Disruptive innovation: barriers, opportunities and differences internationally

Historical context

In the UK, paramedics emerged from ambulance staff in the mid-1970s (Baskett et al, 1976; Briggs et al, 1976). They were trained to provide advanced resuscitation using invasive techniques that were almost exclusively the province of medical practitioners at that time. Their purpose was to bring advanced care into the streets and homes of the communities they served.

During the 1960s and 1970s, patient needs were often viewed as reflecting the twin plagues of the 20th century: cardiovascular disease, accounting for more than 300 000 deaths in 1966, often manifesting as acute heart attacks and, sometimes, cardiac arrest (British Heart Foundation, 2011), as well as traumatic injury which, in terms of mortality from road traffic collisions alone, accounted for 7985 deaths in the same year (Keep, 2013).

Even in the most developed countries at that time, including the UK, advanced resuscitation skills were not generally available to patients in the prehospital setting. In some parts of the UK, a relatively small number of general practitioners operated on a voluntary basis as part of local response schemes, usually under the aegis of the British Association for Immediate Care Service (BASICS), tending to focus their efforts principally on trauma from road traffic accidents (which have since been redesignated ‘road traffic collisions’) (Easton, 1969; Hines, 1998). Deaths from blunt trauma caused by road traffic injuries have declined in recent years with the number of deaths down from 3172 in 2006 to 1792 in 2016 (Department of Transport, 2017). General practitioners' involvement in this role has reduced in recent years, often being supplanted by HEMS, which deal with <1% of health-related 999 calls (Mackenzie et al, 2009) and employ doctors drawn from hospital medicine working with paramedics.

Today, more than 99% of 999 calls for health reasons are responded to by ambulance staff, 38% of whom are paramedics working in the NHS ambulance service. There has therefore, in effect, been a repurposing of existing ambulance staff, which was both a pragmatic and economically prudent approach advocated by the Rescue and Resuscitation Committee of the Medical Commission on Accident Prevention (MCAP). MCAP recommended that ‘as ambulancemen were usually the first to arrive at the scene, if they were trained in advanced techniques of resuscitation, not only might the mortality be reduced but also the morbidity in the prehospital phase of patient care’ (Lucas, 1979: 9).

Economics have been an important aspect of paramedic development. A landmark economic study, commissioned by what was then the Department of Health and Social Security Standing Medical Advisory Committee, later sought clarification of the health economics basis for such an approach. Subsequently, a report by the University of York's Institute for Research in the Social Sciences (Wright, 1984) concluded that the saving of between four and five lives each year for every ambulance staffed, 24 hours per day for 365 days per year, with an extended trained personnel would be a reasonable and conservative estimate. This claim was not universally accepted by the medical profession, leading Baskett (1991) to criticise the ‘dog in the manger attitudes’ held by some of his colleagues, describing it as a prejudice best left in the past.

From the perspective of definition, the UK model of ambulance staffing falls under the umbrella category of the ‘Anglo-American model’, which is represented not only in the United States and Canada, but also throughout much of the English-speaking world and beyond. Anglo-American and similar terms are used to categorise system configuration. The alternative Franco-German model (Page et al, 2013), in which doctors, rather than paramedics, work in ambulances are found in some European countries, in addition to France and Germany, including Spain and European Russia. While there have been disputes over which system is more effective (Dick, 2003), a national review on behalf of the Office of Strategic Health Authorities (2009) concluded that ‘neither [system design] outperformed the other’ but recognised that medical staffing models would have a higher operating cost.

In the Anglosphere countries, this has led to a ground-based ambulance service staffed by paramedics rather than doctors, as advocated by Giround (2012). Medical input in the UK occurs at both the executive level on ambulance service boards with field input increasingly via HEMS, which has progressively displaced many voluntary general practitioner-staffed immediate care schemes that existed previously.

The progressive expansion of paramedics' scope of practice accompanied by a gradual process of professionalisation, closely linked to educational developments, ultimately, led to the designation of paramedics as AHPs and their professional registration in 2000—a process now managed by the Health and Care Professions Council (HCPC).

Adding value to existing personnel in this way led to other advantages, as these staff brought with them an inquisitive willingness to learn, a can-do attitude and an emergency services culture. These attributes are very much in demand today, in an environment of patient demand that has changed, with the proportion of people presenting with life-threatening problems continuing to decrease.

