-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
1/43
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!
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
2/43
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.
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
3/43
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.
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
4/43
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.
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
5/43
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!
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
6/43
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
7/43
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..???
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
8/43
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
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
9/43
Commonwealth Fund, 2014 17.7% ofUS GDP
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
10/43
*** ***
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.
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
11/43
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.
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
12/43
Ambulance services in UK
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
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
13/43
Ambulance services in UK
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.
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
14/43
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.
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
15/43
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.
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
16/43
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
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
17/43
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.
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
18/43
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
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
19/43
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
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
20/43
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.
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
21/43
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?
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
22/43
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
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
23/43
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!
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
24/43
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
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
25/43
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
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
26/43
SHAARC - patient satisfaction
Again, taken directly from SHAARCs own data - patient love the service.
The evidence
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
27/43
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
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
28/43
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
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
29/43
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
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
30/43
g
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
31/43
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
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
32/43
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
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
33/43
Case Study 2- Yorkshire
Yorkshire
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
34/43
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
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
35/43
Case Study 3- North Wales
North Wales
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
36/43
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
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
37/43
Case Study 4- Outer Hebrides
(Scotland)
Stornaway (Outer Hebrides)
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
38/43
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
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
39/43
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
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
40/43
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
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
41/43
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
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
42/43
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?
-
8/10/2019 Community Paramedics in the UK - presented at EMS World Expo 2014
43/43
@mmbangor
www.mountainmedicine.co.uk