community paramedics in the uk - presented at ems world expo 2014

8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014

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Dr Linda Dykes @mmbangor

Consultant in Emergency Medicine,

Ysbyty Gwynedd (Bangor, Wales)

Honorary Assistant Medical Director, Welsh Ambulance

Community Paramedicine

in the UKAs presented at the 2014 EMS World Expo in Nashville TN,

but without the pretty pictures!


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So, this is where Im from.Im English, but I live and work in Wales which is the country in red. Its part of the United Kingdom, but we have a partly devolved government, including adi"erent political party running the NHS to that in England.


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Menai Bridge (1826) Menai Straits & Llyn Peninsula

Snowdonia National ParkView from hospital helipad

Caernarfon Castle (1283)

Snowdonia National Park from Anglesey

As you can see, North West Wales is both very beautiful and very historic!The Menai Suspension Bridge, built by Telford in 1826, is the oldest suspension bridge in the world and I drive over it every day to work. It took 7 years tobuild.


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Some scene setting

The National Health Service (NHS)

Paramedics in the UK - how it works

Whats driving the development ofCommunity Paramedics in the UK?

What UK community paramedics do & whothey are

A tour of some UK schemes

What the literature says: safety, quality,acceptability & cost

So, here is our plan for this session. In order to take an informed perspective on community paramedicine in the UK, and in particular to make best use of any literature about community paramedics & paramedicpractitioners emerging from the UK, you need to have a bit of an understanding about the NHS, and how paramedics in the UK are trained and regulated. Im then going to take you through some schemes runningin the UK, and wrap up with a quick look at what the literature says about our version of what youd recognise as community paramedics.

Im hoping you will end up understanding a little more about how both normal and extended-scope paramedics fit into the UK NHS, and also gain some ideas of areas of community paramedic practice that youmay wish to explore.

For our tour around Britain, using four regions as examples, I also asked those I spoke to to share with me their caveats and cautions and things they would do di"erently if they were doing it all over again fromthe start.


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Im not going to talkabout the money

What Im not going to do in this session is speculate how on earth the USA might untangle the money flow in the EMS system. I understand that ambulanceservices earn their income only by conveying to hospital, and it make take state or national legislation to break that link. But Im definitely not the personto speculate on what solutions in this country might be - there are sessions later in the conference if you are interested in this aspect!


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Founded 1948

Funded by taxation, free at point of use

Universal coverage

7.8% of UK GDP (allhealth spending = 9.4% GDP)

France 11.6%, Germany 11.3%, Canada 11.2%

and the USA..???


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Everyone has a General Practitioner (GP) -i.e. family physician

Primary Care Gatekeeper roleDistrict nurses

Palliative care services

Various specialist community schemes(COPD, heart failure etc)

(Community hospitals)

Community provision


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Commonwealth Fund, 2014 17.7% ofUS GDP


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*** ***

I cant credit this meme, although it has been widely circulated so I hope the original creator doesnt mind.I was specifically told I must not use rude words with an American audience, so I have covered up the expletives, but you get the idea most of us workingin the NHS are intensely proud of it, if we had a written constituition, free-at-point-of-need healthcare would be in there but it can also be a veryfrustrating organisation to work within, especially in this era of financial austerity.


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1867 - London (fever& smallpox)

1894 - ambulance tram

Ambulance services in UK

1946 - LocalAuthorities (nothealth) wereresponsible fortransport to hospital

So, lets bring you up to speed on how ambulance services and paramedics work in the UK. We may have built the first suspension bridge in the world, butwe didnt build the first ambulance service - that was here in the USA, in Cincinnati Ohio in 1865.


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1968 - first clinical training

Early 1970s - first paramedics

1974 - Ambulances servicesbrought into NHS

1986 - National Paramedicprogramme

1990 - Paramedic on everyambulance

Moving forward, these were the landmarks in the development of the paramedic profession in the UK. Until 1968, there really were only ambulance drivers, so the start of the Miller Course was a big thing - a 6 week clinicaltraining programme. The first paramedics emerged in several areas of the UK in 1971, with one example being the cardiac paramedics in Brighton, who could defibrillate, and use four drugs - atropine, lidocaine, adrenaline(intracardiac) and dexamethasone (if ROSC but remained unconscious).

By the mid 1980s, each ambulance service was training their own paramedics, and a typical programme would be about 360 hours of clinical education - not a lot in comparison to todays university courses.

Photo courtesy Rhydian Wyn Owen


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2000 - First JRCALC guidelines

2001 - HCPC Registration

Switch to university (HEI) training

Now for some acronyms

JRCALC is the Joint Royal College Ambulance Liaison Committee, and they produce clinical guidelines for paramedic, which most UK ambulance services choose to use. I suppose the nearest equivalent would be if your Gatheringof Eagles came up with a set of guidelines to use across the USA. The reason Im telling you about JRCALC is because its a marker of some fundamental di"erences between US and UK paramedicine you have PROTOCOLS, anduse quite a bit of medical control, whereas my UK paramedic colleagues use professional GUIDELINES, from which they can use their discretion and deviate from if they believe it is in the patients best interests to do so.

