Ambulance Service 2020

603 Pages·2014·8.73 MB·English

Ambulance Service 2030:

The Future of Paramedics

Andy Newton

Submitted to the University of Hertfordshire in partial
fulfilment of the requirements of the degree of PhD

November 2013
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Abstract
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Some innovations are termed ‘disruptive’, a designation that is normally applied to
technology; examples include computers, digital cameras, and mobile phones. The
term can also be applied to groups of workers, particularly if they are able to offer
specific technical capabilities within a market at lower cost, but broadly equal and
effective to that offered by traditional products or services.
Paramedics could be described in this way and are a newly professionalised group,
with distinctive capabilities in terms of responding to the needs of not just the acutely
ill and injured, but increasingly those patients with undifferentiated non-life-
threatening conditions, which increasingly make up the bulk of 999 call demand.
The key to their transition from an artisan, skilled worker to professional status is the
acquisition of certain ‘hallmarks’. Perhaps the most important of these is the
completion of more prolonged education that affords the opportunity to graduate with
enhanced decision-making and other clinical skills in order to meet the needs of the
full spectrum of patients in the pre-hospital setting.
Paramedics were surveyed to determine how they rated their ‘traditional’ preparation
and to establish what their attitudes were to a more educationally based approach.
Paramedics themselves proved to be realistic regarding shortcomings in established
training and education systems, while also being strongly motivated to learn more

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within a higher education setting, particularly if this additional effort would result in
being able to offer a wider range of care to their patients.
During the study, major changes in the health care environment and the role of the
Ambulance Service took place, leading to a requirement to undertake a second
phase of research. This took the form of ‘Horizon Scanning’ in an attempt to detect
‘signals’, themes and trends in relation to newly emerging ‘competitors’ to the
paramedic role. These included nursing, new practitioners and most critically, the
rapidly emerging medical sub-speciality of pre-hospital care, staffed by medical
personnel on a pattern found specifically in some European countries, sometimes
termed the ‘Franco-German’ model/System (FGM/S). Hitherto, the model of
provision in the UK had followed the ‘Anglo-American’ model/System (AAM/S),
approach, with paramedics providing direct patient care in the field and medical staff
largely involved in medical oversight, teaching, clinical governance and other higher
level roles.
As part of this research, the evidence base for change was examined and
consideration given to the factors that might help clarify what the likely situation
could be in 2030 in respect of ambulance services, pre-hospital care and
paramedics. This future is uncertain, but factors have been identified that would
militate in favour of one or other model prevailing, with close links established
between educational preparation, system design, career structure and the
continuance of the professionalisation process favouring paramedic progression.
However, other factors, most specifically professional power, the absence of a clear

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evidence base and an apparent reluctance to clearly acknowledge this in some
respects, lead to the conclusion that the future of pre-hospital care remains uncertain
and contested, but also potentially amenable to a well-directed influencing strategy.

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Acknowledgements
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I would like to express my sincere gratitude to both my supervisors, Professor Barry
Hunt and Professor Julia Williams, for their contribution and assistance in the work
presented in this thesis. I wish also to express gratitude to each of the ambulance
services and their staff that cooperated in making this study possible.
I would also like to thank my wife and my children for their support and their
encouragement and for allowing me to take much precious time out of our private
lives.
Thanks are also due to South East Coast Ambulance Service NHS Trust (SECAmb)
and my colleagues who helped and encouraged me with the development of this
study during a period of much dislocation within the Ambulance Service. Finally, and
most importantly, Sally Williamson, who requires a special note of thanks for her
immense patience and fortitude in ensuring the manuscript is arranged in the correct
style for submission.