Shift in patient need

In consequence, realisation has been growing that it is illogical to continue to mandate an emergency response to all 999 calls in England, with response and performance measures across all reference points, again, demonstrating some variation. Since 1996, there have been numerous changes, including many revisions to response time standards and redefinition of categories.

The most recent revision is the allocation of all 999 calls that appear to be imminently ‘life-threatening’ to the ‘C1’ [category 1] group (the highest tier of response), as part of the ‘ambulance response programme’. This project estimated that only 0.6% of 999 calls concern immediately life-threatening cases, such as cardiac arrest, and only 10% are emergencies (Turner et al, 2017).

Inevitably, even the best triage processes will lead to some level of ‘over-triage’ and, therefore, the actual figure of acute emergencies, at least from a purely clinical perspective rather than that of the public, is likely to be in the order of 5%.

Perhaps paradoxically, while resources for the seriously injured and those with acute medical needs have increased, alongside an enthusiasm from the medical profession to become more actively involved (especially in HEMS organisations, of which there are now more than 20 in the UK, operating an increasing number of aircraft), there is often a shortfall in meeting the requirements of those with the next tier of urgent, undifferentiated healthcare problems.

In addition, medical and nursing staffing problems within emergency departments, and in hospitals in general at night and over weekends, are commonly reported in the media. Some patients with developing problems in the community will deteriorate and be in a more serious condition unless identified and treated promptly. These patients often require complex diagnostic decision-making, and risk assessment; in these cases, it is arguably more difficult than in people who have well differentiated major injuries. This has been one issue driving the development of specialist and advanced paramedic roles, which emphasise patient assessment and decision-making in a way not dissimilar to initiatives in nursing and other allied health professions.

Fifty years ago, and indeed more recently in some parts of the UK, patients perceiving an urgent need of care while at home had a 24/7 medically qualified labour force of general practitioners available to respond to their needs and were often attended by their own doctor. However, these services have progressively reduced over time and been replaced by a range of often less adequate provisions with a lower proportion of medical staff. This relative retreat of medical involvement, in contrast to the medical desire to participate as HEMS crew members, has created an opportunity to, once again, reorient paramedics and the ambulance service (although the two are no longer as synonymous as was previously the case) to address this area of service provision. It also offers the prospect of organised interprofessional working between doctors and paramedics.

Care to meet a larger, more diverse and increasingly complex range of need is often accessed through the 999 system. Volumes of such calls have grown tenfold over about half a century, from 1 million in the mid-1960s (Millar, 1966) to 10.7 million calls (including 1.3 million transferred from NHS 111) in 2015–2016 (National Audit Office (NAO), 2017). Today's population of patients seen by paramedics is, therefore, much larger than it was previously. It also contains a greater diversity of patients because of a changing and ageing society, where complex health and social care needs are common. Changes in demographics, epidemiology and demand have led some researchers to conclude that ‘paramedicine and the ambulance service in the UK’ is moving from the ‘extreme to the mundane’ (Brewis and Godfrey, 2019).

Some, including Granter et al (2005; 2018), anticipate no reduction in the level of risks to the physical and psychological wellbeing of paramedics due to the complex societal challenges faced in practice. Peacock et al (2005) found that demographic changes could not account for the doubling of demand for ambulance services their study observed in the 1990s; however, they noted that a rise in the proportion of men needing urgent or emergency attention and an ageing population were significant contributory factors to increased demand.

The precise factors driving these changes remain contested, with some advancing demographic changes. Wrigley et al (2002) identified changes to out-of-hours GP provision among the most important factors. If it is true that NHS policy leading to a radical change in GPs' working arrangements caused the demand pressures plaguing the ambulance service and emergency departments, incurring colossal costs, this would constitute a massive ‘own goal’ for the NHS.

A further review of demand, commissioned by the Association of Ambulance Chief Executives (AACE) fared less well in definitively nailing down the root causes of growth, but added several categories for contention, including the increase in patients with long-term conditions, deprivation, population growth and lifestyle factors, and also agreed that changes to out-of-hours service provision were implicated (Edwards, 2014). These findings were echoed in a comprehensive review of the literature (Radcliffe and Heath, 2010).

Whatever the multifactorial causes, the current scale of demand is a major challenge to service planners who, despite more than a decade of policy initiatives, struggle to keep pace with the need for innovation and change in both service design and workforce planning. These difficulties are exacerbated by the multiplicity of urgent care models, a concern captured by Turner et al (2015) in their evaluation, What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review.

