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Tim Edwards, London Ambulance Service NHS Trust, discusses how paramedics can help ease A&E pressures, the importance of new NICE guidelines and what this means for patient care
It’s only been a matter of weeks since the National Institute for Health and Care Excellence (NICE) recommended that the NHS should provide more Advanced Paramedic Practitioners (APPs) to relieve pressure on emergency departments, within their new draft guidelines. The guideline shows that using APPs can reduce hospital admissions by 13 per cent compared with standard paramedics.
My role at London Ambulance Service NHS Trust is quite varied – no day is the same. I have four areas of key responsibility which include clinical practice, research, education and service development. I undertake at least one operational clinical shift each week where I respond to emergency calls as an advanced practitioner or as an ambulance paramedic. This means working closely with other clinicians, dispatchers, operational managers, GPs and emergency department staff to help provide care to our patients. So when the opportunity came up to join the committee for this guideline I was really interested. The National Ambulance Service Lead Paramedic Group was asked to consider sending a candidate for the committee, so I put forward an application and was accepted.
As a part of the committee, we discussed and looked at a range of evidence to come up with the findings. The committee brought together a range of multi-disciplinary clinicians, researchers and statisticians. Like any committee, we had the patient’s voice reflected in the room, and we benefited from an expert chairman who carefully looked at the information we had and ensured we were able to develop the guideline based not only on practical clinical evidence, but also on the lived experience of patients. By doing so, we were able to discuss and make appropriate recommendations.
The guideline makes a wide range of recommendations relating to the systems that provide care for adults who experience an acute medical emergency. It also looks at how various parts of the health care system, which are responsible for caring for patients in an emergency, can be configured and managed together. In particular, it strongly recommends the further development of APPs. These are experienced paramedics who undergo further intensive higher education to broaden their knowledge and scope of practice. This means they can provide more comprehensive care for patients with urgent care needs. The research we reviewed on the guideline committee indicated that such schemes were safe and cost effective. So what does this mean for hospitals and more importantly patients with urgent care needs?
Well, paramedics are frequently the first response to patients experiencing a medical emergency, and it suggests that we can treat more patients in their own homes or within their community, avoiding where possible visits to already overstretched A&E departments. A&Es are frequently overwhelmed and staff who strive to provide clinical care for patients should be commended for their hard work in difficult circumstances. If you look at the figures you can see the challenges staff face. The Kings Fund found that in 2016/17 alone, the NHS didn’t meet the four-hour standard, failing it every month of the year. They established that the standard had now not been met for the past 17 months. In fact in the third quarter of the year the proportion of patients spending longer than four hours in A&E reached its highest level for this time of the year for more than a decade. So the benefits of these recommendations can be huge for acute trusts across the country, especially as the British Medical Journal study suggested that for each APP, the NHS can save up to £72,000. These are significant savings and it’s essential we spend what money we have wisely, investing in areas where we’ll see a real improvement in care for everyone.
Paramedics are unique as we’re the only group of allied health professionals whose pre-registration training is dedicated to urgent and emergency care. We often provide the first response to patients experiencing medical or other health related emergencies. This means we’re well placed to help reduce hospital admissions and promote care closer to home for patients, which is something that was also described in The Five Year Forward View. In order for paramedics to reduce hospital admissions and really deliver on care closer to home, I think the system needs to provide adequate investment in post-qualification training and development. The NHS will need a sufficient number of advanced paramedics to be trained and developed before we can see widespread benefits. Many ambulance services have gone some way towards achieving this and the findings and recommendations from NICE should be taken into account for future developments, on a national scale.
I think this guideline comes at an important time for the NHS. It will provide a framework against which existing services and approaches to care may be benchmarked. I also think we need to look at the evidence underpinning these recommendations and if there are any future areas for research then we should look into them. Ultimately this means patients will benefit and services will improve – which is what we need, to ensure patients and their families receive the best possible care.
We know hospital A&E departments are facing a huge amount of pressure. Unfortunately there are no magic solutions, however it is clear that reducing unnecessary admissions where appropriate through expansion of the paramedic role can play a significant part in improving the situation – which is where this guideline comes into play. Having expert APPs is one cost effective way of reducing the impact on A&E services.
Working with NICE to develop this guideline has been a great experience, I’ve learnt so much and I look forward to receiving feedback from the consultation and seeing the final publication.