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Important developments in the delivery of emergency care
With rapidly changing healthcare provision, many new job roles and titles are appearing in emergency, primary, and secondary care. This proliferation has led to a degree of confusion that may have detracted from some very important developments that are taking place in the delivery of out of hospital emergency and unscheduled (urgent) care.
In out of hospital care, the previous descriptors of technician, paramedic, and immediate care doctor were born out of a hierarchic structure, however as education and training opportunities have occurred there has been a blurring of the edges between all these groups.
Within primary care and A&E units, the introduction of new targets and ways of working are demanding the introduction of clinicians with new skills and competencies.
In tracing the origins of these new developments, the first ideas on practitioner development in prehospital care were put forward by Douglas Chamberlain, the then Chairman of the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) and the Ambulance Services Association (ASA) in January 2000.1 The resulting “practitioner in emergency care” (PEC) concept started the debate that has evolved or metamorphosed to become the more elegant sounding emergency care practitioner (ECP).
What does this title mean and what areas of practice may those in these new roles undertake clinically? There is no doubt that when the Changing Working Force (NHS Modernisation Agency) programme2 proposed the extension of the work being undertaken in Coventry and Warwickshire to develop professionals from a paramedic and nursing background to dual role, its emphasis was on reducing the A&E four hour waiting times.
There are other new pressing demands on out of hospital emergency care provision. The new GP contract and the change in the provision of out of hours, the incessant and increasing demand upon ambulance trusts through the 999 service, and this year the increasing threat posed to round the clock hospital emergency services under the working time directive, are all leading to the requirement for clinicians to be trained to undertake new roles.
One such educational package with a clear view to the end clinical requirements is described in this issue.3
The dangers are great. Merely to train in new areas and increase salaries of these new roles does nothing to increase the number of staff in the system nor does it encourage new ways of working or providing health care.
The underpinning need is to invoke fundamental system change in emergency and urgent care and new roles are merely a component. If we take the opportunity to develop staff (career progression) and at the same time create an integrated and clinically supported system, then patient care can be significantly improved while minimising risk associated with uncoordinated development of “ad hoc” new roles, sometimes in reaction to changes in healthcare circumstances.
There are some ideological debates to be concluded. We want to break down barriers between professional groups and in doing so create functional teams; supportive of each other but able to deal with the patient’s problem at the first point of contact. “Appropriate care at the point of need” (ACAPON) is a concept developed in a practice in Norfolk using a community paramedic and creating a team from differing professional backgrounds to improve each other’s competencies and abilities to manage the problem presented by the patient in the community. The initial pilot, which has been reported in the Health Service Journal,4 showed considerable benefit in preventing patients being transferred to the local district general hospital (some 20 miles away) in 30% of patients seen by the community paramedic.
People within such a system require senior clinical support (whichever way round that system triangle is created—pyramid or inverted pyramid). While at the point of contact, the staff member is acting independently their actions are not truly autonomous; but constrained and supported by the system of care provided by the team. This fundamental point about defining the system the practitioner is about to work within is central to considering the person’s task and therefore the educational or curricular content and planning of courses.
The ECP has to be able to undertake the “first point contact” role and to achieve this, the person must be able to undertake and interpret the findings gained during a formal history taking and comprehensive and appropriate examination. However, the system will have gained little if at that point the patient is merely referred to some other clinician or agency. The ECP has to be able to start simple investigations and to provide explanation to the patient together with starting a treatment management plan, some of which the ECP must be able to provide.
From this comparatively simple description I suspect many different perceptions of this new person will have been acquired and they are probably all correct. However, go and challenge your vision again, but this time look for the reasons why the virtual image may fade as we turn it into reality.
Problems with implementing this new practitioner most effectively still remain, drug provision being the most obvious, but none are insurmountable.
It is the end product that must be clearly defined. Educational pathways must be refined to support these developments and must link to core programmes. There is a chance here to promote the undergraduate (before registration) and postgraduate (after registration) components of a career pathway. This would enable those who wish to work at some point in their clinically active life in the out of hospital or in-hospital fields to rotate into different roles with only minor additional development in modular form from a common core knowledge set acquired in basic ECP training. This would have clear service and individual benefits compared with the current more secular training courses.
Finally, how will success be recognised or gauged? No single organisation will be able, except in very parochial terms, to evaluate this new role. We will require central funding and academic university department assistance to undertake this evaluation work. But it will have to include scrutiny of the ECP educational development, the patients’ perspective, the ECP’s effect on the whole system of health delivery—both primary and secondary—and the benefits accrued by the individual clinicians involved.
Important developments in the delivery of emergency care