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PurposeReview of major policy paper in relation to the ambulance service [in England] efficiency and productivity with reference to observed “unacceptable variation”.Design/methodology/approachCritical review of ambulance service/EMS policy approach in England.FindingsLord Carter’s review describes failings in performance of UK ambulance service/EMS. However, the identified failings are essentially a repetition of many almost identical similar findings. There is a tendency of policy in respect of the ambulance service in England, as exemplified by Lord Carter’s report to consider analysis of the problem a more significant task that actually addressing the shortcoming defined.Research limitations/implicationsThis viewpoint comment piece is produced as a viewpoint with all the attendant limitations implied in this approach. However, it has been produced from an informed position.Practical implicationsChallenge to current UK ambulance policy. Previous repetitious finding need to be addressed definitively.Social implicationsThe efficiency of UK ambulance services/EMS is seriously impaired, and indeed these findings have been acknowledge previously. However, little by way of active remediation has been attempted. The current approach as exemplified in Lord Carter's recent review appears to ensure that analysis of the long- standing problems that exist is sufficient and possible preferable to active remediation and improvement.Originality/valueNo previous critical review of this type has been attempted (as it would be career-limiting).

Around the world, the paramedic profession evolved from a small number of pilot programmes in the early 1970s, becoming a widespread trend in healthcare across much of the world. This case study focuses primarily on the UK, and England in particular, but also reflects on the international nature of the paramedic phenomenon, seeking to learn lessons from the successful features of individual programmes and approaches, in order that good practice can be promoted and shared. It also indentifies barriers to progress as well as opportunities. The purpose of all early paramedic initiatives described was to address the unmet needs of patients with serious injury and illness. Over the following decades, paramedics developed a clear identity which, in many countries, was professionally recognised and regulated. This trend can be termed ‘disruptive innovation’—something that creates a new market and value network while disrupting existing ones. The steep developmental trajectory of paramedics has not been mirrored by a comparable pace of reform and modernisation in all ambulance services or emergency medical systems, which in some cases have lagged behind and failed to adapt to significant changes in the pattern, quantity and epidemiological characteristics of patient demand. This has led to a mismatch between the capabilities offered by paramedics and the professional opportunities available to them in ambulance services, which have hampered practitioners' ability to make full use of their skills. This has often manifested as low levels of paramedic and other ambulance staff satisfaction, resulting in high rates of staff turnover in the UK and sometimes elsewhere. For many reasons, most evidently the reality of changing patient demand, an increasing number of ambulance services are gradually morphing into primarily urgent care organisations, de-emphasising the transport aspect of the service. Changes are therefore needed to its model of operation and to staff management and support.

The paramedic profession in the UK evolved from a small number of pilot programmes in the early 1970s that focused on training selected NHS ambulance crews in advanced resuscitation techniques. Similar initiatives occurred almost simultaneously in the United States, Australia, New Zealand and Canada. This case study focuses primarily on the UK, and England in particular. The purpose of the initiatives described was to address the unmet needs of patients with serious injury and illness. Over the following decades, paramedics developed a clear identity and became fully professionally recognised and regulated as allied health professionals, becoming an example of the phenomenon termed ‘disruptive Innovation’; this is something that creates a new market and value network while disrupting existing ones. The steep developmental trajectory of paramedics has not been mirrored by a comparable pace of reform and modernisation in NHS ambulance services which, in comparison, have lagged behind and also failed to adapt to significant changes in the pattern, quantity and epidemiological characteristics of patient demand. This has led to a mismatch between the capabilities offered by paramedics and the professional opportunities available to them in ambulance services, and hampered these practitioners' ability to make full use of their skills. The consequence of this has often manifested as low levels of paramedic and other ambulance staff satisfaction, resulting in high rates of staff turnover. Parallel developments in medical personnel deployment have increased the quantity of medical labour available to patients with serious or life-threatening injuries, with medical staff added to helicopter emergency medical crews. While many patients with urgent conditions would have benefited from general practitioners being available out of hours, proportionally fewer doctors are available to fulfil this role today and those that are attracted to working with the ambulance service often prefer to respond to cases involving major injury. For these reasons and given the reality that the ambulance service is morphing into primarily an urgent care organisation, de-emphasising the transport aspect of the service, changes are needed to its model of operation and to staff management and support.