The appropriateness of demand has also been a topic of interest, with studies describing a range of inappropriate use, a perspective that is often, as Ahl et al (2006) caution, defined from the perspective of the professional, not the patient. Estimates of non-appropriate calls were researched during the late 1990s and were found to vary from 16% reported by Palazzo et al (1998) to 40% by Victor et al (1999). This type of study appears less common today, with perhaps an acceptance of advice offered by Snooks et al (1998), which suggested that services should worry less about appropriateness of demand and devote more effort to providing appropriate care.

The reality is that, while much of the demand routed through the 999 system could be handled by a range of other services including GPs, out-of-hours community nursing services and other provisions, these options are either unavailable throughout the 24-hour period or do not always have the resources or responsiveness expected by the public. Therefore, much of this healthcare demand behaves rather like water or electricity—flowing to the line of least resistance. This continues, in many cases, to be 999 access and the ambulance service, which acts partly as a safety net for failures and gaps in other parts of the NHS.

Disruptive innovation

After coining the term ‘disruptive innovation’ (Bower and Christensen, 1995), Christensen went on to apply it to healthcare in his book, The Innovator's Prescription (Christensen, 2009). He offered some examples of new professional groups, including those working in healthcare, but not specifically citing paramedics. He made the observation that innovations in developing new practitioners in dental care, being stopped almost dead in their tracks by vested interest, emphasises how this sort of protectionism drives up cost and impedes the reforming impact of disruptive innovation. His key point—that disruption within the healthcare workforce could help to positively reform healthcare systems with constructive clinical and financial consequences—was well made. The size of the cost burden to the public purse, had the NHS ambulance services followed the Franco-German model as advocated by some (including Beaulieu and Vilain (1992) and Banks (1999)), has not been calculated, but is likely to be considerable.

There are many examples of AHPs other than paramedics operating in a positive and disruptive way, including physiotherapists expanding their role as first-contact diagnostic practitioners and taking on independent prescribing roles. Another example is that of radiographers interpreting x-rays, which previously was a role reserved exclusively for medical personnel, especially qualified radiologists.

In this context, paramedics are near-perfect illustrations of disruptive innovation. They have, in effect, always been first-contact practitioners, only more recently becoming better equipped to carry out the complex clinical care associated with undifferentiated patient need. Their precursor role as ambulance men and women, which took root within the comparatively simple operational requirement that emphasised providing first aid and transport, created opportunities for relatively independent practice and required the ability to think on one's feet and adapt.

In terms of disruptive innovation, the developmental pressures placed on paramedics have resulted in several advantageous transformative adaptive responses, which can be highlighted as follows:

Opportunities and barriers

Fifteen years ago, the ‘Bradley’ reports recognised that the default action taken by many ambulance crews during that period was nearly always ‘transporting most patients to hospital’, and that this was often neither in the patient's, nor the healthcare system's, best interests (Department of Health and Social Care, 2005; AACE, 2011).

Other commentators have suggested that the experience of dealing with large numbers of patients with often seemingly minor problems could create ‘blasé’ attitudes among ambulance crews (Woollard et al, 2010). The implication was that training and educating paramedics to manage these cases more appropriately was the only logical course of action.

The means to achieve this have been articulated many times over the last two decades, with the fundamental requirement of safe practice stated by Gilhooly (1990) and improved clinical reasoning and patient assessment later becoming a recurrent theme (Charlin et al, 2000). These researchers were clear—and few would disagree with them today—that meeting the prime responsibility of competency for first-contact practitioners is an assessment to place a patient accurately along the acuity spectrum. This requires a detailed educational process for paramedics, as articulated in the Paramedic Evidence Based Education Project (PEEP) report (Lovegrove and Davis, 2013). For the most part, the reference countries do seem to have absorbed this sentiment.

Any educator will attest to the difficulty of creating learning outcomes that permit a practitioner to assess, treat and discharge safely below undergraduate level. This is a key reason why the College of Paramedics has placed so much emphasis on educational development for paramedics. This has resulted in a change by the HCPC (2018) to approve only programmes offered at degree level.

These developments, in part due to the associated educational investment in degree-level education, have strengthened the foundations of paramedic practice in the UK, as in South Africa, Australia and New Zealand. It has also helped to pave the way for its further advancement, such as by increasing postgraduate opportunities for paramedics (College of Paramedics, 2017a). This is continuing to expand and now incorporates independent prescribing for some paramedics in the UK, a development that required legislative change (College of Paramedics, 2017b). Similar trends and opportunities have been recognised in Ireland by the State regulator of prehospital care (Pre-Hospital Emergency Care Council, 2016).

