The paramedical field is a rapidly growing profession—not only in the United Kingdom (UK), but internationally. The aim of the current article is to discuss some of the differences and similarities between the UK and South Africa (SA) in terms of pre-hospital medicine. In the UK, the paramedic field of study is typically referred to as ‘paramedicine’, whereas in SA, it is referred to as ‘emergency medicine’. In the current article, it will be referred to as ‘pre-hospital medicine’ in the interests of simplicity (Edge Hill University (EHU), 2017; University of Johannesburg, 2017). The current article is an overview and not all topics will be discussed, nor will they be explored in depth.
A ‘paramedic’ is a loose term in colloquial dialect. However, in many instances, it is actually a protected title, such as is the case in the UK. The Health and Care Professions Council (HCPC) describe paramedics as:
‘practitioners, who provide specialist care and treatment to patients who are either acutely ill or injured, that can administer a range of drugs and carry out certain surgical techniques’
Education in SA vs. UK
Pre-hospital medicine has grown from its roots in shorter-course training to current-day education, which is at degree level in universities (First et al, 2017). This is a trend that has been followed in both SA and UK, and demonstrates a positive direction for the profession as a whole (EHU, 2017).
A range of titles and qualifications are associated with paramedics. Those which are most commonly encountered are explained in Table 1.
| Title | Qualification in UK | Qualification in SA |
|---|---|---|
| Paramedic | Diploma/Degree (2/3 year) | Diploma/Certificate (2/3 year) |
| Technician | Short course (<1 year) | Diploma (2 year) |
| Advanced Paramedic | Trust-dependent | N/A |
| Consultant Paramedic | Trust-dependent | N/A |
| Emergency Care Practitioner (ECP) | Used but with a smaller scope and different context to South Africa; has been removed from some trusts | 4-year degree |
Source: Berry et al, 2015; HPCSA, 2017
Pre-hospital medicine is a unique area of study, as it focuses its content towards the requirements of the specific country, or even county, in which it is practised. As needs and requirements can vary vastly from one geographical location to the next, course content can differ significantly.
Violence in SA vs. UK
In SA, levels of violent trauma are extremely high, particularly when compared with the UK. There are many statistics which are combined however, and which can therefore be difficult to decipher. One comparable variable is violent murder. In the UK, over a 12-month period from June 2016 to June 2017, it was found that 664 people were murdered. In SA, the value in the same context was 19 016 people (Office for National Statistics (ONS), 2017a; South African Police Service, 2017). In simpler terms, on average, less than two people die in the UK as a result of intentional violent causes a day—whereas in SA, just over 52 people die everyday owing to such causes. This provides just one example of how patient requirements may differ between the two countries.
Dealing with violent trauma
In SA, the skill bases and scope of practice allow practitioners to deal with trauma in a very efficient manner—yet no referral pathways or systems exist (Health Professions Council of South Africa (HPCSA), 2016). This means that in SA, some patients with minor illnesses would still be transported to hospital as opposed to being managed in an arguably more efficient and effective manner. It is not uncommon for rescue training to form part of degree programmes in the SA setting (University of Johannesburg, 2017).
In the UK, the situation is different; life expectancy is higher and violent crime is lower in comparison with SA (ONS, 2017a; 2017b). The practitioners in the UK are better equipped to do referrals and associated assessments. Once again, this is owing to differences in training resulting from the requirements of the public.
Scope of practice
One characteristic that is common among paramedics is that their skill-set is in high demand worldwide (Home Office, 2016). With regards to scope of practice, there are many similarities between the UK and SA. The core of any differences result from the UK having a single paramedic registry with multiple titles/ranks; while SA has multiple registries, each with their own scope of practice but with a single title. This is not to say that one system is better than the other—but this disctinction is key to understanding how each operates.
The Trust in which the practitioner is employed in the UK determines what rank/title structure is followed and how they are assigned. These ranks then determine the permissions the practitioner holds to administer different medications and procedures. In SA, the qualification held determines which register the practitioner can join, and thus which corresponding license they will practise under. The license specifies the scope of practice for that practitioner and is country-wide, run by the HPCSA.
Comparing high-level practitioners
For the sake of comparison in the current article, the highest-level UK paramedic with the largest and most advanced scope of practice (i.e. generically termed consultant paramedic) will be compared with an emergency care practitioner (ECP), which is the highest level of practitioner in SA (HPCSA, 2016). After reading each practitioner's scope of practice, it is interesting to note that the similarities in fact outweigh the differences. In a general overview, most skills and scopes of practice are found to be common between both practitioners—this includes the use of guidelines and resources to support practitioners in appropriate decision-making (HPCSA 2017; Joint Royal Colleges Ambulance Liaison Committee (JRCALC), 2017).
There is a strong focus in SA to push ECPs to be independent and critical-thinking practitioners, who can make decisions in the pre-hospital environment. This is done partly by avoiding the use of guidelines, such as protocol books, as ‘rule’ books.
