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Commentary from BASMeD
  1. J Scott

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    I am grateful to have the opportunity to provide a commentary on this paper, responding on behalf of the membership of the British Ambulance Services Medical Directors Group (BASMeD).

    There is clear support from the membership for the idea and principles in the paper. BASMeD particularly welcomes the opportunity that this paper provides to stimulate the debate, but would like to emphasise that the paper should not be seen as an endpoint. The need for a sub-specialty and linkage to ambulance trusts is overwhelming, but in striving for that goal, any change must not alienate those doctors providing real and additional clinical care for patients, often before the ambulance response arrives.

    There is a particular need to establish clinical standards (individual competencies/proficiencies) with regulation of those who aspire to practise to those standards. There is certainly a need to ensure that examination points are consistent and that there is equity of clinical standard throughout the body of doctors providing services to support ambulance work.

    Who should regulate this sub-specialty? There is presently a vacuum that must be filled before yet more fragmentation occurs. Medical directors of ambulance services with a governance "hat", require, probably more than any other group, the creation of a sub-specialty, not only for their own clinical practice, but as managers of a publicly funded clinical service. The sub-specialty must not detract from the voluntary aspects of the existing immediate care groups, but should ensure consistent standards of care, facilitating much needed education, research, and audit across lines or disciplines of service provision.

    To that end, the sub-specialty is essential to develop governance, but there has to be a pragmatism that recognises the real world of targets placed on all health economies. As medical directors, we would expect benefits from such a development, and if benefits were demonstrated, then it is hoped that funding and support would follow.

    The principles of a competency based framework are to be applauded. However, the academic support should not be narrow but as widely based as possible, being intercollegiate. There is a need to break down professional barriers, and this proposal must not be allowed to create divisions or fragmentation. As medical directors, we work across many professional groups, particularly in the rapidly developing or evolving ambulance provision. If this proposal is to succeed, we need to think beyond the concepts of the major incident or serious incident, and include the whole range of resuscitation skills coupled with the more minimalist interventions required in the provision of out of hours, telemetric, or virtual medical support to ambulance trusts and their staff. There should be professional links established to those staff providing other aspects of ambulance response, be that paramedics, nurses, or doctors.

    So what, if any, are the downsides? The title of the sub-specialty strikes a discordant note. Colleagues in BASMeD were unhappy with the use of the word “retrieval”. Only one alternative name was suggested: “early emergency interventional care”. The present title of the sub-specialty is not supported.

    The paper challenges us and does indeed open the debate. Let us not close the door just because it seems to touch a nerve; BASMeD must engage in this debate or be left behind, and that would harm patient care. BASMeD supports the debate and congratulates those who have set the fox among the chickens; let us now together build a coop for the future, providing a way of life for both foxes and chickens.

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    • Competing interests: none declared

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