Emergency medical personnel in the United Kingdom

Dr Peter Baskett was one of the world's leading figures in cardiopulmonary resuscitation and pre-hospital medical care. In the early 1970s alongside Professor Douglas Chamberlain, Baskett developed advanced training for the ambulance personnel who then became the first paramedics in Europe.[5]

Professor Douglas Chamberlain, together with Peter Baskett (see above), pioneered the first recognisable paramedic training programme in the UK, up until this point, only basic ambulance training had been in place nationally, having been rolled out only four years earlier.[6]

Prof Julia Williams is a pioneer in the area of paramedic led research.[7] She holds a senior post at the University of Hertfordshire and is a senior advisor to the College of Paramedics.

Over 4 decades, Prof Malcolm Woollard was a leading voice for the paramedic profession. His passion for the development of the profession and was described as a ground-breaker for the paramedic profession.[8] He died in 2018[9] but has a legacy of research that lives on.[10]

Emergency Care Assistants or Emergency Care Support Workers are trained to a basic level of ambulance practice. As a result, they typically work as assistants to a Paramedic, Technician or AAP and do not have clinical autonomy.[13] Their role varies widely between services and as such, their clinical knowledge is typically from that of First Aid up to the FutureQuals Level 3 Diploma in Ambulance Emergency and Urgent Care Support.[14]

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.[15]

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. Generally, ambulance Technicians can either work autonomously, making their own clinical decisions within their training and remit, or as assistants to a paramedic.

Technicians within the ambulance services have generally completed the Institute of Healthcare Development (IHCD, now defunct) Ambulance Technician award (awarded by Edexcel, part of Pearson) which was 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.

Associate Ambulance Practitioners work as non-registered healthcare professionals, similar in scope of practice to the now discontinued IHCD Technician qualification. In contrast to the unprotected title of 'Technician', a nationally recognise standard was agreed between the national Ambulance Trusts which is now defined by the FutureQuals Level 4 Diploma for Associate Ambulance Practitioners.[16]

The College of Paramedics has published a framework for paramedic education which details the attainable clinical grades of UK paramedics as below[17]

• Paramedic (BSc (Hons))
• Specialist Paramedic (PgC/PGDip)
• Advanced Paramedic (MSc)
• Consultant Paramedic / Director (PhD)

Paramedics take potentially life-saving decisions about treatment needed and, if appropriate, will then administer the treatment.[18] They work utilising their own clinical knowledge and as registered health care professionals.

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 Qualified Ambulance Man/Woman and, after qualifying, those who wanted to increase their knowledge and skills joined the Association of Emergency Medical Technicians. This was an organisation run by members to promote and train Paramedics. The AEMT was supported by BASICS and large numbers of hospital doctors. Training took place at various locations with members attending off-duty and at their own expense. Trainees followed a wide academic curriculum which led to a written exam and if successful, they became Associates and entered the clinical phase of training. They then attended hospitals to receive their practical skills training. The final examination was designed to put as much pressure on the candidate as possible. The hospital consultant would sign to say that he was happy for a passing candidate to treat their family.

In the early to mid 1980s some ambulance service training departments started offering advanced skill training. In 1986 the NHSTA introduced the certificate in Extended Ambulance Aid. Existing AEMT Paramedics were forced to sit a conversion examination. The curriculum for the new qualification was substantially smaller cutting out a lot of anatomy and physiology as well as pharmacology and obstetrics. In November 1986 the examinations took place with the first certificates issued alphabetically. The candidate with highest score received certificate 177 and was the only Paramedic at Huntingdon. Training was introduced the following year but due to costs the time was kept to a minimum. The AEMT folded in the 1990s as the training offered was no longer recognised by the ambulance services. Equipment owned by the branches was given to hospitals.

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. The Institute was acquired by the Edexcel examination board in 1998, and Edexcel was acquired by Pearson in 2004. Pearson continued to operate the IHCD 'brand' until 2016. This 'in-house' paramedic training was a modular programme, usually between 10 and 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 2002.

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.[19]

Paramedics in the UK are increasingly becoming involved in academic research and education with the move to higher education training being required for entry to the national HCPC register as a paramedic. There are now paramedics in post as professors, and senior lecturers across the United Kingdom. There is also a monthly peer-reviewed UK paramedic journal in the form of the Journal of Paramedic Practice, which publishes primary research and other articles of interest to UK paramedics and prehospital care clinicians.

The College of Paramedics has delineated a post-graduate career pathway for paramedics in academia and education, although this varies by institution and is only a guide.

• Research Paramedic / Paramedic Lecturer (PgC, PGCE, PGCHE etc)
• Research Fellow / Senior Lecturer (PgDip, PGDE etc)
• Reader / Principle Lecturer (MSc,MEd etc)
• Professor (PhD, DProf etc)

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,[20] 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.[21]

Many paramedics choose to progress their career by qualifying to further levels, such as by doing additional diplomas in critical (intensive) care.

Paramedics or pre-hospital care providers in the UK may also use other titles such as:

• Critical Care Paramedic[22][23]
• HEMS Paramedic[24][25] Air ambulances in the United Kingdom
• Advanced Paramedic Practitioner
• USAR Paramedic[26] - Urban Search and Rescue
• HART Paramedic[27][28][29] - Hazardous Area Response Team
• Paramedic Lecturer Practitioner[30]

The drugs administered by Technicians or AAPs are given under provision of The Human Medicines Regulations 2012[31] and under direction of the JRCALC Clinical Practice Guidelines. They include General Sales List (GSL), Pharmacy (P) and Prescription Only (PO) medicines.

Procedures carried out by Technicians or AAPs can include:[16]

• Intermediate Life Support, including manual defibrillation and supraglottic airway placement
• Chest palpation, auscultation and percussion
• Manual or electrical suctioning
• Traction and pelvic splinting
• 12-Lead ECG Placement and ST-Elevation Myocardial infarction interpretation (with the ability to admit directly to a hospital with percutaneous coronary intervention)
• Abdominal palpation, auscultation and percussion
• Catastrophic haemorrhage management
• Ability to discharge patients to different care pathways

The drugs paramedics are allowed to administer are regulated in UK Law and include Controlled Drugs (CD). The Joint Royal Colleges Ambulance Liaison Committee provide clinical guidelines on when they should be used.[32][33][34][35] Paramedics can administer drugs that are available to Technicians/AAPs (above) as well as:

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.[32][36][37]

Procedures carried out by Paramedics include that of Technicians/AAPs as well as potentially:

• Endotracheal intubation
• Needle thoracentesis
• Needle cricothyrotomy
• Transcutaneous pacing
• Intravenous cannulation
• Intraosseous cannulation
• Autonomous cardiac defibrillation
• Cardiac auscultation[38][39][40]

• Autonomous thrombolysis[41][42]
• Capnography[43]

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[44] 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.

Advanced Paramedics typically hold an MSc in Paramedic Science and can deliver care in a pre-hospital environment that has traditionally only been performed by doctors.[45]