HCPC is the Health Care Professions Council, a statutory body who regulate a wide variety of healthcare professions from art therapists and osteopaths to dieticians. Basically just about anyone who isnt a doctor, dentist, nurseor midwife. Thus, UK paramedics all have to be HCPC registered to be able to work as a paramedic in the UK, and the HCPC regulate the profession, including taking disciplinary action if someone has been naughty.

So, you can see how theres possibly more uniformity in training and skills, and certainly more uniformity in clinical practice in the UK.

But theres one MASSIVE di"erence that you need to bear in mind too the number of ambulance services.


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15,276 ambulance services

serving 317 million people

You guys do seem to like your plethora of ambulance services. this comes out as a mean of 21,000 people per ambulance service.


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14 ambulance services

serving64 millionpeople

Clearly the NHS believes in economies of scale, because our ambulance services look after a mean of 4.6 million people each, although theres still wide variation - our tiniest ambulance service is the Isle of Wight with only140,000 people, whereas London is the busiest ambulance service in the world.

Until about 20 years ago, ambulances tended to be arranged on a county basis, but then merger after merger happened until in 2006, there were only 15 left. A further merger in 2012 left us with a grand total of 14 11 inEngland, and one each in Scotland, Wales and Northern Ireland.


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What's driving community paramedicine?

Rising demand on ambulance services

1994/5 to 2012/13 - 248%growth in call numbers

Ageing populationGP services under strain

ED crowding & access block

Delayed handovers at hospital

Reduced asset availability


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but more importantly

Patients come to harm. This is what the media have had to say about the NHS in Wales recently. It makes sad reading, but fundamentally we are working inan unsustainable service with unsustainable rising demand in the UK, just as you are in the US.


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So, what do communityparamedics do in the UK?

Three main models:

1. Working as part of Primary Care2. Admission avoidance

3. See & treat at scene

Some work in Minor Injuries Units

Do not generally check up on people post discharge, or visit familiar faces.However, some work in specific schemes such as falls or geriatric assessment schemes


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Example scope of practice

Trips and falls

Minor wounds (exceptfacial triangle, palmar orglass injuries)

Minor head injuries (excepton anticoagulants)

Corneal abrasions or minoreye infection/injury

Dental abscess/pain

Soft tissue neck injuries

Mild/moderate pain control

?UTI

Extremity injuries notrequiring x-rays

Chest, skin & ENT infectionsnot requiring admission

Some abdo pain (e.g.gastroenteritis, biliary colic)

Social care & safeguardingadvice

Urinary catheter issues

Mental health problems

Mild/moderate allergicreactions

Heres our first example - a list of additional skills handled by one community paramedic service in the UK - this one is from South West England

A h l


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Another example

Back pain - 1%

Unwell - 11%

Other - 12%DIB - 2%

Falls - 74%

Originally set up to deal with elderly fallers

And heres a second example - a di"erent emphasis of cases, as this scheme (SHAARC in Essex) was originally set up to handle elderly fallers.


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A plethora of titles

I have heard it said that if you see one ambulance service in the USA, youve seen one ambulance service. Well this is the right royal mess we managed toget into regarding terminology with only 14 ambulance services so I I dread to think what you manage here in the USA with 15000!

Since the development of so-called Paramedic Practitioner roles in the UK about 10 year ago, there has been a plethora of job titles, and no uniformity injob title between one ambulance service and another. So, you might have an Emergency Care Practitioner in Eastern England and an Advanced ParamedicPractitioner in another, whilst a third would just call them paramedic practitioners.

Clearly theres two problems here firstly, ECP doesnt have paramedic in the title (which was deliberate in some places, because nurses do the role tooin some services) but most obviously, this is the NHS

Who are they?


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Who are they?

BSc + extra training/skills

5

6

7

8

Band

MSc

BSc/foundation degree

4

2

1

and bearing in mind this is the country that likes uniformity in the health services to such an extent we only have 14 ambulance services, the UK College of Paramedics Career Frameworkdevised this structure for job titles within paramedic profession to try to clean things up a bit. As you can see, out goes anything with the word Practitioner!

Extra training at each level


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Extra training at each level

Level 7 clinical skillsand diagnostics

10 additional drugsincluding antibioticand analgesia

Wound closureincluding suturing

MSc in AdvancedClinical Practice

Active in all four pillars

of advanced practice

And at this, my friends, my courage failed me. Diving into the murky world of educable in the higher education institute world of allied health professionalsleft me wanting to flee. But basically, you get promoted to a Specialist Paramedic - thats a Band 6 - once your clinical skills and diagnostic synthesis havebeen upgraded, yourve learned a load more pharmacology and some new tricks to your toolbox.

and the crunch point pay!


