Emergency medical personnel in the United Kingdom
Emergency medical personnel in the United Kingdom are people engaged in the provision of emergency medical services and this includes paramedics, emergency medical technicians and emergency care assistants. 'Paramedic' is a protected title, strictly regulated by the Health and Care Professions Council, although there is tendency for the public to use this term when referring to any member of ambulance staff.
Emergency medical personnel most often work in an ambulance alongside another member of staff. Typically, an ambulance will be crewed by either a paramedic with another crew member (technician or emergency care assistant), two technicians or a technician with an emergency support worker. No NHS ambulance trust in the country currently offers a paramedic on every ambulance. Further to this ambulance staff at technician or paramedic grade may drive solo responder rapid response vehicles (RRV) after completion of a two-day driving course to familiarise them with the RRV's.
The majority of emergency medical personnel are employed by the public ambulance services of the National Health Service, although many are also employed by private ambulance companies and the two voluntary aid societies (British Red Cross and St. John Ambulance), either providing private services such as event medical cover, or providing support to the NHS ambulance services under contract.
As part of a cost-saving exercise NHS is in the process of phasing out the ambulance technician/emergency medical technician (Band 4 on the Agenda for Change) role from the services and replacing it with the Emergency Care Support Worker or Emergency Care Assistant roles (Band 3 on the A4C), and most services are no longer training staff at technician level.
Levels of staff
The specific skills performed by each group of emergency medical personnel will be dictated by a combination of training, the legal framework and the policies of their employer. The most homogenous group is the paramedics, as the framework of practice is largely dictated by their status as registered healthcare professionals, although local policy differences are still in effect.
The other grades, including technicians, support workers and emergency care assistants do not have legal status as health care professionals, and their skill sets and permitted interventions are governed by their employer. This has led to significant differences in training and skill between staff in different services with the same or similar job titles, especially within the private sector.
There are standards in place for all ambulance staff, written by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC), which is a body made up of representatives from a number of expert organisations including medical, nursing, allied health professional and ambulance communities. JRCALC publishes guidance based on the principles of evidence-based medicine and best practice, but adherence to JRCALC is not mandatory, and organisations and individuals can choose to deviate from it.
All ambulances services, as well as the provision of treatment by health care professionals (paramedics), whether public, private or voluntary are regulated by the Care Quality Commission, and they control the operation of all services.
Paramedics take potentially life-saving decisions about treatment needed and, if appropriate, will then administer the treatment. They work utilising their own clinical knowledge and, as registered health care professionals, they carry full responsibility for their actions.
The original route to becoming a paramedic was to join an NHS ambulance service and work towards the position from non-emergency patient transport roles through to the emergency division as a technician, and after a period of time, it was possible to internally apply for paramedic training.
Although offered at ambulance service training departments, the curriculum and certification were initially awarded by the NHS Training Authority, NHSTA, (which became the NHS Training Directorate and then the NHS Training Division, which in turn became the Institute of Health and Care Development (a Next-Steps organisation working in partnership with the Open University). The Institute was acquired by Edexcel examination board in 1998 and re-badged as IHCD. Edexcel (which also owned the BTEC brand) was acquired by Pearson in 2004. Pearson continued to operate the IHCD 'brand' until 2016. This 'ih-house' paramedic training was a modular programme, usually between 10 to 12 weeks followed by time spent in a hospital emergency department, coronary care centre and operating theatre, assisting the anaesthetist and performing airway management techniques such as endotracheal intubation. Completion of the course allowed the paramedic to register with the Council for Professions Supplementary to Medicine (CPSM), which was superseded by the Health and Care Professions Council (HCPC), a Regulatory body.
Prior to regulation and closure of the title, the term "paramedic" was used by a variety of people with varying levels of ability. Paramedics could apply to register via a grandfather scheme which ended in 2007.
Eventually the IHCD began to accredit a few non-NHS training establishments, allowing them to teach their curriculum. In the mid 1990s some universities started to offer para-medicine diplomas and degrees, in association with local Ambulance Trusts. By necessity these included all of the practical skills found in the IHCD curriculum and allowed applicants to apply for registration with the HPC.
Amongst the professionals regulated by the Health and Care Professions Council, paramedicine was the only one not to have an extant professional body, until the British Paramedic Association was formed in 2001. This later became the College of Paramedics and now acts as a representative organisation for the paramedic profession. Unlike some other professions, membership of the college is not mandatory in order to be a registered paramedic.
There has been expansion of allied health professions who are regulated, leading to the regulatory body being re-established as the Health and Care Professions Council (HCPC). In 2010, the IHCD route (which by now was jointly badged with BTEC) which as a route to becoming a registered paramedic was largely deprecated, although is still recognised by the HCPC, and anyone successfully completing the BTEC Level 4 qualification is entitled to register as a paramedic. This leaves the university route as the primary pathway for new paramedics, with a number of universities offering qualifications which can lead to registration, both as full-time courses for new students (although they must also be accepted for the practical element of the training by an ambulance service) and part-time courses for existing ambulance staff.
Standards of proficiency which every paramedic must meet in order to become registered were first issued in 2003, with the most recent revision issued by HCPC in September 2014.
Grades of Paramedic Roles
Although 'paramedic' is the only protected title for the profession, some paramedics undertake further training or higher educational programs in order to work as advanced practitioners. These may be known as community paramedics, paramedic practitioners, critical care paramedics and emergency care practitioners.
Across the country the scope of practice of each advanced paramedic varies, however many can be found offering unscheduled care in situations where the patient does not need to travel to hospital, when the practitioner decides care can be provided without needing to see a GP. Some of these roles are very similar to those carried out by specialist nurses, thus, blurring professional boundaries. Some roles like advanced practitioner courses and the emergency care practitioner courses are offered to both professions as interchangeable skills are present.