It is worth stating that different ranks/qualifications have different scopes of practice—this seems to be logical as the lower ranks of paramedics have the most commonly used skills in the UK; for example, the ability to use nebulisers for respiratory conditions (JRCALC, 2017). As a person gains a higher-ranking position, the rarer and potentially more dangerous medications and procedures are permitted. For more senior-ranking positions, it is an expectation that further study has taken place and/or further qualifications obtained (College of Paramedics, 2015); for example, a master's degree, or in-house training on ultrasound for consultant paramedics.
Requirements for a paramedic
Owing to the nature of the work of paramedics, there are requirements to be able to work safely in such environments. For example, it is a requirement for the paramedic to hold an appropriate driver's (C1) license (College of Paramedics, 2017). A C1 license means that the person may drive heavier vehicles, such as ambulances, ranging from 3500-7500 kg (Driver and Vehicle Licensing Agency (DVLA), 2017). General good health is also required to meet the demands of the job with a general consensus on most requirements between the two countries (Wilson, 2015; University of Johannesburg, 2017). An example of an exception is that no Disclosure and Barring Service (DBS) checks are done in SA; hence it could be easy for someone with a history of anger or abuse to have access to treating vulnerable patients in SA.
In both countries, the course is a difficult one to qualify for and requires evidence of excelling in school and/or studies—these are generally sufficient only to have an interview granted (College of Paramedics, 2017). Hence, qualifying for paramedic education is a detailed process that may not be accessible to all. Other checks are also involved because of the nature of the work; however, as briefly mentioned, these checks are much more thorough in the UK including DBS for example (College of Paramedics, 2017), whereas in SA, the person would simply meet basic requirements and have driver's license, registration card, etc checked.
Public vs. privatisation of medicine
The next topic of discussion gives an overview of private medicine vs. national health care. This can have an impact on paramedics as will be discussed. The author will provide a context for each country and some of the pros and cons of each with associated discussion.
Public health care in the UK
As stated previously, a paramedic's main function is the urgent care of acutely ill patients. This means that they only form part of the health-care system regardless of the country. In the UK, general practitioners (GP) are available to the public, as are paramedics (NHS Choices, 2016). This is also true for other emergency services, all without fear of any cost to the patient (NHS Choices, 2016). A down side is that the more people use this service (and sometimes do so inappropriately (Seager, 2014)), the more this can create longer wait times for ambulances in emergencies, as well as delays in appointments. The benefit is that the public is aware that regardless of monetary situation, they are eligible for assistance and care. If a person has a disability or disease that requires medications, that person will be supported and cared for (NHS Choices, 2016).
Private health care in SA
SA works predominantly in the context of the privatisation of medicine. However, it also operates according to a ‘right to life’ that everyone is entitled to (United Nations, 2014). Hence, no person can be left with any form of life-threatening injury or illness, without receiving treatment, regardless of financial situation. To note though, if the person does have finances available, they will be charged pre-set rates depending on the level of care provided (Department of Labour, 2017). GP appointments, as well as hospital visits to private hospitals, are paid for by the patient. There are government-funded hospitals where medication and treatment are made available to all (KZN Department of Health, 2001). It is also notable that there are government-funded ambulance services that do not follow the same system as private services. However, these government-funded services are overwhelmed and private medicine does rule overall (TMG Digital, 2016).
In terms of private services, some have support from hospital groups, and some don't. In the interest of providing a better understanding of the system in SA, it will be explained in the context of those services with hospital group support.
The private medical model
The author will discuss the private medical model based on his experience working within a private and government service in SA, as well as in the NHS system in the UK. The private medicine model works in a symbiotic partnership. A hospital (or hospital business group—sometimes unrelated to medicine) will fund and support an ambulance service that will then be associated with them. This means there will be an understanding that the associated ambulance service will bring medical aid (SA)/or insured patients to these particular hospital facilities, which means that the hospital can bill the patient and make a profit. For example, a serious or critical patient will bring in roughly the equivalent of 300 GBP to the ambulance service, but spend 3 days on a ward, and one day in intensive care, earning the hospital approximately 4200 GBP, not including the doctors' bills. Of course, this cost is not fixed and would depend on the injuries and treatments required, as well as on the medical facility's own rates. However, ambulances generally run from the hospital, and it must be noted that the hospital group will support an ambulance service even if it means the service runs at a loss—simply to allow availability of ambulances in the area of that hospital; thus permitting local patients to be transported to that hospital in most cases.
There are also ambulance services that are not associated and that do operate purely from profits of transport and management; however, these services can also sub-contract to the larger ambulance services which are associated with hospital groups.
Ethics in the private model
The patient must always go to the most appropriate facility based on his or her care requirements. However, if an option exists between facilities, the patient is transported to a facility associated with the ambulance service provider. Ethics and morals always play a role in medical practice; though they make some decisions difficult in private medicine (HCPC, 2014). Having the patient brought to the associated hospital allows for an income to be drawn from the patient for services rendered. The hospital group thus benefits, and the ambulance service also charges a service fee (Department of Labour, 2017).