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and the crunch point pay!

43k ($69k)

5

6

7

8

Band

48-56k ($77-89k)

34k ($54k)

Talking to a new friend and fellow EMS World Expo delegate in the bar last night made be realise how much better paid UK paramedics are compared to USones - it seems to be about 50% more pay and only a 37.5-hour week, which seems much more civilised than having to work multiple jobs to earn areasonable wage.

What does it cost - Example


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What does it cost - ExampleSoutheast Hospital Admission Avoidance &

Referral Care Service (SHAARC) - Essex

252 ($403) per encounter cf.229 ($366) for usual

ambulanceED visits = 107/$171

Admission avoided =705/$1128 saving

Non-conveyance rate now83% (cf. 59% usually)

Saved 167k/$267k in 2012/13

So South East Essex, just north of London, have had a scheme called SHAARC running since 2010. I lifted this data from their commissioners report, whichis freely available on the internet.

The group commissioning NHS services in that region have to pay the hospital 107/$171 for each ED attender and an average of 705/$1128 peradmission.

SHAARC currently manages to attend about 65% of total demand, if the service were expanded to cope with all anticipated cases suitable, savingsestimated to be 240k/$384k per annum and save 850 attendences/year from the local ED.

As of 2013, they commented they had had no incidents, complaints or near misses

SHAARC i i f i


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SHAARC - patient satisfaction

Again, taken directly from SHAARCs own data - patient love the service.

The evidence


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The evidence

Building the evidence basein pre-hospital urgent andemergency care

A review of research evidenceand priorities for future research

by the University of SheffieldMedical Care Research Unit

Research funded by the Department of Health Policy Research Programme

The English Department of Health is very interested in the potential scope of community paramedics to support the UK and has commissioned work toassess their utility. You can find the full report here:https://www.gov.uk/government/publications/building-the-evidence-base-in-pre-hospital-urgent-and-emergency-care-a-review-of-research-evidence-and-priorities-for-future-research

The evidence - non transport


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The evidence non transport

Mixed evidence as to how well paramedics canidentify patients who dont need to go to hospital(Schmidt 2000 & 2006)

Guidelines/protocolsHelp, but need to be focussed or may be mis-used(Gray 2007, UK)

Dont necessarily increase proportion of patientsleft at home, but increase job cycle time (Snooks2004, UK)

Schmidt in 2000, a a 1300-patient what if study, asked EMTs to categories patients as needs ambulance, needs ED but not ambulance, needs primarycare provider, or treat & release. Between 3% and 11% of patins categorised as not needing transportation had critical events

Schmidt in 2006 looked back at 1501 patients - transported and non-transported - and found that older patients were more likely to be transported, aswere patients with CVS, respiratory & GI complaints plus renal obstetric and haematology/oncology px. Mortality 4.9% in transported and 1% in nontransported.

Gray in 2007 (UK) devised non-transportation guidelines for four conditions: no injury, minor limb injury, resolved hypo, resolved fit. Reviewed after 4months. 39.5% of applications of protocol deemed inappropriate.

Snooks (2004) looked at 23 treat-and-refer protocols for non serious 999 calls. 251 interventions versus 537 controls and no di"erence in proportion leftat home (37.1 vs 58%). Three cases in each group were admitted within 14 days and judged to have required transport. Patients valued the advice givenabout self help, but some safety issues identified and decision support & training need further refinement.

The evidence - Paramedic Practitioners


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PPs attending elderly patients within their scopeof practice (Mason 2007, UK)

Less likely to attend ED (62.6% versus 87.5%)

Less likely to require admission (40.4% vs. 46.5%)

Higher satisfaction in the PP group

PPs can safely reduce ED visits & admissions inelderly patients with falls and breathingdifficulties (Gray 2008, UK)

PPs cost more than usual care but still cheaper forhealth economy overall (Widiatmoko 2008, UK)

Sue Mason - cluster randomised trial, 1549 pc in intervention group and 1469 in control group (standard paramedic crew)

Gray 2008: For DIB, 36% attended ED vs 76% historical controls For fallers, 26% vs 51%Estimated admission reduction rate for PP calls of 46% for breathing di#culties and 56% for falls

Widiatmoko 2008, 286/$458 extra to prevent a conveyance

Lets go on tour


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g


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Case Study 1- East Anglia

Im going to take you on a mini-tour of some far-flung parts of the UK, to show you some examples of how Community Paramedics are being used bydi"erent and diverse ambulance services. Because we are looking at making greater use of Community Paramedics in North Wales, Ive been phoning roundcontacts in various ambulance services to ask them what happens in their patch. I also asked them to tell me what theyd do di"erently if they were settingit up all over again!