Use of point-of-care testing (POCT) equipment by paramedics for triage may reduce unnecessary attendance in emergency departments and inconvenience to patients. A hospital pathology service and an ambulance trust wanted a system for safe and effective use of diagnostic devices by paramedics at the patient bedside. A suite of POCT devices to perform an expanded repertoire of pathology tests was provided, along with technology for electronic data capture, temperature control and monitoring, in a specially designed kit bag—the Labkit. Following a proof-of-concept phase, three Labkit bags were deployed as a pilot in rapid response vehicles and used by specialist paramedics in urgent and emergency care who had been trained in their use. The paramedics used the bag in 25% of patient interactions, typically three times every 24 hours. Having POCT results available at the time of paramedic assessment reduced conveyance to the emergency department by 21%. There was also a 10% rise in admission of patients where pathology results indicated problems that required urgent treatment which would otherwise have gone unnoticed. Overall, 31% of conveyance decisions were changed as a direct consequence of the Labkit results. Patients reported high levels of satisfaction, and paramedics said it added value in 97% of cases where it was used to support decision-making. Reliable, quality-assured POCT by paramedics has the potential to improve efficiency in the healthcare system and benefit patients.

BackgroundTRIM is an evaluation of the models used to triage and manage emergency ambulance service care for patients with suspected Covid-19 during the first wave of the pandemic in 2020. We aimed to understand experiences and concerns of clinical and managerial staff about implementation of triage protocols in call centre and on-scene.MethodsResearch paramedics in four study sites across England interviewed purposively selected stakeholders from ambulance services (call handlers, clinical advisors in call centres, clinicians providing emergency response, managers) and ED clinical staff from one hospital per site. Interviews (n=23) were conducted remotely using MS Teams, recorded, and transcribed in full. Analysis generated themes from the implicit and explicit ideas within participants’ accounts, following the six stages of analysis described by Braun and Clarke, conducted by a group of researchers and PPI partners working together.ResultsWe identified the following themes:Constantly changing guidelines– at some points, updates several times a dayThe ambulance service as part of the wider healthcare system- changes in other parts of the healthcare system left ambulance services as the default optionPeaks and troughs of demand- demand fluctuated greatly over time, with workload varying across the ambulance service, including an increased role for clinical advisorsA stretched system -resources to respond to patient demand were stretched thinner by staff sickness and isolation, longer job times, and increased handover delays at EDEmotional load of responding to the pandemic -particularly for call centre staffDoing the best they can in the face of uncertainty -in the face of a rapidly evolving situation unlike any which ambulance services had faced beforeDiscussionImplementing triage protocols in response to the Covid-19 pandemic was a complex and process which had to be actively managed by a range of front line staff, dealing with external pressures and a heavy emotional load.

Simulation is increasingly being utilised for pre-hospital professional education in Europe. To ensure this growth continues, it is important that experience is shared throughout Europe to help ‘spread the word’ and share examples of ‘best practice’. The Society in Europe for Simulation Applied to Medicine (SESAM) is an organisation which was set up to help facilitate and exchange knowledge about the use of simulation in medical (and paramedical) education throughout Europe. Previous SESAM annual meetings have not attracted significant numbers of delegates from the pre-hospital professions. This could be because previous programmes have not had much direct relevance for this audience. Working with the SESAM executive committee for the 2012 annual meeting in Stavanger, the authors helped co-ordinate a group of European pre-hospital simulation educationalists to create a programme of presentations and workshops designed to be directly relevant to a pre-hospital professional audience. Attendance overall for the 2012 annual meeting in Stavanger was significantly higher than in 2011 and it appears that more pre-hospital professionals attended in 2012 (but this cannot be supported in this paper). The increased emphasis placed on pre-hospital simulation in Stavanger helped create a specific SESAM supported network (Pre-Hospital Special Interest Group or PH-SIG) and this network will help share simulation ‘best practice’ amongst European pre-hospital professionals in the future.

Around the world the emergency medical services (EMS) profession has made tremendous strides over recent decades. We have become more professional, have a rapidly growing proportion of paramedics who are university qualified, our practice has become more evidence-based, and a growing number of paramedics are completing graduate-level programs and going on to conduct their own research. As a profession we have much to celebrate when we consider these accomplishments.In some ways we are also following in the footsteps of other professions that have developed along similar pathways. A century ago physicians were trained in hospital basements and practiced procedures that had little evidence to ensure their quality or effectiveness. A half century ago nurses were largely trained in hospital basements and again had little research to justify their practices. Members of those professions recognized that the only way out of the basement was through the university. Members of those and other health professions took it upon themselves to make a university degree a requirement to enter practice. They recognized that a university degree was a key requirement of professionalism. Today we could not imagine a physician without a university degree and almost all new nurses and allied health professionals are now graduates of university programs.

As the financial recession bites ever deeper, it becomes even more important to know how to put our personal finances in order. Andy Newton and Karin Kjellberg report on some recent initiatives

As 2014 draws to a close, Andy Newton, chair, College of Paramedics, looks at another notable year for the profession, commenting on the developments arising from the Urgent and Emergency Care Review, progress that is being made in paramedic independent prescribing, and the need for the College to develop a Clinical Advisory Committee.

The Journal of Paramedic Practice was saddened to learn of the death of editorial board member Dr Mark Bloch. Prof Andy Newton, chair of the College of Paramedics, reflects on a great clinician, educator and proponant of the paramedic profession.