This development should act in favour of more appropriate approaches to patient transportation rates. Emergency transport rates across English ambulance services were considered by the NAO (2011), and have periodically attracted the attention of ambulance commissioners, although translation into widespread practice remains disappointing. This indicates that the advances made have not been fully translated into practice or changes to the dominant service model. Other reports, which might have been expected to be influential—most notably, Transforming urgent and emergency care services in England. Clinical models for ambulance services (NHS England, 2015)—have offered clear, well-conceived guidance, but to little avail.

Finding opportunities to reduce the number of patients transported is ever-more important, yet barriers and contradictions to progress remain. Implementing the necessary changes in ambulance services, which often have cultures that are not fully compatible with the needs of patients or paramedics, impede improvement and have often been slower than necessary. The Carter review into variation in ambulance service performance (NHS Improvement, 2018) has highlighted this issue, which has been considered in previous reports without resolution.

The Carter review (NHS Improvement, 2018) was published shortly after the detailed study, Understanding variation in ambulance service non-conveyance rates, by O'Cathain et al (2018). This presented many pertinent findings, which regrettably were not available to Lord Carter. These included the tendency of ambulance services to use different grades of staff to attend emergency calls and significant differences in the perception of risk between services. It also suggested linking ambulance and hospital data; this should be relatively easy in the NHS and would be desirable because giving feedback to staff would facilitate learning, but is rarely evident in practice.

The strategic vision, which has gradually become more coherent, has been accompanied by an implementation gap primarily in the system of NHS regulation and at ambulance trust level. This has resulted in a failure to modernise services' model of operation from being transport-dominated to gaining the maximum advantage from the skills and abilities of paramedics. Wide differences in performance across the UK are evident, with the NAO (2017) reporting that the number of cases resolved by ambulance trusts using control room-based triage varied between 6.2% and 16.2%. A similar level of variation between ambulance services was apparent in transport rates when crews attended a scene. Recontact rates between trusts also differed markedly, ranging between 8.5% and 29% (NAO, 2017).

Fundamentally, the NAO (2017) considered that some services sent out ambulances too frequently when this was not needed, and transported too many patients, often to overcrowded hospitals for what were often clinically unnecessary journeys. These attendances and conveyances were, therefore, frequently inappropriate. The safety of such activity, in terms of the differences in rates of triage and decisions on whether to send an ambulance and the consequent frequent journeys, requires further scrutiny and detailed research.

Figure 2 (Newton and Hodge, 2012) shows that the transition from transport to clinical decision-making is the best chance of improving services to patients and this relies upon using paramedics and those with specialist, advanced skills to the full.

It also indicates that ambulance services that remain committed to the traditional model of operation (left triangle in Figure 2) are likely to be less equipped to deal with contemporary challenges in patient demand.

Other significant leadership and human resource inadequacies exacerbate deficiencies. Wankhade (2012) identifies problems such as a target-driven culture, suggesting that this hinders service improvement and the processes of professionalisation. These factors exacerbate staff turnover and hamper efforts to retain the most skilled paramedics, who are better prepared to seek opportunities outside the ambulance service. High sickness rates and staff dissatisfaction have been repeatedly noted and featured in the NAO (2017) report and have attracted media interest (Wakefield, 2014a; 2014b), as have instances of bullying (Twist, 2015) and sexual harassment (Lewis, 2017). Excessive rates of self-referral to the HCPC (van der Gaag et al, 2018) are also suggestive of poor working conditions and a lack of support.

All of these factors allude to a culture that has toxic elements, existing in a harsh regulatory environment in the UK that relies upon inspection for data gathering; this approach has often been criticised as outmoded, ineffective and a waste of money (Flodgren et al, 2016), including by the prolific healthcare commentator and former NHS chair, Roy Lilley (2019).

McCann et al (2012) echo similar themes and make it clear that paramedics are still ‘blue-collar workers’ in some ways, largely because of the constraints placed upon their practice as well as a lack of opportunities to develop because of managerial failings. These constraints originate from a variety of sources, including governmental targets and poor leadership within the ambulance sector. It is hard to imagine that there has been much positive progress in recent years, given the lacklustre results of NHS ambulance service staff surveys. The College of Paramedics (2017c) has published a career framework making the link between paramedic education and service delivery clear, but implementation at individual service level is lagging.