East Anglia


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East Anglia

Started with band 5 paramedics in Primary Care(but available for red calls)

Then developed Emergency Care Practitioner

university courseNow used in three ways:

Urban areas - admission avoidance

Rural areas - broader scope inc minor illness/injury

Work in GP Out-of-Hours (50% of that servicesmanpower)

Primary care paramedics started first - health screening and eyes and ears at home visits.Good model - got patients seen and werent thrown by big sickECP programme initially struggled to find suitable GP placementsLong development essential - takes 18 to 24 months after qualification to build up experience for GPOOH


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Case Study 2- Yorkshire

Yorkshire


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ECPs (band 7)

in control room spotting cases for other ECPs toattend (elderly patients, DIB).

Also advice for band 5/6 colleagues

Cost effective (commissioners insist on the service)

Paramedic practitioners (Band 6)

6-week additional course

Prime role is to refer to GPs

? this role now partially overtaken by referralpathways


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Case Study 3- North Wales

North Wales


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North Wales

Advanced Paramedic Practitioners (Band 6/7)

3 qualified, approx. 10 in training

MSc course & new Clinical Supervision Group

Have a good record for safe discharging from scene butNot reached critical mass in numbers

Keep getting used as a normal rapid response vehicle or forcover

Band 5 paramedics wont refer to them

Dont have any written scope of practice


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Case Study 4- Outer Hebrides

(Scotland)

Stornaway (Outer Hebrides)


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Stornaway (Outer Hebrides)

Band 6 Paramedic shared between Western IslesHealth Board & Scottish ambulance

Undertook an Unscheduled Care Course atPaisley university (consisting of modules inclinical examination, acute illness, minor injuries)

Home visits on behalf of GPs

50-60% discharge from scene

GP supervisor discusses about 30% of his cases

Lessons shared by colleagues


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y gwhove done it

Select paramedics who can survive uncertainty

Set up a suitable university course locally

Consider rotational posts (ambulance, MIU & GP)

Problems keeping competencies up (woundclosure, catheters)

Skilled people-management required: make themwork up to their skills/training (or theyll getpicky and stagnate)

When I was phoning round colleagues elsewhere in the UK, I asked them to tell me - warts and all - what di#culties they had encountered as well as whatbenefits. Here are some of their thoughts on the challenges..

Conclusion


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Community paramedics in UK are useful, cost-effective, and safe

Patients love them

Still multiple challenges:

Tasking appropriately/ can you keep off main shift plot?Keeping skills current

Not understood by colleagues & other agencies

Scope to expand preventative role in UK

Most schemes dont finish where theyd plannedto - local adaptation essential

Acknowledgments


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Alan Murray (Access 24)

Sarah Black & Matthew Davis (SWAST)

Andy Jones (WAST, CoP)

Jim Walmsley (SE Coast Ambulance)

Janette Turner (ScHARR)

Dr Brian Michie (GP, Stornaway)

Dr Scott Turner (East of England Ambulance)

Dr Alison Walker (Yorkshire Ambulance)

+ the UK EMS community on Twitter!

References


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Schmidt, T. A., Atcheson, R., et al. (2000). Evaluation of protocols allowing Emergency Medical Technicians to determine need for

treatment and transport.Academic Emergency Medicine, 7(6), 663669

Schmidt, M. J., Handel, D., et al. (2006). Evaluating an emergency medical services-initiated nontransport system. Prehospital Emergency

Care, 10(3), 390393

Gray, J. T. and Wardrope, J. (2007). Introduction of non-transport guidelines into an ambulance service: a retrospective review.Emergency

Medicine Journal, 24(10), 727729

Snooks, H., Kearlsey, N., et al. (2004). Towards primary care for non-serious 999 callers: results of a controlled study of Treat and Refer

protocols for ambulance crews. Quality & Safety in Health Care, 13, 435443

Mason, S., Knowles, E., et al. (2007). Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community:

cluster randomised controlled trial.British Medical Journal, 335(7626), 919

Gray, J. T. and Walker, A. (2008). Avoiding admissions from the ambulance service: a review of elderly patients with falls and patients with

breathing difficulties seen by emergency care practitioners in South Yorkshire.Emergency Medicine Journal, 25(3), 168171

Widiatmoko, D., Machen, I., et al. (2008). Developing a new response to non-urgent emergency calls: evaluation a nurse and paramedic

partnership intervention. Primary Health Care Research & Development, 9, 183190

Questions?


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[email protected]

@mmbangor

www.mountainmedicine.co.uk

community paramedics in the uk - presented at ems world expo 2014

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