There is unanimous agreement that there is a need to further improve pre-hospital emergency care (immediate care) training, but strong disagreement that the core activities that define the clinical practice of immediate care have remained unchanged over the past 40 years. In Scotland, and other areas of the UK, the standard and availability of training has increased dramatically in the past 10 years. More recently, there has been a significant improvement in the provision of equipment. As a consequence, a broader range of interventions can be undertaken by a large number of practitioners with more skill, more knowledge, better equipment, and within a well defined system of care.

We would question the number of situations requiring skills greater than those of the immediate care trained general practitioner. This is especially true in urban areas, where time to hospital is short and prolonged entrapment rare. It has to be remembered that as well as the immediate care training, such practitioners have already had a minimum of 9 years of medical training before they enter independent general practice. This delivers a level of expertise well above standard UK paramedic training for most conditions.

The reality of the delivery of pre-hospital care in Scotland is that because of the large proportion of rural areas, many general practitioners and rural nurses are actively involved. These practitioners have a large number of demands on the limited amount of time they have available for education and training. If many of the standards referred to in this paper, particularly the FIMC, were rigidly applied, it would be impossible for rural practitioners to meet them. The likely consequence is a fear of litigation that would stop rural practitioners practising immediate care altogether. It is felt by BASICS Scotland that this would be extremely detrimental to patient care in Scotland and other rural areas. The reality of life for rural practitioners is that training is mostly based on advanced life support principles. Because of geography and time constraints, any more elaborate training would be totally impractical.

It is also felt that if a specialty is to be developed, then more opportunities should be created for our ambulance and nursing colleagues to gain further qualifications in this area. The proposals as suggested are too doctor centred.

It is felt that the paper did not produce any evidence to justify the argument that there is a need for a significant amount of training beyond that currently taught on immediate care courses. We would like to see any evidence of which we are not aware that justifies the increase in training and the time that would be required to undertake such training to develop enough pre-hospital and retrieval medicine specialists to provide a service across the UK. Just what exactly are the additional critical care skills that will have a major impact in terms of early diagnosis, meaningful interventions, triage, or advocacy?