It is also normal practice to charge a ‘call-out fee’ when a vehicle is dispatched to an incident but there are no emergency services to render to the patient post assessment and no emergency transport is required; however, this is at the senior practitioner's discretion. For example, some families may not be able to afford a fee. Furthermore, if the service is purely for a declaration, the family is typically not billed for this.
However, this also means that patients that may have abused the system with inappropriate calls are now rendered fees (Department of Labour, 2017). As is a current topic of discussion in the UK at present, people call the ambulance service for many reasons unrelated to a need for emergency care, from stubbed toes to having caught a snake (a call the author received in SA). There is no real research into whether or not this fee deters such calls but it is assumed that perhaps it could.
Such a model whereby finances may potentially play a role in the level of care a patient receives could lead to a lower level of care for a larger number of patients. There is a risk that patients could be ‘over-treated’, allowing for higher charges or potentially transporting more patients than is needed so that costs may be rendered. These would of course be considered completely unethical actions—however, such situations are a possibility, especially when the patient is vulnerable, such as after a motor vehicle accident.
This ethical issue has been addressed to some extent through the addition of specific criteria, rules and regulations to practice (Van Huyssteen, 2016). For example, a practitioner may not ‘over-treat’ patients as discussed, or hand a patient that requires care from a senior practitioner over to a practitioner with a lower scope of practice. Practitioners may face ethical dilemmas when making decisions regarding patient management, which may not have arisen if there were no finances involved. It is vital that practitioners always keep their ethics in consideration, regardless of the country within which they are practicing, or the patient whom they are treating. The pros and cons of this system are wide and numerous—however, delving into all of them in detail is beyond the scope of this overview.
Education for pre-hospital medicine
As the focus of training and education in the field of pre-hospital medicine is related to the requirements of the public, equipment must be discussed. Paramedic courses cover a variety of topics regardless of the country in which they are studied. Many skills and procedures are shared between practitioners practicing in the UK and SA. One commonality among higher-level practitioners is the pre-hospital ultrasound.
Pre-hospital ultrasound
Use of pre-hospital ultrasound has grown in SA over recent years, with courses being offered and taught to paramedics, practitioners and doctors alike (International Federation for Emergency Medicine (IFEM), 2014). It is used in the UK by specialised services and certain paramedics with specialised training (Russel, 2015).
Pre-hospital ultrasound offers many advantages previously thought impossible in an uncontrolled environment. For example, it allows for the rapid diagnosis of many abnormalities, injuries and even haemorrhage, with a large degree of certainty (IFEM, 2014; Russel, 2015). This allows for better triage and assessment, as well as more effective management of patients with medical or trauma-related conditions, as well as being useful for patients in cardiac arrest (Link et al, 2015). Another potential benefit of pre-hospital ultrasound is that it could feature in possible referral pathways; this could take place during home visits, allowing for a more thorough assessment (Russel, 2015).
These benefits could lead to patients receiving a higher quality of management, and better use of NHS resources. Effective use of technology such as pre-hospital ultrasound provides yet another example of how rapidly the paramedic profession is expanding and evolving, becoming a true specialty of its own.
Direction of pre-hospital medicine
After comparing the pre-hospital fields in both the UK and SA, some patterns have emerged. Upon superficial analysis of the topics discussed in the current article, one such theme is apparent.
The common thread revealed between the UK and SA with regards to the direction of pre-hospital medicine is that paramedics are not only professionals but, to a large extent, are also clinicians. Paramedics are involved with higher education, training, practice and research.
The populations of both countries are overwhelming the capabilities of their current services within the Government healthcare system (Vize, 2016). The lack of staff only hinders this issue further (Gov, 2017). What this means is that efficiency must be improved in order for services to cope with demand. Currently, one way of doing this is by evolving the paramedic into a fully autonomous thinking practitioner; hence the increased focus on diagnostics and assessment, which are now becoming second nature to the paramedic. Patients' conditions can then be better understood and managed. This in turn decreases the need for extra resources. The field of paramedicine is rapidly growing and the changes discussed within the current overview are by no means a complete account of all of the developments and areas of growth.
Conclusion
Pre-hospital medicine is growing rapidly internationally, and there are many common characteristics and push factors for its growth. These are based on patient needs and the environments in which they live. Although many skills and scopes of practice are shared, there are still many learning opportunities internationally, as paramedics in each country have developed their own specialised skills and methods of managing patients. There is no evidence to say that this knowledge could not be beneficial if shared and used. Equipment and training is diversifying rapidly, allowing practitioners in paramedicine to become more effective in the management and assessment of the patients they are privileged to treat. The hope is that there will be further discussion and more in-depth analysis on many of the topics mentioned in the current article.