Reforming the paramedic profession? Two weeks with paramedics in Germany

Aims

This article aims to provide a perspective of emergency care in Germany and the paramedic profession in times of change, alongside future expectations among staff and in politics. It outlines the current role of paramedics and EPs within the EMS system, examines issues in the system, including historic discrepancies in the paramedic role, and introduces the proposed changes and examines their possible impact on paramedics, EPs, and identified issues in the EMS.

Method

Spending around 80 hours over 2 weeks in the field with German Red Cross ambulance crews, including on the ambulance and the EP response car in the federal state of Thuringia, allowed the author to gain firsthand insights into everyday practice.

Interviews with a variety of stakeholders, including paramedics, emergency medical technicians (EMTs), EPs, special operations staff, students and trainees, helicopter staff, management and control staff, underpinned the observations.

In discussions with staff, relevant resources were identified, including German legal documents, news publications, reports and internal documents, which formed the background for the findings.

German ambulance services and paramedics: a brief overview

Counties have to fulfil the federal emergency services plan (Thüringer Innenministerium, 2009), which details the requirements as stated in the federal emergency services law (Thüringer Landtag 2008) by employing an EMS provider, which in turn is usually funded by health insurance. The providers run ambulance service schools, coordinate ambulance staff and vehicles, and run the control room.

To facilitate the settlement between the ambulance service and insurers, patients ideally have to provide an insurance card at the scene.

Table 1 gives an overview of key features of German ambulance services and associated agencies specific to the area observed.

The control room of the observed region is staffed by one fire service employee and one paramedic, who take calls, dispatch services and give informal clinical advice. No triage system is used in this area (although it is in use in services elsewhere) so there is no distinction between hot and cold responses. The response time as the main performance indicator for all calls is stated in the emergency services plan as 12 minutes or 15 minutes in less densely populated regions, with a target of 95%.

The profession of ‘Notfallsanitäter’ (paramedic) is protected by the national Paramedic Act (Bundesamt für Justiz, 2013a), which sets out the requirements to carry the title, and paramedics have to register with their individual federal state to be able to practise.

Qualifying involves completing a comprehensive education as per national Education and Examination Regulations for Paramedics (Bundesamt für Justiz, 2013b). The education consists of theory and practice phases in hospitals and ambulance stations, the latter facilitated by experienced paramedics in the role of qualified practice educators.

Continuous professional development is required but how this happens in reality varies. In the observed area, this includes evidence of practised skills and a certain number of hours spent on recognised courses.

Scope of practice dilemma

The Paramedic Act forms the foundation of the standard operating procedures (SOPs) (Landesärztekammer Thüringen et al, 2019) of every federal state.

These break down paramedics' scope of practice regarding interventions, the treatment of certain conditions and drug administration in a similar way to the Joint Royal Colleges Ambulance Liaison Committee clinical guidelines. This scope has been drawn up by the Consortium of Thuringian EPs, among others.

The key feature is that all skills and medications are divided into two categories: autonomous and delegated. Paramedics can carry out autonomous interventions independently in line with their own judgment and accountability. The delegated interventions, however, ‘expressly serve to provide patients with prompt, qualified help in the event of an EP-led resource not being available as part of the emergency competence of the paramedic, or in the event of danger to life or serious impending health damage’ (Landesärztekammer Thüringen et al, 2019). These relate mainly to medication administration. Table 2 provides examples of the interventions.

The SOPs serve to cement these skills in everyday practice, but only the head EP in each county determines definitively which of these can be carried out by paramedics in their area. Paramedics, who will have learned the skills as part of their education, are required to hold an assessment talk (oral exam similar to an objective structured clinical examination (OSCE) in the UK) with the head of EPs to be authorised to carry out the intervention.

The difference between the two categories of intervention stems from a discrepancy. The Paramedic Act requires paramedics to carry them out to provide help, while the Medical Practitioners Act (Bundesamt für Justiz, 1939) states they can be carried out only by doctors.