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Table of Contents
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Chapter I .................................................................................................................... 1
Introduction .............................................................................................................. 1
I.1/ Theme of this Thesis .......................................................................................... 1
I.2/ Background, Motivation and Rationale ............................................................ 4
I.3/ Research Question, Aims and Objectives ..................................................... 18
I.4/ Original Aspects and Approach to the Research .......................................... 22
I.5/ Summary ........................................................................................................... 23
Chapter II ................................................................................................................. 26
Strategic Foresight & Horizon Scanning .............................................................. 26
II.1/ Scenario planning ........................................................................................... 29
II.2/ Definitions ........................................................................................................ 32
II.3/ Health Technology Assessment and Methods ............................................. 34
II.4/ Horizon Scanning Techniques in Europe and the UK .................................. 40
II.5/ Summary .......................................................................................................... 44
Chapter III ................................................................................................................ 46
Overview of the Ambulance Service Workforce .................................................. 46
III.1/ Overview of the environment that the NHS Ambulance Service in England
operates within ....................................................................................................... 51
III.2/ Summary ......................................................................................................... 60
Chapter IV ............................................................................................................... 62
Literature Review ................................................................................................... 62

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IV.1/ Search Strategies ........................................................................................... 62
IV.2/ Electronic Databases ..................................................................................... 64
IV.3/ Search Terms ................................................................................................. 65
IV.4/ Retrieval of Literature .................................................................................... 67
IV.5/ Management of Literature ............................................................................. 68
IV.6/ Summary ........................................................................................................ 69
Chapter V ................................................................................................................ 70
The origins and emergence of the paramedic profession .................................. 70
V.1/ Historical development of the Ambulance Service and the Paramedic
Profession ............................................................................................................... 71
V.2/ The Early Years, Ancient to Medieval Periods ............................................. 74
V.3/ The Development of both the Ambulance and a Recognisable Pre-hospital
Care System ........................................................................................................... 80
V.4/ The Rise of Humanitarianism: An Essential Ingredient in the Development
of Ambulance Services .......................................................................................... 86
V.5/ Pre-hospital Care in an Age of Industrialisation and Industrialised Warfare
................................................................................................................................. 88
V.6/ The Evolution of a Civilian Ambulance Service; the Emerging Roles of
Doctors, Ambulance Attendants and Feldshers in Pre-hospital Care ............... 92
V.7/ The 20th Century, the Development of Pre-hospital Care in War and Peace
............................................................................................................................... 101
V.8/ The Post-WWII Evolution of a Socialised Health Care System and the
Provision of Ambulance Services....................................................................... 106
V.9/ The Origins of Paramedics .......................................................................... 114
V.10/ Developing Paramedics in the UK ............................................................. 120
V.11/ Discontent and Professional Awakening .................................................. 129

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V.12/ A New Beginning ........................................................................................ 132
V.13/ The New Millennium ................................................................................... 138
V.14/ Summary ..................................................................................................... 141
Chapter VI ............................................................................................................. 143
Methodology: Phase A - Questionnaire ............................................................. 143
VI.1/ Introduction .................................................................................................. 143
VI.2/ Phase A : Research Design and Methods ................................................. 144
VI.3/ Aims .............................................................................................................. 144
VI.4/ Objectives ..................................................................................................... 144
VI.5/ Unique challenges in pre-hospital, ambulance and paramedic oriented
research ................................................................................................................ 145
VI.6/ Context and Philosophy .............................................................................. 146
VI.7/ Questionnaire Development ....................................................................... 148
VI.8/ Ethical Considerations ................................................................................ 151
VI.9/ Arrangements for data collection, storage and security .......................... 152
VI.10/ Data Analysis ............................................................................................. 154
VI.11/ Development from Phase A to Phase B ................................................... 154
VI.12/ Summary .................................................................................................... 155
Chapter VII ............................................................................................................ 157
Results from the questionnaire based study ..................................................... 157
VII.1/ Results from Phase A: Views and Opinions of Ambulance Technicians
and Paramedics Regarding their Preparation and Aspiration in Terms of Future
Training and Educational Opportunities ............................................................ 157
VII.1.1 Questionnaire Return Rate ................................................................................ 157
VII.1.2 Ambulance Staff Demographics ........................................................................ 158
VII.1.3 Length of Service at Paramedic Level ............................................................... 162

