The specific skills performed by each group of emergency medical personnel is dictated by a combination of education, associated legal frameworks and the policies of their employer. The most homogeneous group are the Paramedics, as the framework of practice is largely guided by their status as healthcare professionals registered with the
HCPC. Other clinics grades such as emergency medical technicians, emergency care support workers and emergency care assistants are not registered professions nor is their job title or role protected or dictated by any national body. Therefore, their skill sets and permitted clinical interventions are governed primarily by their employer within the scope of relevant legislation. This has led to significant differences in training and skill sets between staff of these grades with different employers. National clinical standards exist for all ambulance clinicians, written by the
Joint Royal Colleges Ambulance Liaison Committee (JRCALC). This body is made up of representatives from a number of medical, nursing, allied health professional and ambulance organisations. JRCALC publishes guidance based on the principles of
evidence-based medicine and
best practice, but compliance with JRCALC is based on the employing organisations and the judgement of individual clinicians.
Emergency care assistants (ECA) or emergency care support workers (ECSW) 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. 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 or, in the private sector, Qualsafe FREC4. 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. Some U.K. ambulances services have taken this one step further by hiring "emergency drivers" with no medical training.
Ambulance Technicians Ambulance technicians, or
emergency medical technicians (EMTs), form a large proportion of the workforce in emergency medical care, although the title lacks formal definition or protection. However, moves within the private sector is being made to start regulating and adding accountability to non-registered Healthcare Professionals in the Pre-Hospital Arena. Due to the lack of regulation and standardisation of the Technician Scope some private companies use First Aiders as Technicians which has given private companies a bad name which is potentially unwarranted. 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 historically completed the Institute of Healthcare Development (IHCD) ambulance aid award (awarded by Edexcel, part of Pearson) which was a course lasting around six weeks in the classroom A three-week emergency driving programme was available alongside the Ambulance Aid qualification. 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 up until Pearson stopped running the courses in 2016. 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 QualSafe Level 5 First Response Emergency and Urgent Care and the FutureQuals Level 4 Diploma for Associate Ambulance Practitioners (L4AAP). QualSafe also run the Associate Ambulance Practitioners course covering the same topics. The term EMT has gained some tension between NHS Trusts and some Private Providers as some of them use lower clinical grades which do not meet the FPHC PHEM Grade F standard as EMTs. The term Emergency Medical Technician is not a protected title they are allowed to do this however the scope of practice difference has caused issue, especially when time critical patients are being transported by NHS resources from an event site. This has led some companies and charities to call those with the Level 4 Diploma for Associate Ambulance Practitioners by their qualification as opposed to a job title like Ambulance Technician.
Similar roles St John Ambulance (SJA) is the only voluntary aid society in the UK to provide emergency ambulance response at events and/or in support of the NHS. In 2020, the charity launched a new internal qualification called
Emergency Ambulance Crew (EAC) specifically for its volunteer ambulance clinicians. This replaced previous ambulance roles, which were essentially ECA/ECSW roles. The EAC course takes around five to six weeks in the classroom depending on cohort size, with a minimum Guided Learning Hours (GLH) of 160hrs, in addition to around 60hours of on-road experience shifts. This is then followed by a 12-month preceptorship period where newly qualified crews must be suitably supervised. The classroom hours component of EAC is comparable to that of the FREUC5 delivery plan which specifies a minimum GLH of 154hrs in the classroom setting. Importantly though, the EAC qualification does not include the 750hrs of frontline practice placement time required of FREUC5 and AAP, instead St John Ambulance has an annual revalidation / appraisal cycle and requires all EACs to deliver a minimum of 240hrs per year in their clinical role in order to be revalidated into the following year. This appraisal includes review of a portfolio which must include: • 6 Reflective Practice write-ups showing evidence of self-development (taken from patients attended in that calendar year) • Evidence of completion of relevant CPD (40hrs p.a target) • Evidence of attendance at mandatory 2 days face to face training • Evidence of annual ILS assessments (adult, paediatric