Only a legal construct using the ‘justifiable emergency’ clause in criminal law (clause 34 StGB, Criminal Code) reduces the risk of paramedics being liable to prosecution. This clause states that an action that would be considered criminal under normal circumstances—in the case of paramedics, the conduction of interventions permitted only by doctors—is not necessarily unlawful when it serves to prevent danger to life, among others, as long as it is appropriate. In addition to this, clause 32 StGB of the Criminal Code specifically sets a 1-year prison sentence if reasonable help in an emergency or danger is withheld by any person, which further complicates the position of paramedics exercising their duties.

Not only does this whole set-up leave paramedics in an uncertain position regarding their liability and insurance rights but also it causes huge differences in scope of practice at county level, making collaboration between different ambulance services difficult.

In the observed area, for example, the Head of EPs promoted a very liberal approach to paramedic practice and authorised the majority of skills, making the county one of the leading areas in terms of interventions used by paramedics. During talks with stakeholders, it became clear that, especially in cities where travel times are shorter, this is rarely the case.

The argument that these historic laws should remain to ensure patient safety is negated through the widespread use of the legal ability to work outside them. Through talks required with the local head of EPs, paramedics are being individually assessed for their ability to perform the procedure, which increases safety. In addition, paramedic interventions require subsequent assessment and possibly treatment by a doctor, either at scene or in hospital.

Nevertheless, because of the discrepancy, effective patient care is hindered more often than it is facilitated, which is why changes in the Paramedic Act have been proposed, which are described below.

Questioned whether paramedics themselves would appreciate more skills and autonomy, most stated that it was not so much the list of interventions permitted that would need updating but the law surrounding this issue since they already practise within the scope but without legal certainty.

During the research for this article, an impression formed that little input on the scope of practice comes from paramedics themselves. The German Professional Association for Emergency Medical Services (Deutscher Berufsverband Rettungsdienst eV; DBRD), the main interest group for paramedics, issues statements on current discussions and is a member of relevant bodies (e.g. expert panels in the ministry of health). However, the key contributor to the Thuringian SOPs, for example, are physician-centred organisations. Therefore, a large part of paramedic practice, including the authorisation of interventions, is governed through decisions by EPs, possibly because of historic and patient safety considerations.

On scene, paramedics seem to limit their assessment and interventions to the absolute minimum. Only in very few incidents would they use more extensive skills, including delegated ones. In discussions with paramedics, it became apparent that this is to reduce the risk of litigation; also, patients will be seen by a doctor anyway, either at scene or at hospital. Since paramedics have almost no alternative pathways available, they do not feel the pressure of deploying every possible assessment tool to safeguard the patient (possible pathways in Figure 1). This culture is in keeping with the Paramedic Act, which mostly refers to interventions in line with further medical attention (clause 4, subsection 2, paragraphs 1c, 2c).

It should also be mentioned that career opportunities for paramedics in Germany are fairly limited. Only a few development opportunities are available with additional training, for example, to serve as a practice educator or to become a community paramedic as trialled in a pilot project in areas of Lower Saxony (Schmitz-Eggen, 2020), which is similar to advanced paramedic practitioner roles. Recently, several universities have created a bachelor of science degree in emergency services, with a focus on managerial roles.

Current emergency physician role

As mentioned, EPs are at the core of prehospital care in Germany. Their deployment is guided largely by an indications document (Bundesärztekammer, 2013), with guidelines listing incidents and conditions in which a physician has to be dispatched immediately; these include, for example, paediatric patients, and patients who are experiencing seizures, or who are unresponsive or suicidal. The SOPs for paramedics include prompts where physician backup has to be requested to the scene if initially not dispatched, such as for severe limb trauma that cannot be managed easily.

Although they were not representative, out of 21 incidents during the observed period, 10 were attended by an EP; the rest did not require their attendance or the delay through waiting would have been detrimental for the patient. Figure 2 shows resource attendance and management outcome of observed incidents. To give a national comparison, in 2016, 39% of callouts were responded to by EMS vehicles versus 16% by EPs; the remaining calls were attended by urgent care services (Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen (SBEG), 2018).