- Paramedic (BSc (Hons))
- Specialist Paramedic (PgC/PGDip)
- Advanced Paramedic (MSc)
- Consultant Paramedic / Director of Services (PhD)
Ambulance technicians, or emergency medical technicians form a large proportion of the workforce in emergency medical care, although the title lacks formal definition or protection, and there is no restriction who can use it. Generally, ambulance technicians can work either autonomously, making their own clinical decisions within their training and remit, or as assistants to a higher skilled paramedic.
To reduce costs, many ambulance organisations have tried to reduce the number of ambulance technicians, increasing the number of Emergency Care Support Worker or Emergency Care Assistants. Many of England's ambulance trusts were looking to stop training staff at technician level, although large numbers remain operational.
Technicians within the ambulance services generally completed the IHCD (formerly the Institute of Health and Care Development) ambulance technician award (awarded by Edexcel, part of Pearson) which is a course lasting around 12 weeks. A 3 week emergency driving programme was available to accompany the technician award, which was titled Ambulance Aid and Driving. This qualified the person as a trainee technician, and after a period (usually around a year) on the road, a plenary examination is taken to complete the training and become a qualified ambulance technician (QAT). Whilst now deprecated by the NHS services, the qualification is still available as a BTEC level 4, and can be trained by the ambulance services or a number of private training providers. The IHCD emergency driving programme was certificated as a 'stand-alone' qualification.
Alternative qualifications exist, especially in the private sector, although there is no set standard between qualifications. Other qualifications include the Emergency Care Technician award from the Royal College of Surgeons of Edinburgh and numerous in-house qualification courses offered by individual providers.
Emergency care assistants
Emergency care assistants (sometimes called emergency care support workers) are trained to a basic level, and do not have clinical autonomy, relying on a paramedic or technician to make clinical decisions. Their role varies widely between services, but they are normally expected to perform driving duties, and to assist the clinician in their work.
Paramedics or pre-hospital care providers in the UK may also use other titles such as:
- Critical Care Paramedic
- HEMS Paramedic (Helicopter Emergency Medical Service)
- Flight Paramedic
- USAR Paramedic - Urban Search and Rescue
- HART Paramedic - Hazardous Area Response Team
- Paramedic Lecturer Practitioner
Scope of practice
- Activated charcoal
- Dicobalt edetate.
- Glucose 5%
- Glucose 10%
- Influenza Vaccine
- Ipratropium Bromide
- Morphine Sulphate
- Nalbuphine hydrochloride
- Naloxone hydrochloride
- Paracetamol (PO & IV)
- Sodium chloride
- Sodium lactate
- Sodium thiosulphate
- Tenecteplase / Reteplase
- Tranexamic acid
A number of other drugs are given by Paramedics with advanced training, either by utilising a Patient Group Direction (PGD) or simply because they are classified as Over the Counter (OTC) medicines which are available to anyone.
- Chlorphenamine maleate tablets 2 mg/5ml
- Chlorphenamine maleate tablets 4 mg
- Chlorphenicol 1% eye ointment 4g tube
- Co-amoxiclav 125/31 suspension
- Co-amoxiclav 250/62 suspension
- Co-amoxiclav 375 mg tablets*
- Co-codamol 8/500 mg tablet
- Co-codamol 30/500 mg tablet
- Codeine phosphate
- Diazepam 2 mg tablet
- Diazepam (IV sedation)
- Diclofenac Suppository
- Diclofenac IV
- Erythromycin antibiotic 250 mg
- Flucloxacillin antibiotic 250 mg capsules
- Flucloxacillin antibiotic syrup 125 mg/5ml
- Flucloxacillin antibiotic syrup 250 mg/5ml
- Fluroescein 1% eye drops minims
- Ibuprofen suspension 100 mg/5ml
- Ibuprofen tablets 200 mg
- Instillagel Lidnocaine (pre-filled syringe)
- Lidnocaine Hydrochloride
- Metronidazole 200 mg tablet
- Metronidazole 400 mg tablet
- Morphine Sulphate (IM)
- Oxybuprocaine 0.4% eye drops minims
- Paracetamol tablets 500 mg
- Prochlorperazine injection
Procedures carried out by paramedics include:
- Endotracheal intubation
- Needle Thoracentesis
- Needle Cricothyrotomy
- Transcutaneous pacing
- Intravenous Cannulation
- Intraosseous Cannulation
- Full Autonomous Cardiac Defibrillation
- Cardiac auscultation
- Autonomous thrombolysis
Paramedics and EMTs in some parts of the country are now able to diagnose ST-Elevation Myocardial infarction (heart attack) and bypass the closest Accident and Emergency Department to transport the patient to a hospital able to provide percutaneous coronary intervention.
In some parts of the country paramedics and EMTs are able to bypass Accident and Emergency Departments for specialist units with patients suffering from a stroke. Currently the FAST-Test is used to determine a patient's suitability to be transported directly to a specialist unit. On admission to the specialist hospital the patient should rapidly receive a CT scan of their head, to guide treatment.
There is currently no requirement for 'blue light' drivers to undergo any additional training to claim exemptions such as use of blue lights, exceeding the speed limit, or passing through red traffic lights. However, the majority of NHS, private, and voluntary providers who undertake emergency drives do provide extra training in the form of IHCD D1 (Non emergency driving) and ICHD D2 (Emergency driving) or a recognised BTEC Level 2 in Emergency Response Driving. In spite of this, road traffic collisions do occasionally occur which involve ambulances and other road users.
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