It appears that, while disruptive innovation is a powerful force and one that, in this professional case study, offers at least a substantial part of any explanation about the success of paramedics over the past few decades, it does have its limitations. It is also important to recognise that innovation and disruption tend to occur when a variety of factors are present together.

The change in thinking that brought about the paramedic profession was certainly assisted by technological developments, including the creation of portable defibrillators. Technology will certainly continue to act to shape and enable the clinical practice of paramedics and the systems they work in, as recognised by Heaney et al (2020) and Davison and Forbes (2015). Equally important was a recognition by a small number of senior doctors of the potential of ambulance personnel, which occurred almost simultaneously in the UK and Australia, as well as with fire service personnel in the United States. This was coupled by a willingness on the part of these individuals to take on more advanced training and education.

In the UK, paramedics provide a significant level of support to patients seeking care via the 999 system. However, they have not replaced medical practitioners in prehospital care for many seriously injured patients. This is in contrast to both the United States and Australia and, indeed, much of the English-speaking world, where critical care has become a largely delegated phenomenon. In that sense, the Anglo-American model, although increasingly widespread, is playing out differently and becoming more hybridised.

The advent of a medical subspecialty in prehospital care within the UK might be seen as innovation; however, Rawlins (2012) noted that if cost-ineffective, it cannot be considered innovation as far as the NHS is concerned, and Barker (2010) cautioned against new specialties.

Attempts to qualify the relative merits and cost of lifesaving by professional groups have been attempted. A quarter of a century ago, New (1992) commented on the overprovision of medical teams and underuse of paramedics. Jashapara (2011) reached similar conclusions when considering the role of critical care paramedics.

Other commentators question the evidence of the value of paramedics operating in the advanced critical care role in England (Von Vopelius-Feldt et al, 2014a; 2014b). It therefore seems that there is a sharp divide in medical opinion in the United States, Australia, Canada, New Zealand and South Africa, where prehospital advanced life support and critical care roles tend to be delegated to paramedics. In the UK, this may be influenced by national cultural difference and the preferences of medical professionals themselves. This has resulted in the UK, Europe, and Russia, developing a scope of paramedic practice that is more constrained at the critical care end of the spectrum. Certain skills remaining exclusively within the domain of medical practitioners, who greatly prefer to be directly involved in what might be perceived as the more glamorous aspects of prehospital care. These commentaries have not gone undisputed and a multi-professional consensus as to the optimal arrangements or ratios of staff (medical or paramedical) for prehospital care remains elusive.

The fact is that, despite more than 70 years of the NHS and 50 years of paramedics, nobody really knows how many ambulances, paramedics, helicopters or doctors are required. Consequently, what evidence does exist is often at risk of being interpreted in a partisan manner. These ambiguities are unhelpful, especially given that the British Medical Association (BMA) (2017) and the Royal College of Emergency Medicine (2017) have reported that shortages of medical labour are particularly acute in emergency medicine. With press reports, including those published in The Lancet (Black, 2016) and implying a lack of medical staff in areas including emergency care. This raises the question of whether medical staff should be diverted into prehospital activities and, if so, in what numbers, both now and in the future.

Would opportunities to work in the prehospital environment increase medical recruitment and what are the implications for patient outcomes? In the UK, at least, it is very difficult to say. However, Liberman et al (2000), in Canada found no advantage from medically-delivered advanced life support and McSwain (1995), one of the architects of the American EMS, found little merit in ‘physicians functioning as emergency medical technicians.’ In a similar vein, Sancton and MacLeod (1998) investigating the death of Princess Diana, noted that the superiority of medically staffed systems cannot automatically be taken for granted. Perhaps the most grounded comment, by Westaby (1989), is that ‘it is extremely unlikely that the status of the attendants has an important bearing on the [patient] outcome. What is more important is the training, organisation, and speed of response of the service’. This could be interpreted as: ‘it doesn't matter who does what needs to be done as long as it gets done competently’.

Part of the attraction of the prehospital space for emergency medicine doctors in the UK may be the opportunity to carry out certain resuscitation skills, such as rapid sequence intubation (RSI), that would often be performed by other medical specialties in the emergency department. Professional fulfilment is, therefore, another potentially distorting factor that affects paramedics who, in other countries, would be performing these sorts of skills outside hospital with support from emergency medicine doctors who would be carrying them out in their emergency departments. It is a fascinating irony that RSI is a commonly used technique by paramedics elsewhere and that the only major randomised control trial demonstrating the value of prehospital RSI was by mobile intensive care paramedics in Melbourne (Bernard et al, 2010).

