence the outcome and ensure they have access to a range of different care and health professionals. When the multidisciplinary team is integrated in this way, they can share ideas and bring a diverse amount of expertise and skills to caring for the patient which will increase the effectiveness of patient care. When team members work together they are also learning the importance of one another’s roles which brings a high level of respect for each other and gives an understanding of the roles of others within the health and social care genre. Sir Bruce Keogh, former Medical Director for the NHS in England, stated in his review of urgent and emergency care in 2013 that when NHS trustees collaborate together and health services integrate this has substantial benefits to patient outcomes.
The wider multidisciplinary team consists of any service that a paramedic may interact with when treating a patient, or any service they refer patients to for follow-up treatment and care. This could be staff in a hospital such as doctors, nurses, and health care assistants. It could also be other members of the health and social care team in non-emergency situations such as general practitioners (GPs) when patients need follow-up care or social care in situations where extra interventions are needed for the long-term care of patients. For this teamwork to be successful it is important to communicate with each other effectively and place the patient at the center of care by sharing knowledge, values, and principles to deliver exceptional care. When paramedics are sharing ideas with other members of the multidisciplinary team, they are also sharing responsibility and accountability, which should have positive results. The National Institute for Health and Care Excellence has identified cases of poor practice due to inadequacy in communication across the multidisciplinary team, leading to an emphasis on the importance of understanding the roles and responsibilities of one another to minimize the chances of adverse effects. Paramedics and the multidisciplinary team must feel comfortable raising concerns amongst each other, where appropriate. They must always support and encourage each other to be truthful and never discourage each other from speaking out when something goes wrong. This highlights the importance of effective communication across the multidisciplinary team, as after assessing the severity of the illness or situation, paramedics now have the option of referring non-emergency patients to other multidisciplinary teams within the community or even to keep patients within their own home if it is deemed appropriate.
The healthcare multidisciplinary team all have one common goal, which is to provide successful care to patients and their families. Achievement of this will be considerably improved by each team member being an expert in their own role and never exceeding their clinical knowledge, whilst also understanding each team member’s roles and being able to make and take decisions together. This highlights the importance of ensuring the right education and training is in place to equip paramedics with the necessary skills and knowledge for the job and to ensure ambulance teams contain the correct skill mix of staff. Whilst recognizing the transformation taking place within the ambulance service, Lord Carter included in his review of ambulance services in 2018 the need to adapt training to meet this change and ensure its clinical workforce is able to make autonomous clinical decisions. Also included was the need to continue with the recommendations of the paramedic evidence-based education project from 2014 that “HEE and AACE should standardize education and training nationally, including its funding, and enhance the level of clinical skill on the curriculum to meet changing demand”.
This directly impacts on the unscheduled care agenda which sees 10 million 999 calls every year, with unplanned assistance provided by paramedics for any condition and any severity. In addition to formal training, it is important that paramedics participate in continuous professional development to keep their knowledge and clinical skills up-to-date and ensure they are delivering care to patients which is of a high standard. It is an important part of paramedic practice and ensures paramedics are aware of any new guidelines or research in order to advance their clinical skills and increase awareness in current practice which will improve patient outcomes. This is vital at a time when healthcare is changing and supports Lord Carter’s view that mental health needs are just as important as physical health needs.
The often disorganized and chaotic environment in which paramedics work means they must be able to remain calm and to get some form of order within any given situation. This requires excellent on-scene management skills enabling them to resolve situations for the welfare of the patient. The way a scene is organized is crucial to the outcome of the patient being assessed and treated thoroughly, therefore paramedics need not only to be able to organize what is going on around them but also to make the patient’s needs the first priority and give them fast access to acute treatments. This requires good leadership skills, meaning they can quickly and confidently assess the situation efficiently and effectively. Paramedics who have good leadership skills can constructively assess a situation and plan a care package in the best interests of the patient, with a clear vision of the clinical route they intend to follow to ensure their wellbeing. They can collaborate well with others within the multidisciplinary team, which has beneficial effects for the patient and the care they receive as there is a team of people caring for them with an understanding of the role they have been given in pursuit of a successful outcome.
In 2017, 10 million 999 calls were made, with 90% of these being non-emergencies, highlighting the need for paramedics to have a broad range of skills to be able to treat patients appropriately in all situations. These skills are not just clinical, but also the skills needed for the evolving role of the paramedic as they attend to patients not only with physical healthcare needs but also an increasing number of those with mental health problems. Over the past 5 years, ambulance services have seen a 6% annual increase in demand, and a significant contributor to this has been in relation to those with mental health issues and minor illnesses and injuries. These figures show the extent to which calls to emergency services have risen in recent years.