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VII.1.4 Relevance of PTS Experience to prospective Accident and Emergency
(Paramedic) Personnel ..................................................................................................... 168
VII.1.5 Ambulance technician training ........................................................................... 170
VII.1.6 Technician and Paramedic Curriculum .............................................................. 178
VII.1.7 Technician and Paramedic results ..................................................................... 185
VII.1.8 Anatomy & Physiology ATT Training Module ..................................................... 185
VII.1.9 Clinical Patient Assessment ATT Training Module ............................................. 189
VII.1.10 Clinical Patient Assessment Primary & Social Care Needs ATT Training Module193
VII.1.11 Clinical Patient Ethics, Law & Professional ATT Training Module .................. 196
VII.1.12 Management Critical Medical Emergencies ATT Training Module ................. 200
VII.1.13 Psychiatric Disorders ATT Training Module ................................................... 204
VII.1.14 Paediatric emergencies ATT Training Module ............................................... 207
VII.1.15 Training and educational opportunities .......................................................... 211
VII.1.16 Ambulance Technician Qualifications ............................................................ 215
VII.1.17 Summary ....................................................................................................... 231
VII.1.18 Reflection on the Emergent Research Design ............................................... 234
Chapter VIII ........................................................................................................... 236
Methodology: Phase B – Horizon Scanning ...................................................... 236
VIII.1/ Phase B – Research Design and Methods ............................................... 236
VIII.2/ Summary .................................................................................................... 247
Chapter IX ............................................................................................................. 249
Results from Phase B: Horizon Scanning .......................................................... 249
IX.1/ Horizon Scan: Paramedics, with reference to competing workforce
technology options, (Medical, Nursing and New Practitioners) ....................... 249
IX.1.1 Introduction ........................................................................................................ 249
IX.1.2 Data by Profession Workforce Numbers ............................................................ 261
IX.1.3 Evidence Base by Profession ............................................................................ 265
IX.1.4 Policy Documents .............................................................................................. 268
IX.1.5 Professional body, regulatory and other promotional activity ............................. 271
IX.2/ Target Group of Scan patients who would be served by Paramedics, who
are therefore described as the ‘product’ or the ‘disruptive innovation.’ ......... 274

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IX.3/ Description of the technology & Intended Purpose [Paramedics as ‘the
technology’ being described] ............................................................................. 276
IX.4/ Innovation and advantage ........................................................................... 282
IX.5/ Stage of Development ................................................................................. 285
IX.6/ Relevant Guidance from the National Institute for Clinical Excellence
(NICE) .................................................................................................................... 287
IX.7/ Relationship with NHS priority areas ......................................................... 288
IX.8/ Clinical Need and the burden of disease ................................................... 291
IX.9/ Place of Use.................................................................................................. 297
IX.10/ Developers.................................................................................................. 298
IX.11/ Efficiency & Safety ..................................................................................... 299
IX.12/ Existing Comparators ................................................................................ 307
IX.13/ Cost Analysis ............................................................................................. 321
IX.14/ Limitation of this Study ............................................................................. 323
IX.15/ Summary .................................................................................................... 325
Chapter IX ............................................................................................................. 327
Discussion ............................................................................................................ 327
IX.1/ Change, the only constant .......................................................................... 328
IX.2/ The Coveted Role of the Paramedic ........................................................... 346
IX.3/ Specialist Paramedic Practice .................................................................... 365
IX.4/ The Relationship Between the Operational Model, Workforce
Development and the Delivery of Cost Effective Health Care .......................... 385
IX.5/ A Possible, Probable or Preferable Future 2030: ...................................... 392
can a Preferable Future be made more likely? .................................................. 392
IX.6/ Summary ...................................................................................................... 399

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