In most cases, the EP input consisted of decisions around ongoing care and liaising with other agencies. Only a few incidents required the physician to get involved in patient treatment, such as in a cardiac arrest or severe haemorrhage following a suicide attempt. Occasionally, the physician accompanied the patient and crew during transport. Only a few interventions, such as gastrolavage or the administration of certain medications, can be carried out only by physicians.

A strong advantage of having a physician on scene, as observed and from discussions with stakeholders, was the increased flexibility regarding ongoing care and direct referrals. Therefore, the physicians could contribute in particular to less acute cases. However, this contradicts the indications document, which places their role in true emergencies. There is therefore a possible discrepancy between the original purpose of EPs and their use in today's emergency care system. This is mentioned in a statement by the DBRD (2019a), which highlights that physicians are frequently dispatched unnecessarily. Whether the ability of physicians to access different pathways is of benefit and therefore their role should be expanded towards non-emergency incidents is not examined, however.

Since almost no formal, alternative pathways are available to paramedics, the burden of decision-making when discharging or referring patients lies with the EP. In this sense, legal security for paramedics is high, although this comes at the price of autonomy. However, ambulance services need to transport patients to claim costs so physicians do not always explore alternative pathways to their full extent.

For paramedics, having access to a physician not only means that senior clinical advice is immediately available and the risk of litigation low, but also it allows them to discuss and follow up cases. This is a major opportunity for paramedics to develop their practice.

Emergency care reform in Germany

Even though in the area observed, the increased demand on the ambulance service—often with non-acute or inappropriate calls—was not obvious, it is a bigger issue in other German areas. This national trend has attracted great political interest in recent years, alongside increasing pressures on hospitals, in particular emergency departments, and shortages (e.g. staff, budget) in GP and GP out-of-hours services.

A 2018 report by the Advisory Council for the Evaluation of Developments in Health Care (SBEG, 2018) observed a shift from emergency to urgent care in recent years. Also, patients were often unaware of appropriate pathways available. The demographic change towards an ageing population has been identified as one of the main challenges. Because of a range of factors, a nationwide rise of 105% of callouts has been observed over 2000–2016, with 60% of patients being over retirement age (SBEG, 2018). The report highlighted the need for change in emergency care, including the ambulance service.

This has led to draft reforms to emergency care laws being drawn up (Bundesministerium für Gesundheit, 2020) in Germany. Recommendations are aimed at all three sectors of emergency care (emergency departments, GP/GP out-of-hours and ambulance service) and include, among other proposals, a combined emergency control system for emergency calls under 112 and the GP out-of-hours equivalent under 116 117 with improved triage functionality, and integrated emergency care centres in certain hospitals to determine the need for further care of presenting patients.

As mentioned above, ambulance services can only claim expenses for a callout if the patient is transported to further care; budget allowances allow the occasional non-transport. This, of course, has a huge influence on decision-making around patient management, since there is no incentive to keep patients out of hospital. While systems have been coping with this so far, it is up for question how long this will remain the case. A suggested reform is, therefore, to define callouts and medical assessments by a paramedic or EP crew as separate entities regardless of transport requirements.

Developments for paramedics and emergency physicians

Related to the proposed changes, the autonomy of paramedic practice is particularly under scrutiny. The report by the Advisory Council has clearly identified a need to resolve the discrepancy between the Paramedic Act and Medical Practitioners Act to restore legal security for paramedics. This has been followed up by a proposal from the Federal Council to amend the Paramedics Act to contain a suitable exclusion (Bundesrat, 2019). The health secretary has stated that the issue will be considered (Bundesministerium für Gesundheit 2019).