Christensen's (2009) analysis makes clear that logic, evidence and health economics often matter less than eminence-based opinion and professional interest. To what extent these factors influence decision-making in the UK is difficult to quantify, but the UK differs markedly from other reference countries in the way that medical options have often promoted parallel and paramedic-based services with medical ones. Examples of senior figures encouraging such development include Cooke (1994; 1999), Porter and Greaves (2009), and Miles (2011), with many lesser known personalities keenly supporting such initiatives.

The UK military has often been supportive of these arrangements and advocated for medically-led retrieval services during the war in Afghanistan (Hodgetts and Mahoney, 2009; Morrison et al, 2013). Once again, it is airway management where the debate over the relative merits of who does what seems to create controversy in the UK. It is somewhat telling that the UK armed forces rely on medical support in the most complex missions on United States Air Force Paramedic Rescue Forces, whose paramedics have a scope of practice (Peck, 2006 and Rush et al, 2015) that involves the very technique deemed inappropriate by some UK medical commentators. Advanced airway management of this kind is, therefore, often suggested to be something of a signature technique offered by its medical proponents as solely medically-provided skills. Cowan et al (2012) invoke recommendations from the anaesthetists of Great Britain and Ireland and reinforce the point that airway management, using medications to facilitate intubation, is exclusively a medical procedure. Simply writing guidance that confirms a professionally protectionist view is not entirely convincing.

Claims made by the same authors, that ‘the UK is still lagging behind many other countries with regard to physician delivered pre-hospital care…’ (Cowan et al, 2012; 138), are questionable, unless viewed solely through the lens of an isolationist medical view point. It is of course correct to say that countries such as France, Russia and others deploying the Franco-German model, but rather misses an appreciation of the Anglo-American model. Comments by Spencer et al (2008) citing the feasibility of UK of paramedic deploying RSI, albeit in the presence of medical practitioners found: ‘Our experience supports the growing recognition that appropriately trained non-anaesthetists can perform RSI as safely as anaesthetists in both the hospital and pre-hospital environments. Our study also suggests that, with appropriate training and supervision, paramedics carry no greater risks in RSI than their anaesthetic and non-anaesthetic medical colleagues' (Spencer et al, 2008: 17). There are therefore at least some dissenting voices who hold a more eclectic viewpoint. The role of UK ambulance medical directors is important here and currently seems to side with the conservative standpoint, thus far curtailing any scope of practice development in the area of advanced airway management. This contrasts in terms of appetite for innovation from earlier generations such as Chamberlain and Baskett. The views of Pepe et al (1989) are evident in all reference countries (except the UK) and are a testament to what can be achieved outside the UK: ‘The future of emergency services and excellence in pre-hospital care depend on physicians who seek to broaden, not reduce, paramedics’ scope of practice'.

Taking stock

Over the last half century, paramedics in the Anglosphere countries have made great strides, resulting in the successful transition from vocational healthcare workers with a limited set of capabilities, to established health professionals. The resemblances in how paramedics practise across these countries are more apparent than the differences and there are some very clear patterns. Among the most evident is that each country has a clear standard. In some cases, these are overseen by national regulatory bodies and this is becoming more common. The role of professional bodies has also played an important part in development, for example in the UK.

In all examples, the scope of practice of paramedics has expanded but the emphasis differs somewhat. Australia, Canada, New Zealand, South Africa and the United States all have multiple examples of very advanced critical care practice. Techniques such as RSI and other sophisticated resuscitation techniques are practised relatively independently, with strong physician buy-in and support. In the UK, the situation is different with a strong policy and largely medically supported view that primary and urgent care are areas that are highly suitable for paramedic practice to engage in. Indeed, it is unlikely that independent prescribing would have been authorised for paramedics, had the recognition not been recognised of the potential benefits of deploying paramedics into the space. Many paramedics have migrated towards these settings and processes, accelerated by the, sometimes difficult, nature of working within the NHS ambulance service—an organisation that has been much slower to adapt to change. The resurgence of medical interest in prehospital working for more serious and often trauma cases, where opportunities exist to attend the scene by helicopter, has reduced opportunity in this area for paramedics to carry out this role in a manner that would reflect the model used in the other reference countries. Professional interest rather than evidence or financial considerations are likely to be the main drivers for this pattern of working to continue into the future.

There is, therefore, an arguable case for giving more thought, as was suggested in The Economist (2012), as to just how the unique capabilities that medicine offers can be deployed to best clinical and financial effect.