and neonate) • Certificates for all online learning elements • Up to date Prescription Medication Authorisations (for Salbutamol, Adrenaline etc) The EAC role and qualification were developed to meet the specification for a national ambulance auxiliary for NHS England, which required a large cohort of ambulance clinicians capable of deploying to all categories of 999 call, which SJA was formally commissioned for in 2022. The EAC scope of practice has been designed to incorporate all required skills and interventions within FPHC Skills Descriptor F and includes all competencies required of an EMT/AAP. When working for St John Ambulance on events, EACs and AAPs carry the same medications & equipment and work to the same scope of practice. When describing the skills and competencies of an EAC on their website, the charity says;
Our Emergency Ambulance Crew (EACs) are trained and equipped to modern pre-hospital standards. They support our First Aid volunteers on events, work on specialist NHS contracts, and provide additional capacity to NHS 999 services. Competencies include: •
Comprehensive patient assessment skills including obtaining 12 lead ECG and recognition of gross abnormalities. •
Intermediate life support including airway management with i-gels and capnography. •
Administration of analgesic and lifesaving medications such as adrenaline, Penthrox, salbutamol, glucagon and more. •
Assessment and management of obstetric, medical, surgical and trauma patients including management of catastrophic haemorrhage. •
Assisting Healthcare Professionals to provide advanced life support and enhanced patient care. •
Selecting appropriate treatment pathways for patients in their care, discharging or referring to a variety of NHS care providers and specialist centres, including providing blue light emergency transport when required. Associate Ambulance Practitioners (AAP) Associate ambulance practitioners work as non-registered healthcare professionals, similar in scope of practice to the now discontinued IHCD technician qualification. after a nationally recognised standard was agreed between the national ambulance trusts and is defined by the FutureQuals Level 4 Diploma for Associate Ambulance Practitioners. Generally, AAPs can either work autonomously, making their own clinical decisions within their training and remit, or as assistants to a paramedic. The idea of having the NENAS involved in the creation of the scope and abilities of an AAP and to create a qualification which is portable and accepted everywhere within the UK. The role is commonly known within NHS Trusts and beyond as Emergency Medical Technicians, Ambulance Technicians, Technicians, or Associate Ambulance Practitioners (AAP). The range of titles come from when the IHCD copyrighted the title Emergency Medical Technician which only allowed those who had completed the IHCD Ambulance Aid qualification to be called an Emergency Medical Technician. The title of the role being an Associate Practitioner brings the naming of Ambulance Roles inline with the NHS Career Framework and helps to identify responsibilities amongst the mass of titles across the health services. AAPs are trained to a minimum of FPHC PHEM Grade F like the IHCD Technicians, many NHS Ambulance Trusts train their AAPs with some more advanced skills such as advanced ECG recognition and wound closure on top of the national standard. Some companies and charities call those who hold the Level 4 Diploma for Associate Ambulance Practitioners by their qualification as opposed to a job title like ambulance technician to make it clearer they hold the portable Level 4 Diploma.
Paramedics Clinical grades of paramedic The
Royal College of Paramedics has published a framework for
paramedic education which details the attainable clinical grades of UK paramedics as below: • Paramedic (
BSc Honours) • Specialist paramedic (
PgDip) • Advanced paramedic (
MSc) • Consultant paramedic / Director / Professor (
Doctorate)
Consultant paramedic controversy While the Royal College of Paramedics is clear that a doctorate is required to work at consultant paramedic grade, When directly questioned about this issue,
NWAS admitted that out of their 8 consultant paramedics only 1 had a doctorate degree. Although the College of Paramedics stipulates a doctorate degree being required in its career framework to be considered a consultant paramedic, the college accepts consultant paramedics onto their register with only a
master's level degree.
Academic paramedicine Paramedics in the UK are involved in academic research and education. There are now a number of paramedics in post as professors, associate 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, paramedic practitioners,
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. Many paramedics choose to progress their career by qualifying to further levels, such as by undertaking additional diplomas or higher degrees. Paramedics or pre-hospital care providers in the UK may also use other titles such as: • Critical care paramedic • HEMS paramedic • Advanced paramedic practitioner • USAR paramedic -
Urban Search and Rescue • HART paramedic -
Hazardous Area Response Team == Scope of practice ==