However, the proposed change is still awaiting implementation by the Ministry of Health, and paramedics remain in a legal trap (Sauer, 2020). The DBRD emphasises that autonomous decisions are at the core of paramedic practice in line with the high-quality education that paramedics receive but it does not believe the issue will be resolved under the proposed change (DBRD, 2019b).

Physician-based organisations nationwide, on the other hand, have repeatedly voiced concerns over additional autonomy regarding patient safety and legal protection (Bundesverband Ärztlicher Leiter Rettungsdienst eV, 2019). From their perspective, the idea of paramedics carrying out physician-owned interventions should be strongly discouraged. According to the author's observations, some paramedics opined that safeguarding the EP role might be an ulterior motive.

Whatever the outcome of the proposed changes, there is no explicit intention to create an EP-free ambulance service (Landesärztekammer Thüringen et al, 2019).

How other aspects of the paramedic role will develop—for example, with more career and specialisation opportunities or a stronger input into practice-defining decisions—is uncertain given the current focus on emergency care reform and the Paramedic Act.

Another core suggestion of the advisory council report was to standardise the paramedic scope of practice nationwide via a national emergency services law to equalise practice and facilitate cross-border operations.

The DBRD has proposed a change in the indications document for EP dispatch (DRBD, 2019a). They acknowledge that incidents are changing towards low-acuity presentations and that this change is not reflected in this document. In this context, it emphasises that paramedics, as highly qualified health professionals, have the abilities to ascertain whether EP attendance is required. The proposed change not only answers the need for efficient resource management in a challenged healthcare system but also strengthens the paramedics' position. Nevertheless, the question of whether EPs can be employed increasingly to access alternative pathways is not discussed.

Regarding EPs, they have to obtain a licence to operate within in the prehospital environment as described in Table 1. However, no specialty around emergency medicine or prehospital emergency medicine has yet been established. So far, only an additional qualification in acute and emergency medicine has been created, based on other specialties. In particular, the fact that EPs, including physicians in emergency departments, come from a variety of specialties often leads to confusion and communication issues (SBEG, 2018), which is compounded by different requirements between federal states, similar to the local inconsistencies seen in the paramedic profession. Whether there will be a specialty in emergency medicine with a streamlined national approach remains open.

Conclusion and outlook

Traditionally, the allocation of roles between paramedics and EPs in German ambulance services was clearly defined. As per the Franco-German model, EPs are still the main influencers of prehospital care and paramedic practice.

During the placement, it became apparent that paramedics in Germany enjoy an excellent education that gives them all abilities to practise to a very high standard but with restrictions. Their role is not considered to be one of an autonomous practitioner and the profession is not positioned as independently and initiating as in countries where the Anglo-American model is adopted. This can be seen, for example, by the limited career opportunities.

Alongside the attempt to reduce some of the increased pressures on ambulance services with nationwide reform, significant change is expected to affect the legal position of paramedics. While conflict between stakeholders continues, this could be a unique opportunity to strengthen the paramedic role. Whether it could lead to a general rise of the profession in the near future, however, is open to question.

The role of EPs is less debated and they will still be essential for emergency care, although their use in line with the proposed alterations could change as well, in particular alongside changes to paramedic practice. Their input in the paramedic profession will most likely remain significant. As for the creation of a prehospital medicine sub-specialty alongside an emergency care specialty (as in other countries) rather than an add-on to existing specialties, no proposals are in the pipeline.

At what time and to what extent the proposed changes will be implemented is yet to be see, as is their impact on healthcare challenges and emergency care stakeholders. However, without a doubt, these are important times for the paramedic profession, EPs and, indeed, the whole emergency care system in Germany.

Limitations

The information regarding the observed area is not representative of the whole of Germany because there are significant differences between areas and a limited range of incidents were observed. Insights reflect the subjective opinions of stakeholders and do not necessarily represent the opinion of others involved or the author.

Only German publications were accessed so an international view on the topic was not part of the research. A general comparison of the benefits and drawbacks of the Franco-German and the Anglo-American models was beyond the scope of this article.

Key points

CPD Reflection Questions