Lord Carter also acknowledged the increased pressure on ambulance services by including a recommendation to reduce the number of patients being transferred to A&E departments unnecessarily in his review of the productivity of ambulance services across England. One way he suggests this might be achieved is by improving 111 services by giving its staff extensive training to be able to provide patients with the correct service to fit their needs. Currently, the 111 service has 500 medical professionals such as paramedics and nurses taking calls to provide ‘hear and treat’, where medical personnel determines the severity and condition of the patient over the telephone by asking them a number of questions to give a clinical assessment and determine if the patient needs an ambulance or referring to a more appropriate service. It has been found that this system has worked well within some ambulance trusts with fewer ambulances being dispatched. Lord Carter suggests this could significantly reduce avoidable conveyance even further if the additional medical staff is employed to undertake this role which in effect could reduce ambulance pressures. Similarly, Health Education England (HEE) also recognized this need for change with the introduction of a project which will see specialized and advanced paramedics' skills being utilized across a range of healthcare settings including primary care. This is with the intention of paramedics rotating through a range of community healthcare settings to utilize and enhance the skills and knowledge gained in each rotation and take it to the next one. The aim of this project is to reduce the number of 999 calls by giving definitive care in the community, where appropriate, delivered by a multidisciplinary team which includes advanced and specialized paramedics, reducing the ambulance service as being the first point of contact in non-emergency situations. These are just two examples of initiatives which, if implemented across all NHS ambulance trusts, have the potential to significantly reduce the number of inappropriate ambulance call-outs and to utilize the skills and experience of paramedics in the most efficient and effective way.
The crucial role of the paramedic in improving health outcomes for sick patients is clear from the evidence presented above, as is the need for the role to continue to develop to enable NHS ambulance services to introduce new models of care aimed at meeting increased demand and the changing needs of patients. The College of Paramedics recognizes one of these demands to be the increasing number of patients with a mental health illness on a paramedic’s caseload. One in four people experience mental health problems within their lifetime and the emergency services, particularly ambulance services, are often the first port of call for those in a crisis. Lord Carter’s report on unwarranted variation across NHS ambulance services in England recognized the importance of good mental health services but found that the productivity of them is somewhat poor. Factors contributing to this demand are patients who have mental health issues but are unsure of the various community services available to them and therefore feel the ambulance service is the only option. Another factor is the increase in time spent by paramedics handing a patient over at the hospital which, over the last ten years, and risen from an average of 27 minutes to today’s 35-minute average. This increase is seen in almost every mental health case attended by the ambulance service and is thought largely to be as a result of paramedics trying to get their patients the most appropriate support for their needs. The lack of 24/7 mental health crisis teams in England is a contributing factor in this as paramedics encounter problems handing patients over to these more appropriate services, as a result of which more time is spent on-scene time together with more ambulance conveyances. NHS England is committed to making such services more available by the summer of 2019, which will help in the appropriate triaging for ambulances services when they are presented with a mental health patient.
Dr. Paul Lelliott, Mental Health Chief Inspector of NHS hospitals, welcomed the increasingly positive attitudes towards mental health illness but highlighted that with this comes the need for an increase in mental health services. A survey was undertaken by the Care Quality Commission (CQC) in 2015 found that in adults with a mental health illness, only 14% felt they were given sufficient treatment when they were in a crisis situation and that their local community mental services were unable to offer a 24-hour service in a crisis. Due to this, patients have said that they have felt confused as to where to turn to in a mental health crisis and would ring the 999 emergency number.
Paramedics are increasingly providing pre-hospital psychological support due to the rising number of mental health calls and deficiencies in community mental health services. The Five Year Forward View for Mental Health set out plans to reduce the number of mental health calls attended by paramedics with a focus on expanding community mental health services and developing more talking therapies for common mental health disorders. This included a pilot project introduced in some parts of the country to integrate parts of the healthcare system through the introduction of ‘mental health vehicles’, with paramedics and mental health nurses working together to attend calls to patients in a mental health crisis and determine the best avenue of care for them. Both the paramedic and nurse assess the patient and jointly decide on the best intervention for them which may be referring them to a mental health team or, if necessary, by calling an ambulance. It is thought this could reduce mental health admissions to A&E annually by 28,000, this will not only improve patient outcomes but will also reduce pressure on the ambulance service. This highlights the important and evolving role of paramedics within the unscheduled care agenda, both as professional practitioners and as part of the wider multi-disciplinary team.
As the evidence outlined above demonstrates, the increased pressure now experienced by ambulance services, coupled with the findings and recommendations in Lord Carter’s report into unwarranted variation across ambulance services in England, places even greater responsibility on paramedics to be able to treat a wider group of patients with both physical and mental health needs. This requires a far broader skill set than was previously the case to ensure paramedics are equipped with the knowledge and understanding to make informed decisions about the most appropriate care package. This, together with increased availability and awareness of a wide range of integrated health and social care services across the community as an alternative to calling 999, will enable paramedics to focus their care on those who need it most whilst also contributing to meeting the challenges faced in delivering unscheduled care.