Nevertheless, many doctors and paramedics enjoy working in the systems that have been developed in the UK, and it is doubtful that services that are more centrally directed and influenced by health economics would find favour, particularly among HEMS providers, who can use the presence of a doctor as a ‘unique selling point’ and do so in the knowledge that the costs of providing doctors can often be met through NHS funding. There are some advantages to independence and diversity, including the agility derived from having small, focused, charitably minded HEMS operators, just as there are probably disadvantages in duplication and heavily doctor-oriented staffing patterns. However, separating these factors out is not straightforward. It is also doubtful that ground-based NHS ambulance services would have the ability, influence or inclination to contribute to discussions on how to make future service design theoretically more efficient, given the many challenges in basic service delivery they experience.

Benefits from the wider deployment and expanding role of paramedics, both financially and in terms of being able to reach much of the community are, therefore, more likely to occur in the foreseeable future in mobile urgent care services than in those for patients with the most serious injuries. This is an area of indisputable unmet need and where cooperation, partnerships and other forms of collaboration have great potential to improve patient experience and possible outcomes. Some examples of good practice in this area exist, exemplified by the rotating of paramedics through clinical settings (Turner and Williams, 2018). Ambulance services, at least for now, retain the advantage of employing the highest numbers of paramedic staff, but the ratio is changing as paramedics increasingly develop their careers outside the ambulance service, whether inside or outside the NHS.

One reason for the high staff turnover in the NHS ambulance service is a culture that is less than conducive to meeting the aspirations of paramedics, particularly those with postgraduate education, who have more opportunities to migrate to primary, hospital or other care sectors. Ambulance services' slow adaption of their model of operation to take account of changing patterns of demographics and demand means they are continuing to offer a primarily transport-based model rather than one that emphasises mobile healthcare in collaboration.

The Carter report makes for disturbing reading and indicates that the fitness for purpose of many organisations is open to some degree of questioning (NHS Improvement, 2018). This finding, which took little or no account of internationally similar systems documented high rates of bullying reported in the ambulance service which are corrosive for staff, especially when accompanied by a restrictive, target-driven culture, indicates that urgent action is required. A toxic culture contributes towards a lack of satisfaction within the workplace and a desire to find more enlightened employers in other parts of the health economy. If not addressed energetically, these problems will reduce the changes of any meaningful modernisation of the ambulance service. Attention to leadership (Newton and Harris, 2015) system design and possibly the structure of the ambulance service (Newton, 2019) is urgently required.

Conclusion

In an artificial market such as the NHS, the power of disruptive innovation will always be attenuated. It is disappointing, but not entirely surprising, that despite the solid foundations and building blocks for the paramedic profession which are now largely in place, after half a century of development, achieving the full potential of paramedics remains elusive, partly because of organisational and external professional constraints.

Nevertheless, hard-won successes, including national regulation, undergraduate preparation, postgraduate opportunities, career choices and independent prescribing, are solid foundations for the future of the profession. Where shortfalls are evident, they are largely a function of organisational weakness and remaining professional barriers.

At the critical care end of the patient care spectrum, a compromise has resulted in a form of ambulance delivery system that, despite its Anglo-American designation, exists as a hybrid influenced by the Franco-German model. This has significant, almost universal, medical practitioner involvement, especially in air ambulance provision. Combined crewing provides opportunities for medical staff to experience and contribute to prehospital care, with both paramedics and doctors gaining insights that are valuable for direct care delivery, teaching and research. This may divert medical labour away from other essential areas of practice in a manner that would not occur in the United States or many other countries that follow the Anglo-American model of prehospital care staffing.

Nevertheless, it must be said that, while some important differences exist in the approach of the medical profession across the reference countries, there have been tremendous advocates for the paramedic profession in every case. It is also possible that when negative comparisons are drawn, it is in part because commentators may be inadvertently comparing ‘apples and oranges’. Comparisons between the first-level paramedics and senior medical input are less likely to be as favourable as those where senior paramedics, supervised by senior medical staff remotely, as in the United States, perform advanced resuscitative skills. This point may be underappreciated by most, but not all, as seen in Spencer et al (2008), and is supported by other research, such as Morrison (2013) and Mabry et al (2012). Concentrating high-level skills in small, well supervised groups of critical care paramedics with focused medical oversight, as occurs in other reference countries and which was recognised as key by Pepe et al (2000) and, more recently, Spencer et al (2008), might help alleviate the concerns of some UK medical authorities. It is also worth recalling the words of one of the greatest medical advocates for paramedics, Dr Nancy Caroline (1977: 376–378), whose unswerving support also included the advice to paramedics to never become ‘intoxicated with their new knowledge’ and advised ‘humility’. That was a very different era, at a very different stage of paramedic development, but the advice remains valid. It is less possible to be so sanguine about the role of nursing, whose recent coveting of the paramedic role, most notably in the UK but drawing on the Swedish experience, seems altogether ill-judged.

For the foreseeable future, preference for some doctors to work in prehospital care, finding this work more stimulating than other duties, is not likely to change unless the financial or clinical evidence become clearer or, most importantly, until the preferences of the medical profession itself results in a change in attitude.

At the urgent care end of the spectrum, the ambulance service has not adjusted its operating model to account for demographic changes, nor moved with the times to create a more integrated offer for patients, despite much encouragement in policy terms to do so. While this will result in a continuing change in patient demand from the ‘extreme to the mundane’, the work will remain physically and psychologically demanding, as well as unpredictable.

Diagnostic complexity in this group of patients is often high and, arguably, much more complex decision-making is required here than for the majority of seriously ill and injured patients where well-established treatment algorithms are available, and all patients go to hospital. For patients where non-transport or referral options can be contemplated, risks that are not always fully appreciated abound. Considerable benefit could be achieved from higher levels of medical input, thus enabling paramedics and others to manage a greater number of patients without transfer to hospital.

In England and elsewhere, the matter is being addressed by two related developments. First is the decisions of many paramedics to move to primary care for better-supported working conditions. Second is encouragement provided by changes to the GP contract that will help fund paramedics in primary care settings in the future (NHS England and BMA, 2019). Publications such as Paramedic specialist in primary and urgent care core capabilities framework (Skills for Health and College of Paramedics, 2019) and positive case studies (NHS England, 2020) helped lead the way to these current developments.

In the ambulance service, there is an increasing implementation gap between the opportunities offered by having a more capable workforce that can exploit the power of disruptive innovation to create higher quality at a lower cost. Some positive efforts by Health Education England and the College of Paramedics have advocated a ‘rotational’ model where paramedics spend time in a variety of settings to improve effectiveness and job satisfaction (Health Education England, 2018). However, widespread change can be achieved only with leadership that appreciates the potential benefits and opportunities.

The situation is exacerbated by the, sometimes poor, working conditions that paramedics experience in ambulance services, where hierarchical, target-driving cultures, frequently accompanied by bullying, often compel staff to seek other opportunities. These failures can be countered if employers demonstrate more imagination and confidence, and work to remove the distorting and demotivating behaviours that are all too common. Failure to do so will lead to a continuation of the low levels of paramedic staff satisfaction, high turnover rates and an increasing flow of paramedics out of the ambulance service to other destinations both inside and outside the NHS. All of these trends are observable today.

Ultimately, coherent national policy and doctrine have a role to play, with upgraded leadership preparation, improved system design and more radical organisational change. At the critical care end of the spectrum, an absence of clarity in terms of policy can result in professional opinion determining approaches to service design and staffing.

As for urgent care, policy and other factors have reduced medical involvement and, while clear policy has been available to guide the development of the ambulance service to act more imaginatively when delivering services to patients, progress in translating these ideas into tangible service improvement for patients has been limited. A more enlightened approach is necessary—one that emphasises assessment, treatment, referral and limiting transport to cases where this is clinically necessary. This is a goal that should be aspired to and is also eminently attainable, given the right managerial focus.

The current circumstances illustrate that the emerging paramedic profession must deal with an environment where the advantages associated with being a disruptive force for positive change exist within a multitude of often conflicting, paradoxical and illogical artificial barriers, sometimes professionally oriented but often also organisational in nature. These factors have reduced the benefits of a new, dynamic and versatile group of AHPs that paramedics have become over recent decades.

Of particular concern to all paramedics, the public and policy makers, must be that a serious gap remains between the capabilities offered by paramedics and the opportunities available at ambulance services; many, if not all, ambulance services have not been able to match the potential attributes presented by a growing and more capable paramedic profession with organisational changes that would enable many benefits to patient care. This is an unnecessary waste and one that can be ill-afforded at a time when healthcare resources are likely to remain under pressure and efficiencies and innovative thinking are required. It is time to seize the opportunities that exist and release the full potential of paramedics.

Key points

CPD Reflection Questions